Object relations assessment predicts outpatients' attrition,early working alliance and psychotherapy process

This study investigated the predictive utility of assessing clients' object relations functioning to prognosticate therapy dropout, quality of the early working alliance and psychotherapy process events reported by clients after their first five sessions. Clients accepting a recruitment invitation were administered the thematic apperception test (TAT) shortly after intake, and those still in treatment three to four sessions later rated the working alliance and psychotherapy process events. Participants were 47 clients beginning psychotherapy with advanced doctoral practicum students at a university-based community-serving training clinic. The Social Cognition and Object Relations Scales (SCORS), an object relations scoring system for TAT stories, was used to assess object relations functioning. The California Psychotherapy Alliance Scales—Patient form measured four dimensions of the alliance. The Therapy Orientation Process Scales, created from the Psychotherapy Process Q-set, measured clients' perceptions of therapy process events as involving relatively more psychodynamic or cognitive behavioural techniques. The SCORS significantly predicted remaining in therapy, client ratings of stronger working alliance and typical therapy process as more psychodynamic than cognitive behavioural. SCORS complexity of representations and capacity for emotional investment in relationships scales were the strongest predictors, especially of the patient commitment facet of the alliance. The findings suggest that (1) beginning psychotherapy with object relations assessment can be useful for treatment planning and (2) the relationship between clients' object relations functioning, working alliance and greater sensitivity to psychodynamic than to cognitive behavioural interventions depends on the aspect of object relations that is being assessed.     

Examining the relationship between object relations and interpersonal distress in a clinical sample

The goal of the present study was to explore the relationship between patients' object relational functioning (Social Cognition and Object Relations Scale‐Global Ratings) as rated by clinicians during the course of outpatient psychodynamic psychotherapy in a university‐based clinic and patient self‐reported interpersonal vulnerabilities (Inventory of Interpersonal Problems‐64). Participants (n = 112) were outpatients entering treatment at a university‐based psychotherapy clinic and were diagnosed primarily with mood disorders as well as Axis II relational problems and features. Participants completed the IIP‐64 prior to receiving therapy, and SCORS‐G ratings were based on patients' level of relational functioning during the evaluation process (i.e., the semistructured interview, follow‐up and feedback) and across the first two psychotherapy sessions. Results showed a significant relationship between the IIP‐64 Total score with SCORS‐GSelf‐Esteem (r = ?.21, p < .05) and Affective Quality of Representations (r = ?.20, p < .05), wherein self‐reported interpersonal dysfunction was greater among patients who had lower self‐worth and perceived others as more malevolent. These findings suggest that patients who rated themselves as having more significant interpersonal difficulty reported more negative expectations and experiences of relationships in their psychotherapy narratives. The utility of the SCORS‐G and the IIP‐64 as two different avenues of assessing patient relational functioning is explored.     

The importance of reflective functioning to the diagnosis of psychic structure

Objective. This pilot study examines the connection between the concept of Fonagy and Target's reflective functioning and the structure axis of operationalized psychodynamic diagnostics (OPD) and assesses the potential of both scales to predict therapy success. Method. In the study, 24 (female) patients of the psychotherapy ward of the Frankfurt University Hospital for psychosomatic medicine and psychotherapy aged 18 to 55 were assessed on the basis of a 90‐minute, semi‐structured interview with regard to their capability for reflective functioning as well as with regard to their structural level according to OPD. In addition, the SCL‐90‐R was administered at the beginning and end of the 3‐month in‐patient therapy. Results. A significant correlation was found between reflective functioning and the structure axis of OPD. Reflective functioning also predicted improvement in overall mental condition through a 3‐month in‐patient therapy. This remained significant even when the influence of the overall assessment of structure according to OPD was removed. Conclusions. The independence of the concept of reflective functioning (RF) and its implications for the clinical stance are discussed.     

