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2 Description of DT RCTs for Anxiety Disorders

2 Description of DT RCTs for Anxiety Disorders

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This chapter summarizes the empirical research on psychodynamic therapies focusing on 3 main questions: 1) what is the evidence for the efficacy of dynamic therapy? 2) what do we know about the role of the therapeutic alliance in dynamic therapy? 3) what do we know about the main mechanisms of change in dynamic therapy?

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... A possible explanation that has been offered to account for this negative association is that therapists use interpretative actions in an attempt to repair a weakened alliance (Barber, Muran, McCarthy, & Keefe, 2013). The results of the current study suggest an alternative explanation to account for this negative association, such that patients simply do not expect such interventions to take place, and hence respond negatively to their presence during sessions. ...
Article
Background: In this study, we aimed to assess the degree to which individuals with varying levels of psychotherapeutic experience have predisposed ideas regarding what works in psychotherapy. Method: Therapists (n = 107), patients (n = 97), and lay individuals with no prior experience in psychotherapy (n = 160) reported their process expectations and ranked seven mechanisms of change in the order of their perceived importance. Results: Therapists rated emotional processing and patient-therapist relations as higher in importance than did patients and lay individuals, but patients and lay individuals rated cognitive and emotional reconstruction higher than did therapists. Furthermore, therapists ranked the exploration of unconscious contents as most important, while patients and lay individuals ranked cognitive control to be the most important mechanism of change. Conclusions: Therapists, patients, and lay individuals expect different mechanisms of change to take place in psychotherapy. Limitations and directions for future research are discussed.
... Robust evidence from individual studies and meta-analyses has demonstrated that psychodynamic therapy (often referred to as insight-oriented therapy) as a whole is associated with symptomatic relief (Barber, Muran, McCarthy & Keefe, 2013;Leichsenring & Rabung, 2008). However, studies examining the effectiveness of specific expressive interventions have produced equivocal results. ...
... Studies exploring the effectiveness of psychodynamic psychotherapy and its interventions assume that their efficacy is partially mediated by heightened self-understanding (e.g. Minges, Solomonov, & Barber, 2017), but empirical investigations of this mediational assumption are scarce (see Barber et al., 2013). Several studies have reported that clients receiving dynamic therapy showed greater gains in self-understanding (or insight) than in other forms of therapy (e.g., cognitive therapy: Connolly- Gibbons et al., 2009, Kallestad et al., 2010. ...
Article
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Clients' emotional experience (EE) and self-understanding (SU) are two clients' processes thought to play a key role in many therapeutic approaches, especially psychodynamic (PD) psychotherapy. Previous studies exploring client processes and the interventions assumed to promote them have found that both processes and interventions are related to a reduction in symptoms. However, the complex associations between the use of specific interventions, clients' processes and symptomatic outcomes have rarely been investigated. Using data collected on a session-by-session basis, we explored (a) the temporal associations between clients' processes (EE and SU) and treatment outcomes (clients' level of functioning), (b) the associations between therapists' AF and PD interventions and clients' processes, and (c) the direct and indirect associations among therapists' interventions, clients' processes, and clients' functioning. Clients (N = 115) undergoing PD psychotherapy reported their general functioning presession using the Outcome Rating Scale, and their EE and SU postsession using the Emotional Experience Self-Report and Self-Understanding Scale, respectively. Therapists reported their use of interventions postsession using the Multitheoretical List of Interventions. Longitudinal multilevel models indicated that higher EE and SU scores predicted subsequent change in functioning. Moderate (vs. high or low) use of AF interventions predicted an increase in clients' EE. Greater use of PD interventions predicted an increase in clients' SU, which also mediated improvement in functioning. These findings highlight the importance of adjusting therapists' use of interventions to promote clients' therapeutic processes and outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
... Several studies have viewed mentalization as a treatment outcome variable and focused on a comparison of 'brand-name' therapies (Barber et al., 2013); however, process research seeks to understand qualitatively what essential factors comprise these brand-name therapies. Few studies to date have studied mentalization as a fluid process of psychotherapy over time (Goodman, Reed & Athey-Lloyd, 2015). ...
