Therapeutic interventions related to outcome in psychodynamic psychotherapy for anxiety disorder patients

This is the first study with acceptable inter-rater reliability to examine specific therapeutic techniques related to change in anxiety disorder patients during short-term psychodynamic psychotherapy. The study first examined the effectiveness of short-term psychodynamic psychotherapy and results showed significant and positive pre-/post-treatment changes on both patient and independent clinical ratings for anxiety, global symptomatology, relational, social, and occupational functioning. Likewise, the majority of patients (76%) reported anxiety symptoms within a normal distribution at termination. Importantly, psychodynamic interventions rated early in treatment (third/fourth session) were positively related to changes in anxiety symptoms. Further, results showed that several individual psychodynamic techniques were meaningfully related to outcome including (1) focusing on wishes, fantasies, dreams, and early memories; (2) linking current feelings or perceptions to the past; (3) highlighting patients' typical relational patterns; and (4) helping patients to understand their experiences in new ways. Clinical applications are discussed.     

Quality of object relations versus interpersonal functioning as predictors of therapeutic alliance and psychotherapy outcome

The purpose of the study was to compare an interview measure of quality of object relations to questionnaire and interview measures of recent interpersonal functioning with respect to the prediction of therapeutic alliance and psychotherapy outcome. The sample consisted of 64 patients who had received approximately 20 sessions of short-term individual psychotherapy within a controlled, clinical-trial investigation. Ratings of therapeutic alliance were provided independently by the patient and the therapist after each session. Outcome measures, which were provided by three sources (patient, therapist, and independent assessor), covered the areas of interpersonal functioning, psychiatric symptomatology, self-esteem, and life satisfaction. Quality of object relations, which characterizes the patient's lifelong pattern of relationships, was the best predictor. It was significantly related to patient-rated and therapist-rated therapeutic alliance and to patient improvement of both general symptomatology and specific target problems. The study also replicated previous studies that have reported significant relationships between therapeutic alliance and therapy outcome. The advantages of pretherapy predictors of therapy outcome, such as quality of object relations, are discussed.     

Therapist actions that address initially poor therapeutic alliances in psychotherapy

The authors studied six patients treated in time-limited dynamic psychotherapy who had initially poor therapeutic alliance scores; three patients went on to have improved alliances and good outcomes, and three had unimproved alliances and poor outcomes. The therapist actions that most strongly differentiated the two groups and occurred more frequently in the cases with improved alliances and good outcomes were 1) addressing the patient's defenses, 2) addressing the patient's guilt and expectation of punishment, 3) addressing the patient's problematic feelings in relation to the therapist, and 4) linking the problematic feelings in relation to the therapist with the patient's defenses.     

Therapeutic alliance, cohesion and outcome in a long-term analytic group. A preliminary study

We studied the ongoing relationship of patients and their therapist in a long-term, analytic group. The therapeutic alliance was rated weekly and group cohesion was rated every month, by patients and therapist. The patients' symptoms (SCL-90-R) and interpersonal problems (IIP-C) were rated every third month during therapy (self-reports). There was a steady increase in the alliance ratings by patients and therapist during the first 2 years of therapy. This differs from findings in short-term therapies, where the alliance quickly reaches a high level and then remains stable throughout therapy. Therapist ratings of early alliance correlated significantly with positive symptomatic outcome, but did not predict interpersonal change. Patients' alliance ratings did not predict change. Early cohesion ratings did not predict change. The concordance between the patients' and the therapist's alliance ratings was highest between 16 and 30 sessions, and was essentially maintained throughout therapy. An early concordance of patient and therapist alliance ratings predicted a better symptomatic outcome. The measures of therapeutic alliance and cohesion used in this study seem to address different elements in the group process.     

