The effectiveness of psychodynamic‐interpersonal therapy (PIT) in routine clinical practice: A benchmarking comparison

Aims . To investigate the effectiveness of psychodynamic‐interpersonal therapy (PIT) in a routine clinical practice setting. Methods . Full pre–post data were available on 62 out of a total of 67 patients aged between 19 and 60 years. Patients were seen over a 52‐month period (2001–2005) receiving a course of PIT therapy (mean number of sessions=16.9, median number of sessions=16). The outcomes were assessed using a range of outcome measures: the 32‐item version of the Inventory of Interpersonal Problems (IIP‐32), the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE‐OM), and the Beck Depression Inventory – Second Edition (BDI‐II). Study data were benchmarked against comparative national and local data. Results . There were significant pre–post reductions on all measures: IIP‐32 effect size (ES)=0.56; CORE–OM ES=0.76; BDI–II ES=0.76. Reliable and clinically significant change was achieved by 34% of clients on the BDI‐II and by 40% of clients on the CORE‐OM. Clients with high pre‐therapy levels of interpersonal problems had poorer outcomes. Conclusion . Benchmarking our results against both national and local comparative data showed that our results were less favourable than those obtained where PIT had been used in efficacy trials, but were comparable with reports of other therapies (including cognitive behavioural therapy (CBT)) in routine practice settings. The results show that PIT can yield acceptable clinical outcomes, comparable to CBT in a routine care setting, within the context of current limitations of the practice‐based evidence paradigm.     

Exploring the Role of Blame in Couple Relationships within the Triangular Setting of Couple Psychotherapy

This paper describes the process of couple therapy with two couples that used blame as the currency of exchange in their relationship. Both couples struggled with managing three‐person relationships. The triangular setting of couple psychotherapy provoked and triggered primitive anxieties around exclusion, rejection and abandonment in both cases. I draw upon clinical work with two such couples to illustrate how one repeatedly collapsed the triangular space whereas the other gradually became more able to bear it. I refer to scientific evidence of the brain's ability to continue to change in response to new learning by forming fresh neural connections throughout life. I suggest that the repetitive occurrence of new experiences within couple psychotherapy can generate new neural pathways thereby biologically influencing new ways of how partners might respond to each other. I conclude by highlighting the therapeutic potential of the framework within which couple psychotherapy takes place, a triangular configuration which offers a developmental opportunity for navigating primitive anxieties related to triangular relationships.     

Stability of the CORE‐OM and the BDI‐I prior to therapy: Evidence from routine practice

Background. It is important to know the stability of standard outcome measures prior to therapy over differing periods of time that map onto the realities of waiting times in routine service settings. Method. We studied 1,684 clients who completed one or both the targeted measures Clinical Outcomes in Routine Evaluation‐Outcome Measures (CORE‐OM) and Beck Depression Inventory‐I (BDI‐I) two times, at intervals of up to 12 months, prior to beginning psychotherapy. We also selected an additional 1,623 clients who completed the CORE‐OM (N=1,623), BDI‐I (N=980) or both at referral, but had no records of further contact with the service. Results. There was little change in the mean CORE‐OM or BDI‐I scores between referral and clinical assessment. The test‐retest correlations showed substantial stability on both measures, declining only moderately at the longer intervals studied. Conclusion. The high test‐retest correlations for periods of up to 6 months suggest that psychological disturbance was both reliably measured by the CORE‐OM and the BDI‐I, and reasonably stable among clients waiting to be assessed. Implications for routine practice are discussed.     

Validation of the Italian version of the clinical outcomes in routine evaluation outcome measure (CORE‐OM)

The Clinical Outcomes in Routine Evaluation—Outcome Measure (CORE‐OM) was translated into Italian and tested in non‐clinical (n = 263) and clinical (n = 647) samples. The translation showed good acceptability, internal consistency and convergent validity in both samples. There were large and statistically significant differences between clinical and non‐clinical datasets on all scores. The reliable change criteria were similar to those for the UK referential data. Some of the clinically significant change criteria, particularly for the men, were moderately different from the UK cutting points. The Italian version of the CORE‐OM showed respectable psychometric parameters. However, it seemed plausible that non‐clinical and clinical distributions of self‐report scores on psychopathology and functioning measures may differ by language and culture. Copyright © 2009 John Wiley & Sons, Ltd. Key Practitioner Message: ? A good quality Italian translation of the CORE‐OM, and hence the GP‐CORE, CORE‐10 and CORE‐5 measures also, is now available for use by practitioners and anyone surveying or exploring general psychological state. The measures can be obtained from CORE‐IMS or yourself and practitioners are encouraged to share anonymised data so that goodclinical and non‐clinical referential databases can be established for Italy.     