Article
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Mentalization has been considered a common factor across therapeutic processes, inherent to all effective treatment models. However, empirical findings and evidence about the presence and relevance of the construct for use in child psychodynamic psychotherapy processes are scarce. To contribute to filling this gap, the aim of this study was to analyse three children's psychotherapies in regards to the similarity of the treatments to the mentalization process prototype. This study is exploratory, longitudinal and descriptive, and is based on the systematic case studies procedure. Three school‐age children and their therapists participated. Two hundred and seventy‐three sessions were coded with the Child Psychotherapy Process Q‐Set and analysed according to their similarity to the mentalization process prototype. The results showed that it was possible to identify the presence of elements based on the mentalization approach in child psychodynamic psychotherapy. In addition, the presence of the therapist's mentalizing attitudes was associated with increased feelings of security and a greater connection of emotions to experiences. The results corroborated the propositions that enhancing mentalization is an implicit process in child psychodynamic psychotherapy, and suggested the importance of acknowledging and understanding the essential elements that compose the treatment models.
... These interventions are frequently applied in psychodynamic psychotherapy (Wöller & Kruse, 2015) and operate on the supportive-expressive continuum of psychodynamic interventions (Luborsky, 1984). The supportive-expressive concept of psychodynamic interventions is empirically based on the data of the psychotherapy research project of the Menninger Foundation (Wallerstein, 1989) and is widely viewed as a core concept of psychodynamic psychotherapy (Barber, Muran, McCarthy, & Keefe, 2013). Interpretive interventions aim to enhance patients' insight into conflict patterns sustaining their problems (Leichsenring, Hiller, Weissberg, & Leibing, 2006;Luborsky, 1984). ...
Background Innovative teaching models promoting beneficial therapist behaviour are central to the improvement of psychotherapeutic practice. This study investigated the effects of peer role‐play (RP) and standardised patients (SP) in the context of an intervention skill training course during psychodynamic psychotherapy training. Methods In a mixed‐method approach, effects of intervention training with RP and SP on trainees’ self‐efficacy and intervention use during treatment were investigated using trainees’ self‐report questionnaires, qualitative interviews and psychotherapy session observer ratings. Twenty graduate psychotherapy students (17 female; mean age 36 years) participated in an intervention skill seminar. We assessed subjective ratings of intervention competence before and after training as well as acceptance of the training format. For a subsample of 11 participants, we examined changes in frequency and competency of intervention use with session‐based observer ratings during their current outpatient treatments. Furthermore, 10 participants reflected on their training experiences in open interviews, evaluated using inductive content analysis. Findings The trainees’ self‐efficacy for the trained interventions increased significantly after training. The training was well accepted and subjectively associated with learning success. Training transfer effects were observed regarding higher frequency and competence in the domain of clarifying and mirroring interventions during participants’ outpatient psychotherapy sessions. Qualitative analysis showed training effects for self‐reflection regarding intervention use, while also promoting the development of therapeutic self‐understanding. Conclusion Our findings provide further evidence that RP and SP training can assist the development of psychotherapy skills. Hence, the regular implementation of RP and SP training during graduate psychotherapy training seems feasible.
... When working on painful issues, adequate interventions might result in more unstable defenses and increased symptoms. In such periods, the therapist's task is to help the patient to process the emerging feelings without fearing the patient's strong reactions, being there for the patient in charged moments (Barber et al., 2013). In less successful cases, the patients did not experience such help. ...
Article
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Despite the general effectiveness of bona fide psychotherapies, the number of patients who deteriorate or fail to improve is still problematic. Furthermore, there is an increased awareness in the field that the therapists’ individual skills make a significant contribution to the variance in outcome. While some therapists are generally more successful than others, most therapists have experienced both therapeutic success and failure in different cases. The aim of this case-series study was to deepen our understanding of what matters for the therapists’ success in some cases, whereas other patients do not improve. How do the patients and their therapists make sense of and reflect on their therapy experiences in most successful and unsuccessful cases? Are there any distinctive features experienced by the participants at the outset of treatment? To explore these issues, we applied a mixed-method design. Trying to keep the therapist factor constant, we selected contrasting cases from the caseloads of three therapists, following the criterion of reliable and clinically significant symptom reduction or non-improvement at termination. Transcripts of 12 patient interviews and 12 therapist interviews (at baseline and at termination) were analyzed, applying inductive thematic analysis and the multiple-case comparison method. The comparisons within the three therapists’ caseloads revealed that in the successful cases the patient and the therapist shared a common understanding of the presenting problems and the goals of therapy and experienced the therapeutic relationship as both supportive and challenging. Furthermore, the therapists adjusted their way of working to their patients’ needs. In non-improved cases, the participants presented diverging views of the therapeutic process and outcome. The therapists described difficulties in the therapeutic collaboration but not how they dealt with obstacles. They tended to disregard their own role in the interactions and to explain difficulties as being caused by the nature of their patients’ problems. This could indicate that the therapists had difficulty in reflecting on their own contributions, accepting feedback from their patients, and adjusting their work accordingly. These within-therapist differences indicate that taking a “third position” is most needed and seems to be most difficult, when early signs of a lack of therapeutic progress appear.