Interaction Structures in the Online Psychodynamic Psychotherapy of a Patient with Anxiety Symptoms

Interaction structures (IS) are reciprocal and mutual patterns of interaction between the therapist and patient, sometimes without either being aware of them. IS are mostly unique to each dyad but also can capture patterns that might be due to a particular therapy approach or clinical condition. The identification of IS in online psychodynamic settings can help clarify whether truly dynamic processes occur in virtual therapeutic relationships. The present study aimed to describe the general characteristics of the psychotherapeutic process and to identify the interaction structures in the online psychodynamic psychotherapy with an anxious patient. This was a longitudinal, systematic case study. The 24 online psychodynamic psychotherapy sessions were analysed by independent judges using the Psychotherapy Process Q-Set. Through the exploratory factor analysis of the main components, four IS were identified: (1) confident patient and encouraging therapist, (2) introspective patient and therapist fostering independence, (3) patient feeling understood and responsive/non-critical therapist, and (4) conflicted dyad exploring relationships. All patterns of interaction showed clinical validity, and pattern number (2) was positively associated with the treatment time. The study suggests that a truly psychodynamic process can be achieved in virtual settings. This kind of study denotes the characteristics of the dyad interaction and can contribute to the development of guidelines for therapeutic management attuned to the idiosyncrasies of the patients. More research on online practice is needed.     

Psychiatric morbidity and treatment pathway outcomes of patients presenting to specialist NHS psychodynamic psychotherapy services: Results from a multi‐centre study

Objective. Little is known about socio‐demographic, diagnostic, and clinical characteristics of patients referred for assessment to psychodynamic psychotherapy services. The aim of this study was to remedy this by prospectively collecting comprehensive and systematic demographic and clinical information on a large number of patients referred to NHS psychodynamic psychotherapy services. Design. Fourteen psychotherapy services operating within a National Health Service joined the study and contributed data for 1,136 patients referred from primary and secondary care clinics. Method. Patients were assessed using questionnaires and self‐rated measures, which included the clinician‐based version of the diagnostic form of the Millon clinical multi‐axial inventory‐III‐revised edition (MCMI‐III‐R), the brief symptom inventory (BSI), the inventory of interpersonal problems (IIP), and the clinical outcome in routine evaluation (CORE). The pathway from assessment through to treatment and variables associated with treatment uptake and exclusion are described and examined. Results. Most patients were in the moderate to severe range of psychiatric severity at the time of presentation. Ninety‐five percent met clinically based criteria for a psychiatric disorder (mostly anxiety and mood disorders) and/or personality disorder. Although the majority of patients were found suitable for treatment (N=935, 82%), analysis of uptake showed relatively high rates of treatment rejection by patients and treatment drop‐out. Partial outcome data at 6‐month follow‐up after intake into treatment revealed significant change but modest effect size (d=0.35). Conclusion. Systematic collection of baseline and outcome data would provide a national database of the performance of psychotherapy services that would be invaluable in facilitating comparative studies.     

Randomized trial on the effectiveness of long-and short-term psychodynamic psychotherapy and solution-focused therapy on psychiatric symptoms during a 3-year follow-up

BACKGROUND: Insufficient evidence exists for a viable choice between long- and short-term psychotherapies in the treatment of psychiatric disorders. The present trial compares the effectiveness of one long-term therapy and two short-term therapies in the treatment of mood and anxiety disorders. METHOD: In the Helsinki Psychotherapy Study, 326 out-patients with mood (84.7%) or anxiety disorder (43.6%) were randomly assigned to three treatment groups (long-term psychodynamic psychotherapy, short-term psychodynamic psychotherapy, and solution-focused therapy) and were followed up for 3 years from start of treatment. Primary outcome measures were depressive symptoms measured by self-report Beck Depression Inventory (BDI) and observer-rated Hamilton Depression Rating Scale (HAMD), and anxiety symptoms measured by self-report Symptom Check List Anxiety Scale (SCL-90-Anx) and observer-rated Hamilton Anxiety Rating Scale (HAMA). RESULTS: A statistically significant reduction of symptoms was noted for BDI (51%), HAMD (36%), SCL-90-Anx (41%) and HAMA (38%) during the 3-year follow-up. Short-term psychodynamic psychotherapy was more effective than long-term psychodynamic psychotherapy during the first year, showing 15-27% lower scores for the four outcome measures. During the second year of follow-up no significant differences were found between the short-term and long-term therapies, and after 3 years of follow-up long-term psychodynamic psychotherapy was more effective with 14-37% lower scores for the outcome variables. No statistically significant differences were found in the effectiveness of the short-term therapies. CONCLUSIONS: Short-term therapies produce benefits more quickly than long-term psychodynamic psychotherapy but in the long run long-term psychodynamic psychotherapy is superior to short-term therapies. However, more research is needed to determine which patients should be given long-term psychotherapy for the treatment of mood or anxiety disorders.     