Dance movement psychotherapy for couples (DMP-C): systematic treatment guidelines based on a wide-ranging study

ABSTRACT

A new body of knowledge, growing out of the clinical and research fields, has been developing in recent years in the area of dance-movement psychotherapy for couples (DMP-C). Formulation of an intervention protocol based on a systematic review of theories and research is crucial to scientifically establishing the field and to implementing research findings in clinical practice. The present article reviews the results of a comprehensive qualitative research study in DMP-C, which addresses the following topics: couple intake, expectations of couples seeking therapy, a projective identification mechanism in the couple relationship, desires and expectations in the sexual relationship, synchrony in the non-verbal relationship, somatic mirroring, and kinaesthetic empathy in the couple relationship. Based on the findings of the research, a systematic intervention protocol for couples psychotherapy through movement and dance has been developed; its unique contribution will be examined alongside other interventions in couples therapy.     

Changes of defensive functioning. does interpretation contribute to change?

In this process–outcome study, we explored the changes of patients' defensive functioning (rated with the Defence Mechanism Rating Scales) over the course of brief dynamic psychotherapy ( N = 39, maximum 40 sessions). We investigated whether therapists' use of interpretation (rated with the Psychodynamic Intervention Rating Scale) would influence the development of maladaptive defensive functioning. The proportion of maladaptive defences was reduced during therapy. A higher proportion of interpretation was associated with less use of maladaptive defence after therapy, whereas the use of interpretation was not predictive of the change of adaptive defensive functioning. Therapists' use of supportive interventions did not impact the development of either maladaptive or adaptive defences. Copyright © 2005 John Wiley & Sons, Ltd.     

Relating Therapy

Relating therapy is a form of psychotherapy that is based upon relating theory. Relating theory is briefly compared with attachment theory and certain aspects of psychoanalysis. The interpersonal octagon (Birtchnell, 1994) represents a person's eight relating positions. People need to acquire the capability to relate effectively in each one of these. Competent relating is called positive and relating that falls short of this is called negative. Ways are described by which patients are helped to shed their negative relating and become more capable of relating positively. The Person's Relating to Others Questionnaire (Birtchnell et al., in press) measures negative relating within the eight positions of the octagon. It identifies a person's areas of negative relating and measures change in such relating over the course of psychotherapy. Interrelating therapy is an extension of relating therapy that is applicable to couples. The Couple's Relating to Each Other Questionnaires (Birtchnell et al., 2006) is a set of four questionnaires by which each of two partners can rate how s/he relates negatively to the other and how s/he considers that the other relates negatively to her/him. It is used to measure change over the course of couple therapy.     

Piloting a practice research network: A 12-month evaluation of the Human Givens approach in primary care at a general medical practice

Objective. To investigate the effectiveness of the Human Givens (HG) approach to the management of emotional distress in a primary care setting. To investigate whether or not the use of a shorter version (i.e., CORE‐10) of a well‐established psychometric instrument (i.e., Clinical Outcome in Routine Evaluation (CORE) CORE‐outcome measure, CORE‐OM) for sessional data collection is feasible for large‐scale implementation of a practice research network (PRN). Design. All clients who chose to opt into assessment for treatment with three accredited HG therapists following referral for management of psychological distress, primarily anxiety and depression, by General Medical Practitioners (GPs) or GP practice nurses working in a primary care general medical practice over a 12‐month period were included. Methods. The primary outcome measures were the CORE‐OM and CORE‐10. Pre–post effect sizes (Cohen's d) were calculated using pre, post, and pooled standard deviations to facilitate comparison with previously published studies. Mixed‐design analysis of variance (ANOVA) was used to look at differences in pre‐ and post‐treatment symptoms and potential treatment effects based on type of termination and gender. Observed intent‐to‐treat pre–post effect size using the CORE‐OM was also benchmarked against data from Clark et al. (2009) improving access to psychological therapies (IAPT) pilot site data. Results obtained using CORE‐OM were compared with those obtained using CORE‐10 to evaluate the feasibility of using the CORE‐10 for routine use in real‐world clinical settings. Results. Pre‐ to post‐treatment changes measured with the CORE‐OM and CORE‐10 suggested that the therapy was highly effective, with clients remaining in treatment to completion demonstrating the greatest benefit. Reliable change and recovery rates comparisons between the CORE‐OM and CORE‐10 indicated that the CORE‐10 is a viable alternative to the CORE‐OM. Result of the benchmarking indicated that the observed pre–post effect size was clinically equivalent to IAPT data published by Clark et al. (2009) . Conclusions. Although replications are warranted as the current investigation is a pilot study, the HG approach appears to be an effective treatment. CORE‐10 is a satisfactory generic sessional assessment to use in place of the 34‐item CORE‐OM. Use of a shorter yet reliable outcome measure is likely to increase assessment completion rates. PRNs appear to be a suitable mechanism to establish treatment effectiveness across a wide range of treatments in different settings.     