Therapist mindfulness, alliance and treatment outcome

The present study investigated the association between therapist dispositional mindfulness and therapist self-affiliation, the therapeutic alliance, and treatment outcome. Total therapist mindfulness was associated with therapist self-affiliation, r=.413, p<.05. Therapist mindfulness was positively correlated with therapist ratings of the working alliance, r=.456, p<.05, though only the Act with Awareness subscale showed a relationship with patient rated alliance, r=.379. Therapist mindfulness was not associated with patient rated decreases in global symptomatology, but was associated with patient rated improvements in interpersonal functioning, r=.481, p<.05. All correlations correspond to a medium effect size. The results indicate that therapist dispositional mindfulness may be an important pre-treatment variable in psychotherapy outcome.     

Countertransference feelings in one year of individual therapy: an evaluation of the factor structure in the Feeling Word Checklist-58

Although countertransference phenomena have been given much attention within psychotherapy theory, single-case studies and clinical anecdotes, empirical research is still conspicuous by its absence. To assess the therapists' emotional reactions, which are understood to be part of the countertransference (CT), we used the Feeling Word Checklist 58 (R?ssberg, Hoffart, & Friis, 2003); a self-report questionnaire, comprising 58 feeling words. The aims of the present study were to examine the underlying factor structure and psychometric properties of these factors, and to validate the factors by exploring the relationships between countertransference feelings and the following variables: therapeutic alliance, patient personality pathology, suitability for psychodynamic therapy, interpersonal problems, level of general functioning, and symptoms. Six therapists, who treated 75 patients, with weekly, psychodynamic therapy, over 1 year, completed the checklist after each session. To establish the number of subscales in the checklist, a principal component analysis with promax rotation was conducted. The analysis revealed four clinically meaningful factors named Confident, Inadequate, Parental and Disengaged. The psychometric properties of all subscales proved to be acceptable. Alliance as reported by both patient and therapist showed differential correlations with the subscales. The patients' relational functioning showed stronger correlations with the CT feelings than the patients' symptoms and level of functioning. The four subscales found in the Feeling Word Checklist-58 seem to capture clinically meaningful aspects of the therapeutic dyad, and countertransference feelings are systematically related to different relational variables.     

Exploration of session process: relationship to depth and alliance

This study investigates the relationship between the Depth of elaboration, the therapeutic alliance, and dimensions of the psychotherapy process--the therapist interventions, the patient contributions, and patient/therapist patterns of interaction. Sixty psychotherapy sessions that were audio-taped and transcribed were rated by external judges by using a battery of instruments that included the Psychotherapy Process Q-Set (Jones, 1985, 2000), the Working Alliance Inventory-Observer (Horvath, 1981, 1982; Horvath & Greenberg, 1989), and the Depth Scale of Session Evaluation Questionnaire (Stiles & Snow, 1984a). The results show a significant positive correlation between Depth and therapeutic alliance, as well as between Depth, therapeutic alliance, and some variables of the therapeutic process. The findings indicate the importance of therapist interventions that focus on the patient's affects, relational patterns, and the "here and now" of the relationship in the increase of the Depth of elaboration and therapeutic alliance. The clinical implications of this study will be discussed.     

Predictive value of object relations for therapeutic alliance and outcome in psychotherapy for depression: an exploratory study

The concept of object relations has been shown to be relevant for the process and outcome of psychodynamic psychotherapies. However, little is known about its relevance for the psychotherapeutic treatment of depression. In this study, we explored the predictive value of object relational functioning (ORF) for the therapeutic alliance and outcome of short-term psychodynamic supportive psychotherapy in patients with mild to moderately severe depression. The ORF of 81 patients was rated by using the Developmental Profile. The overall maturity of ORF measured at baseline was higher in patients who showed a better treatment response. In multiple regression analysis, the adaptive level of individuation appeared to be specifically predictive of outcome. Patients with a recurrent depression showed less mature levels of ORF, lower adaptive levels and a higher score on the symbiotic level. No association was found between ORF and therapeutic alliance during treatment. In contrast to the single measure of alliance early in therapy, the growth of the alliance was related to outcome. The study indicated the relevance of ORF for depression and established that it is distinctive from the actual therapeutic alliance.     