Is there a dose-effect relationship between the number of psychotherapy sessions and improvement of social functioning?

OBJECTIVES AND DESIGN This study describes a randomized controlled trial which aimed to evaluate whether 16 sessions of psychotherapy combined with pharmacotherapy is more effective in relieving depression and improving social functioning than 8 sessions of psychotherapy combined with pharmacotherapy. METHODS. Randomized controlled trial comparing two treatment conditions with different psychotherapy dosages in out-patients with major depression. All patients studied had a baseline score of at least 14 points on the 17-item Hamilton Depression Rating Scale (HDRS). The two conditions consisted of 8- or 16-session short psychodynamic supportive psychotherapy, both in combination with pharmacotherapy. Efficacy was assessed using the 17-item HDRS, the clinical global impression of severity and of improvement, the depression subscale of the Ninety Symptom Checklist, the Quality of Life Depression Scale, and the Groningen Social Disability Schedule. RESULTS. Social functioning improved significantly in both groups. No significant differences were found between 8 and 16 sessions with regard to social functioning. A significant advantage is found for patients in remission on 5 of the 11 dimensions in social functioning over patients not in remission. CONCLUSIONS. At the end of treatment, no clear differences are found between 8 or 16 sessions of psychotherapy - both combined with pharmacotherapy - with regard to severity of depression and social functioning. It is thus still unknown if patients with major depression show more improvement in social functioning and less symptoms of depression after 16 sessions of combined therapy than after 8 sessions. Currently, it seems that for major depression 8 sessions of combined therapy are equally effective as 16 sessions.     

Initial Improvement in Adult Psychodynamic Psychotherapy

This study aimed to determine predictors of initial improvement regarding quality of life, symptoms, and defensive style of adult patients in psychodynamic psychotherapy. This is a naturalistic quantitative study conducted at a mental health outpatient clinic. Patients were assessed before starting psychotherapy and in the 6th month of treatment using the same instruments. Patients who were still in treatment at the 6th month of psychotherapy reported, in general, better quality of life, less symptoms, reduced severity of symptoms, and changes in some aspects of their defensive style. Those patients who sought treatment because of anxiety problems were associated with higher risk of no initial improvement. Clinicians and researchers find it difficult to predict the outcome of patients starting psychodynamic psychotherapy; other clinical settings should be investigated to enable the understanding of this complex phenomenon. Although psychodynamic psychotherapy is a long‐term treatment, patients show evidence of improvement from the beginning of the treatment. Follow‐up studies of these patients are needed to monitor the process of improvement after this initial period.     

Psychodynamic technique early in treatment related to outcome for depressed patients

We examined the relationship between psychodynamic techniques early in treatment with reliable change in depressive symptomatology. Forty‐six patients admitted for individual psychodynamic psychotherapy who received a diagnosis representative of a depressive spectrum disorder were assessed pretreatment and posttreatment through self‐report of depressive symptoms. Videotapes from two early treatment sessions (3rd and 9th) were independently rated on the Comparative Psychotherapy Process Scale for use of psychodynamic‐interpersonal and cognitive–behavioural techniques, with excellent interrater reliability (intraclass correlation coefficient > .75). We found a significant relationship between overall use of psychodynamic technique across early treatment (r = .31, p = .036), as well as specific psychodynamic techniques delivered across early treatment, with change in patient‐reported depressive symptoms. Our findings suggest that focusing on affective experiencing and expression, as well as providing interpretations are particularly helpful early in psychodynamic treatment for depression. Clinical implications and future directions are discussed.     

Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder

Changes in attachment organization and reflective function (RF) were assessed as putative mechanisms of change in 1 of 3 year-long psychotherapy treatments for patients with borderline personality disorder (BPD). Ninety patients reliably diagnosed with BPD were randomized to transference-focused psychotherapy (TFP), dialectical behavior therapy, or a modified psychodynamic supportive psychotherapy. Attachment organization was assessed with the Adult Attachment Interview and the RF coding scale. After 12 months of treatment, participants showed a significant increase in the number classified secure with respect to attachment state of mind for TFP but not for the other 2 treatments. Significant changes in narrative coherence and RF were found as a function of treatment, with TFP showing increases in both constructs during treatment. No changes in resolution of loss or trauma were observed across treatments. Findings suggest that 1 year of intensive TFP can increase patients' narrative coherence and RF. Future research should establish the relationship between these 2 constructs and relevant psychopathology, identify treatment components responsible for effecting these changes, and examine the long-term outcome of these changes.     

A comparison of dose-response curves in cognitive-behavioral and psychodynamic psychotherapies

Changes in patient- and therapist-rated process items, and patient-rated symptom severity assessed over a maximum of 30 sessions of psychodynamic or cognitive-behavioral psychotherapy were compared in an outpatient mental-health clinic. Patients' ratings in psychodynamic psychotherapy on two of the process items were superior to ratings by patients in cognitive-behavioral therapy, and interactions with time were discovered for an interpersonal item. Comparisons between patients who reported their initial symptom severities as most severe and those with less severe symptoms also were made, with results indicating differential effects of treatment according to perceptions of symptom severity. Interactions between length of stay in treatment and number of sessions also were investigated. Findings indicated that patients benefit from psychotherapy over time and support the usefulness of a contextual model for psychotherapy funding.     

A Psychodynamic Perspective on a Systematic Review of Online Psychotherapy for Adults

A variety of new psychotherapy modalities has arisen in which the contact between patient and therapist takes place via the internet. The main objective of this systematic review is to investigate the types of online psychotherapy (OP) conducted nowadays, and to describe their main characteristics to psychodynamic psychotherapists who may wish to better understand the current scientific literature on the subject. The review used two databases, EMBASE and PsycINFO. Fifty‐nine studies were retrieved and the main online psychotherapy modalities identified were self‐therapy programmes using contact via email or chat; videoconference; and therapy exclusively via chat or email. The result of these studies suggests that OP is more effective than a waiting list control group. When compared with face‐to‐face therapies, OP showed similar effects. Most studies involved cognitive behavioural therapy; only two studies involved a form of psychodynamic psychotherapy. Different forms of communication allow patient and therapist to establish different relationships and therapeutic possibilities. OPs may be feasible treatment alternatives; however, it remains unclear, especially in relation to psychodynamic treatments, if therapeutic technique in OP, which involves changes in comparison with face‐to‐face therapies, would be useful in severe cases. Psychodynamic psychotherapists should adopt a posture of constant reflection on the changes taking place in the world and their impact on the minds of individuals, without, nevertheless, idealizing the ‘new’.     

Psychodynamic treatments of self-injury

The authors address psychodynamic therapies, particularly transference-focused psychotherapy (TFP), in the treatment of patients who present with non-suicidal self-injury. In doing so, they briefly discuss various psychodynamic approaches with empirical evidence for their effectiveness. They describe TFP, including its treatment rationale, putative change mechanisms, and outcome research. They then present a case illustration of a patient with borderline personality disorder who engages in non-suicidal self-injury to demonstrate how TFP can be applied to such cases.     

Treatment intensity and regularity in early outpatient psychotherapy and its relation to outcome

The distribution of treatment sessions (number of interruptions, weeks without psychotherapy and number of sessions) during the first three months of psychodynamic psychotherapy (PD), cognitive behavioral therapy (CBT) and psychoanalytic psychotherapy (PAP) was analyzed prospectively over two years in a sample of 256 outpatients. Number of weeks without psychotherapy in early treatment was predicted by initial helping alliance in PD and by initial quality of interpersonal relations in CBT. Level of initial psychological or physical impairment showed no effect on distribution of sessions during early treatment. In PD and CBT, session distribution early in treatment did not predict subsequent course of improvement. Only in PAP did weeks without psychotherapy and number of sessions affect rate of symptom change, in that participants showed better outcome when treatment started continuously at a rather slow pace. Implications for psychotherapy practice and research are discussed. Copyright © 2006 John Wiley & Sons, Ltd.