The relationship of patient defensive functioning and alliance with therapist technique during short‐term psychodynamic psychotherapy

This study investigates the relationship of patient defensive functioning, therapeutic alliance and therapists' use of technical interventions in Short‐Term Psychodynamic Psychotherapy (STPP; Book, 1998; Luborsky, 1984; Strupp & Binder, 1984; Wachtel, 1993). Participants in this study were 44 patients admitted for individual psychotherapy at a university based outpatient community clinic. Patient defensive functioning was assessed with the Defensive Functioning Scale (DFS) of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM‐IV; American Psychiatric Association, 1994). Therapeutic alliance was assessed using patient ratings from the Combined Alliance Short Form (CASF; Hatcher & Barends, 1996). External raters coded videotaped sessions using the Comparative Psychotherapy Process Scale (CPPS; Hilsenroth, Blagys, Ackerman Bonge & Blais, in press) to assess the use of Psychodynamic–Interpersonal (PI) and Cognitive–Behavioral (CB) techniques early (third or fourth session) in psychotherapy. Patient Overall Defensive Functioning (ODF) was found to predict therapists' overall use of PI interventions, as well as specific PI and CB interventions. Additionally, patients who utilized fewer adaptive defenses were found to receive more PI interventions in general. The implications of these findings for treatment planning and intervention are discussed. Copyright © 2006 John Wiley & Sons, Ltd.     

Are patient and therapist characteristics associated with the use of defence interpretation in brief dynamic psychotherapy?

Patient and therapist characteristics were explored as predictors of the use of defence interpretation in non‐manualized brief dynamic therapy (N = 38, max 40 sessions). Therapist interventions were rated with the Psychodynamic Intervention Rating Scale in an early session (7th) and in the mid‐phase of therapy (16th session). Low quality of patients' interpersonal relationships (rated with Dynamic Scales) was associated with more interpretation early in the therapy. Therapists with greater experience gave more interpretation. The combination of more maladaptive defensive functioning (rated with Defence Mechanism Rating Scales) and low quality of working alliance was associated with a high proportion of interpretation. Differences between individual therapists accounted for 35% of the variance in interpretation early in therapy and 42% in the mid‐phase. Therapists gave significantly more interpretation in the mid‐phase compared to early in the therapy. Copyright © 2003 John Wiley & Sons, Ltd.     

Women's experience of IVF: a follow-up study

The aim of this research was to increase understanding of how women feel about the experience of IVF 2-3 years after ceasing treatment. A questionnaire covering issues relating to infertility and the value of the experience of IVF together with three self-report measures [Satisfaction With Life Scale (SWLS), Golombok Rust Inventory of Marital State (GRIMS) and General Health Questionnaire (GHQ-12)] were mailed to all women (n = 229) who had their last contact with the clinic in 1994. The response rate was 55%. Having a baby positively influenced the recall of the IVF experience. Women who did not have a baby were more critical about the clinic and more negative about the experience of treatment but did not regret having tried IVF. These women had statistically significantly lower scores on SWLS but did not differ from those with babies on GRIMS and GHQ-12 scales. The results give insight into how women look back on the IVF experience and what aspects of treatment they recall as particularly difficult. The findings can be used by providers of IVF to implement strategies that may reduce stress and improve the patients' well-being.     

Marital role dynamics during brief group psychotherapy: Assessment of verbal interactions

Examined the impact of brief group psychotherapy on the marital and sex roles of five volunteer couples who participated in two, 15-session, model therapy groups conducted approximately 2 years apart. Assessments are based on Hill Interaction Matrix (HIM) analysis of the style and content of marital partners' verbal behavior during the sessions. Results show that interactional correlates of traditional marital and sex role variations are attenuated, that communication between spouses is improved, and that the therapeutic quality of verbal behavior is enhanced over the course of therapy. Generally, from the perspective of interactional dynamics, these findings suggest that the group psychotherapy model that was being evaluated is an effective mode of brief, precrisis intervention for married couples.     

Cognitive analytic therapy: Comparing two measures of improvement

A sample group of 49 patients began a course of cognitive analytic therapy and completed two questionnaires at the end of the first session. The 32 patients who completed the course completed the same two questionnaires at the penultimate session, and the 30 patients who attended a 3‐month follow‐up completed the questionnaires again then. The two questionnaires were the Person's Relating to Others Questionnaire (PROQ2) and the Clinical Outcomes in Routine Evaluation (CORE). There was a high positive correlation between the total scores of these two measures and between the CORE and two, three and four of the PROQ2 scales at the start of therapy, the end of therapy and at follow‐up respectively. By the end of therapy there were significant drops in scores on three of the eight PROQ2 scales and on the total score, and on the CORE. By follow‐up there were significant drops on four PROQ2 scales and the CORE, but only two of these were the same as at the end of therapy. There was no obvious explanation why some patients registered a greater drop on one questionnaire than on the other.     