Different perspectives of the therapeutic alliance and therapist technique in 2 forms of dynamically oriented psychotherapy.

OBJECTIVE: This study addresses several issues concerning patients' and therapists' perceptions of key therapy process variables. This includes examining whether patients and therapists differ in their perceptions of the therapeutic alliance and therapist technique, what the relation is between perceptions of the alliance and technique, and whether these perceptions are predictive of treatment outcome. METHOD: Patient and therapist perceptions of the therapy process were provided in a comparative trial of 2 forms of short-term individual dynamic psychotherapy. Patients (n = 144) were randomly assigned to each condition. Treatment outcome was assessed using a large, comprehensive battery of reliable measures. RESULTS: The findings revealed several differences in the patients' and therapists' ratings of the alliance and technique in the 2 forms of therapy. Patient ratings of the alliance and technique were predictive of treatment outcome. CONCLUSION: The findings contribute to understanding the extent to which therapy participants share views of therapy processes and highlight the importance of the therapist's attending to the patient's perception of therapy.     

Goldilocks on the couch: Moderate levels of psychodynamic and process-experiential technique predict outcome in psychodynamic therapy

Objectives: Greater symptom change is often assumed to follow greater technique use, a “more is better” approach. We tested whether psychodynamic techniques, as well as common factors and techniques from other orientations, had a curvilinear relation to outcome (i.e., whether moderate or “just right” intervention levels predict better outcome than lower or higher levels). Methods: For 33 patients receiving supportive-expressive psychodynamic psychotherapy for depression, interventions were assessed at Week 4 using the multitheoretical list of therapeutic interventions and symptoms were rated with the Hamilton Rating Scale for Depression. Results: Moderate psychodynamic and experiential techniques predicted greater symptom change compared to lower or higher levels. Conclusion: This “Goldilocks effect” suggests a more complex relation of intervention use to outcome might exist.     

Testing a mediation model of psychotherapy process and outcome in psychodynamic psychotherapy: Previous client distress,psychodynamic techniques,dyadic working alliance,and current client distress

To test a sequential model of psychotherapy process and outcome, we included previous client distress, therapist psychodynamic techniques, dyadic working alliance, and current client distress. For 114 sets of eight-session segments in 40 cases of psychodynamic psychotherapy, clients completed the Outcome Questionnaire-45 and Inventory of Interpersonal Problems-32 after the first and final session, judges reliably coded one middle sessions on the Psychodynamic subscale of the Multitheoretical List of Therapeutic Interventions, and clients and therapists completed the Working Alliance Inventory after every session. Results indicated that higher use of psychodynamic techniques was associated with higher levels of the working alliance, which in turn was associated decreased client distress; and working alliance was higher later in psychotherapy. There was a significant indirect effect of psychodynamic techniques on decreases in distress mediated by the working alliance. Implications for theory, practice, and research are provided.

Clinical or methodological significance of this article: Conducted a longitudinal, latent variable examination of the relationships of psychodynamic techniques and working alliance on client distress. Psychodynamic techniques have an indirect effect on decreases in client distress through the dyadic working alliance.     

The effects of borderline pathology on short-term psychodynamic psychotherapy for depression

Abstract

This study examines the impact of borderline pathology (BP) on the effectiveness of short-term psychodynamic psychotherapy for depression in a naturalistic setting. Two groups were examined: 18 depressed patients with no Axis II diagnoses and 15 depressed patients with comorbid BP. Both groups demonstrated significant changes in depressive symptomatology. Likewise, many patients exhibited clinically significant reductions in depressive symptoms. Secondary analyses demonstrated significant changes for interpersonal functioning; no significant differences for therapeutic alliance were found between the two groups; and five therapist interventions were found to be more prevalent in the psychotherapy of the depressed patients with comorbid BP. The clinical utility and implications of these findings are discussed.     

Assessment factors associated with premature psychotherapy termination.

Characteristics of patients accepted for both intensive psychotherapy and psychoanalysis were rated during their initial assessments. Twenty cases that terminated prematurely (most within the first month) were compared with twenty cases that continued in therapy. While neither specific diagnosis, type of insight therapy, nor gender of the patient or therapist was a reliable predictor of premature termination, it was found that psychodynamic and environmental assessment factors significantly differed between these two groups. In those patients who eventually dropped out, specific ego deficits, primarily introspection, frustration tolerance, impulse control, and motivation, were rated as significantly more impaired. The therapists' negative feelings toward their prospective patients and the patients' hostility toward past caretakers and present life circumstances were also associated with premature termination.     

Short-term psychodynamic psychotherapy for depression: an examination of statistical,clinically significant,and technique-specific change

This study investigates the effectiveness of short-term psychodynamic psychotherapy (STPP) for depression in a naturalistic setting utilizing a hybrid effectiveness/efficacy treatment research model. Twenty-one patients were assessed pre- and post-treatment through clinician ratings and patient self-report on scales representing specific DSM-IV depressive, global symptomatology, relational, social, and occupational functioning. Treatment credibility, fidelity, and satisfaction were examined, all of which were found to be high. All areas of functioning assessed exhibited significant and positive changes. These adaptive changes in functioning demonstrated large statistical effects. Likewise, changes in depressive symptoms evaluated at the patient level utilizing clinical significance methodology were found to be high. A significant direct process/outcome link between STPP therapist techniques and changes in depressive symptoms was observed. Alternative treatment interventions within STPP were evaluated in relation to subsequent improvements in depression and were found to be nonsignificant. The present results demonstrate that robust statistical and clinically significant improvement can occur in a naturalistic/hybrid model of outpatient STPP for depression.     

Relationships between techniques and outcomes for borderline personality disorder

Although a number of psychotherapeutic modalities for borderline personality disorder (BPD) have empirical support, it is unclear what aspects of treatment are responsible for improvement. The present study analyzes the relationships between different techniques and outcomes in a randomized controlled trial of dynamic deconstructive psychotherapy (DDP) for comorbid BPD and alcohol-use disorders. Video recordings of psychotherapy sessions at 3-month intervals were rated to measure therapeutic alliance and the relative frequencies of specific treatment interventions. Outcomes included measures of borderline symptoms, depression, dissociation, social support, alcohol misuse, parasuicide, and institutional care. Discrete sets of techniques were associated with reliable changes in specific outcomes, indicating that treatments for BPD should be tailored to the specific constellation of symptoms presenting in a given individual. The study findings suggest that treatments with a specified set of techniques, such as DDP, dialectical behavior therapy, mentalization-based treatment, schema therapy, supportive therapies, and transference-focused psychotherapy, may be helpful for different individuals, depending on their particular set of symptoms.     

Is there an optimal adjustment of interpretation to the patients' level of defensive functioning?

In this process-outcome study, we explored whether the therapists' Adjustment Ratio of interpretation would be predictive of the development of working alliance in brief dynamic psychotherapy (N = 39, max 40 sessions). Therapist interventions were rated in an early session (7th) and in the mid-phase of therapy (16th session). We found that, what was assumed to be an optimal Adjustment Ratio in relation to patients' defensive functioning, was associated with lower quality of working alliance, whereas what was assumed to be a poor Adjustment Ratio was associated with a more favorable alliance. The general finding was that when relatively more supportive interventions were given to patients with higher ODF, the working alliance was improved. Implications of the findings are discussed.     

Stressful involvement in psychotherapeutic work: Therapist, client and process correlates

Abstract We examined potential predictors of therapists' "Stressful Involvement" (SI) among variables reflecting the psychotherapy process, therapist characteristics, patients' symptom severity or context variables (treatment setting). Ninety-eight sequences from individual psychodynamic treatments conducted by 26 therapists were studied. Data were analyzed using mixed regression models. Between-therapist and within-therapist variance accounted for most of the difference in SI. SI was strongly associated with negative feelings of the therapist about patient and therapy in the time between sessions. Therapists with more 'unassertive' and 'vindictive' interpersonal styles were also more prone to experiencing SI. The strong association of SI with therapist rather than patient characteristics and process ratings indicates the importance of further study of the therapist as a person and participant in psychotherapy.     