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’.     

Measuring interrelating within couples: The Couple's Relating to Each Other Questionnaires (CREOQ)

The Couple's Relating to Each Other Questionnaires (CREOQ) are a set of four questionnaires for measuring negative forms of interrelating within couples. They enable each partner to rate his/her relating to the other and the other's relating to him/her. They are based upon the theoretical structure called the interpersonal octagon, and each questionnaire has eight scales. They are usually accompanied by a brief, single‐scale questionnaire called the US (us as a couple), by which each partner rates the quality of the relationship. The set of questionnaires was administered to 130 English couples from the community, 157 English couples seeking couple therapy and 89 Dutch community couples. The Dutch couples were also invited to rate themselves and their partners according to the items of the revised interpersonal checklist (ICL‐R). The mean scores for the US and for most of the scales of the four CREOQ were significantly higher in the couple therapy sample. The internal reliabilities of the Dutch sample were generally lower than those of the English sample. Correlations were examined between the 10 ICL‐R scales and the 8 CREOQ ones. Some agreement emerged, and for the ICL‐R, there appeared to be one close, one distant, four upper and two lower scales.     

Couple therapy and relational body psychotherapy: Healing childhood wounds

This paper presents an approach to healing childhood wounds through the use of Imago relationship couple therapy in conjunction with relational body psychotherapy. Working with couples in crisis arouses powerful and confusing questions regarding the transference and counter-transference tensions within all aspects of the therapeutic triangle: intra-subjective in each member of the couple, their inter-subjective space, their interaction with the therapist and within the therapist herself. One of the ways of coping with these multifaceted dyads is the use of somatic cues in all three members of the triad. The paper provides three clinical vignettes, which illustrate some of the advantages of the combination of the two theories in relational couple therapy.     

A prospective study of the effectiveness of group and individual psychotherapy for women CSA survivors

Objectives. There is little empirical evidence to guide clinical practice in treating adult patients presenting to adult mental health and primary care services with severe psychological difficulties consequent on childhood sexual abuse. The aim of this study was to determine the effectiveness of a model of short term, focal, integrative psychotherapy with this population of patients and to compare outcomes when the model is delivered on an individual or group basis. Design. This study used a patient preference design with random allocation to one of two treatment modalities (individual or group treatment). There was a waiting list control. Method. A group of 48 women patients were assessed on 4 psychological measures when entering a waiting list condition, immediately before treatment and after completion of 12 sessions of psychotherapy, either in a group or individually. Follow‐up data were collected at 4 months and 8 months. Results. Both individual and group patients showed highly statistically and clinically significant improvements after treatment. These gains were maintained at follow‐up with the exception of one measure that indicated a significant decline from post‐treatment levels for the group patients. Conclusions. This model of psychotherapy is highly effective, when delivered by chartered clinical psychologists to patients whose preferences for individual or group therapy have been met.     

Theory and technique in dynamic psychotherapy--curative factors and training therapists to maximize them

Three principles of curative factors in dynamic psychotherapy are reviewed: (1) Achieving a helping relationship; (2) achieving self-understanding, and (3) maintaining the gains. A new development in psychotherapy research is illustrated: the creation of operational measures that relate to the curative factors: the therapeutic alliance, the transference, accuracy of interpreting the transference, insight, change in transference and psychiatric severity. Such operational measures can be reliably estimated from psychotherapy sessions because they specify what each measure represents. A special format for training therapists to foster these curative factors is presented called 'group training in supervision of psychotherapy'.     

The therapeutic alliance in couples and family therapy

The therapeutic alliance is central to couples and family therapy. Although the formal concept of therapeutic alliance has not been used widely within the family therapy field, virtually every prominent clinical theorist has addressed the importance of establishing and maintaining a positive therapeutic relationship with the family. The alliance in couples and family treatment differs from the alliance in individual psychotherapy in that the couples and family therapist must establish and maintain multiple alliances. They also must adopt a conceptual framework that accounts for the interactions within triangles or three-person systems, recognize the influence of the system operating on him or her, and appreciate how different models of family therapy define the position of the therapist in relation to the couple or family. An integrative review of the therapeutic alliance in couples and family therapy is followed by a discussion of problems in the therapeutic relationship. Two general clinical strategies for managing difficulties in the alliance then are illustrated through case vignettes.