A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder

OBJECTIVE: The purpose of this study was to determine the efficacy of panic-focused psychodynamic psychotherapy relative to applied relaxation training, a credible psychotherapy comparison condition. Despite the widespread clinical use of psychodynamic psychotherapies, randomized controlled clinical trials evaluating such psychotherapies for axis I disorders have lagged. To the authors' knowledge, this is the first efficacy randomized controlled clinical trial of panic-focused psychodynamic psychotherapy, a manualized psychoanalytical psychotherapy for patients with DSM-IV panic disorder. METHOD: This was a randomized controlled clinical trial of subjects with primary DSM-IV panic disorder. Participants were recruited over 5 years in the New York City metropolitan area. Subjects were 49 adults ages 18-55 with primary DSM-IV panic disorder. All subjects received assigned treatment, panic-focused psychodynamic psychotherapy or applied relaxation training in twice-weekly sessions for 12 weeks. The Panic Disorder Severity Scale, rated by blinded independent evaluators, was the primary outcome measure. RESULTS: Subjects in panic-focused psychodynamic psychotherapy had significantly greater reduction in severity of panic symptoms. Furthermore, those receiving panic-focused psychodynamic psychotherapy were significantly more likely to respond at treatment termination (73% versus 39%), using the Multicenter Panic Disorder Study response criteria. The secondary outcome, change in psychosocial functioning, mirrored these results. CONCLUSIONS: Despite the small cohort size of this trial, it has demonstrated preliminary efficacy of panic-focused psychodynamic psychotherapy for panic disorder.     

Changes in Object Relations in Long-Term Mentally Ill Patients Treated in a Psychiatric Day-Care Unit

Abstract

This naturalistic longitudinal study analyzed the reciprocal dependency of the helping alliance and symptom outcome over the course of mid- and long-term outpatient psychotherapy as practiced in routine care in Germany. Patient-rated helping alliance and symptom distress were assessed repeatedly over a 2-year period in a sample of 259 outpatients in psychodynamic, cognitive–behavioral, and psychoanalytic psychotherapy. Hierarchical linear models showed that initial symptom distress negatively predicted subsequent quality of the helping alliance but not vice versa. Only initial symptom distress affected symptom status at the last treatment session. These results raise doubts about the helping alliance being a strong predictor of outcome and indicate that other patient and therapist variables might be more important for treatment success.     

The negative effect of alexithymia on the outcome of group therapy for complicated grief: what role might the therapist play?

Alexithymia is a patient characteristic that reflects deficits in the cognitive processing and regulation of emotions. It is generally considered to have an adverse effect on the outcome of psychotherapy. Little is known about the processes through which alexithymia exerts this effect. One proposed mechanism suggests that patients with alexithymia trigger negative therapist reactions that contribute to poor outcome for such patients. This study examined whether therapist reactions to a patient mediate the relationship between alexithymia and outcome in group psychotherapy for complicated grief. Alexithymia was assessed with the Toronto Alexithymia Scale-20. Therapist reactions to a patient, reflecting the therapist's perceptions of a patient's positive qualities, personal compatibility, and significance as a group member, were assessed with a cohesion questionnaire. Outcome in several areas of functioning was measured. We found that alexithymia (specifically, greater difficulty in communicating feelings and greater tendency to engage in externally oriented thinking) was associated with less favorable outcome and that this relationship was mediated by therapist reactions to a patient. The mediation provided by therapist reactions to a patient accounted for approximately one third to one half of the direct effect of alexithymia on psychotherapy outcome. This suggests that therapist reactions to a patient represent a major mechanism through which alexithymia exerts its effect.