... Panic-Specific Reflective Function. Mentalization or in its operationalized term-Reflective Function (RF)-has been identified as a potential mechanism of change in psychotherapy (Bateman & Fonagy, 2012; see Barber, Muran, McCarthy, & Keefe, 2013 for a review). RF is defined as the capacity to understand and interpret-implicitly and explicitly -one's own and others' behaviors as an expression of mental states such as feelings, thoughts, fantasies, beliefs and desires (Fonagy, Gergely, Jurist, & Target, 2002). ...
Article
Objective: To examine whether working alliance quality and use of techniques predict improvement in Panic-Specific Reflection Function (PSRF), and misinterpretation of bodily sensations in treatments for panic disorder. Method: A sample of 161 patients received either CBT or PFPP (Panic-focused Psychodynamic therapy) within a larger RCT. Data were collected on patient-reported working alliance, misinterpretations, PSRF, observer-coded use of techniques, and interviewer-rated panic severity. Random-Intercept Cross-Lagged Panel Models assessed bi-directional associations, disentangling within- and between-patient effects, and accounting for prior change. Results: Higher alliance predicted subsequent within-patient improvement in PSRF in PFPP, but worsening in CBT. In both treatments, focus on interpersonal relationships predicted PRSF improvement (with stronger effects in CBT), while focus on thoughts and behaviors predicted worsening in PSRF. In CBT only, early focus on affect and moment-to-moment experience predicted reduced misinterpretation, while high focus on thoughts and cognitions predicted subsequent increase in misinterpretation. Conclusion: The quality of the alliance has differential effects on PSRF in distinct treatments. Interpersonal, rather than cognitive or behavioral focus, even when delivered differently within distinct treatments with high adherence, could facilitate improvement in PSRF. Additionally, early focus on affect and moment-to-moment experiences in CBT could reduce misinterpretations.
... Moreover, change seems to occur by allowing dissociated self-states to be acknowledged and negotiated in the relational therapeutic context. Therefore, a key element in achieving effective psychotherapeutic treatment may be the consideration and evaluation of processes occurring between patient and therapist (Barber et al., 2013;Bromberg, 1998;Safran & Muran, 2000). ...
Article
The current study presents an integrative mixed-method examination of a single case using the TPA, or the Two-Person Assimilation of Problematic Experiences Scale (APES). Stemming from the Assimilation Model (Stiles, 2011; Stiles et al., 1991), the TPA integrates relational-psychodynamic thought with an empirical analysis to create a clinical tool that simultaneously tracks and codes change-processes in psychotherapy. The TPA expands the APES by following changes in the quality of movement between self-states, in a continuum ranging from dissociation to dialectic, within both the patient and the therapist. Thus, it allows for an observation of complex intrapsychic and intersubjective processes occurring in therapy, and a simultaneous relating of these processes to symptomatic outcome variables and process variables. The current theory-building case study investigated 26 therapy sessions of a 30-year-old woman who received an evidence-informed psychodynamic-oriented treatment for depression. Sessions were coded quantitatively and then qualitatively analyzed by clinical judges, using the TPA tracking and rating procedure. An improvement in the quality of movement between self-states, as the therapeutic process progressed, was found. In addition, mutual changing (i.e., temporal congruence) between patient’s and therapist’s quality of movement between self-states increased during the last third of the treatment. Results of the study have clinical and empirical implications for an understanding of how therapeutic change is generated, as a process occurring both intrapsychically and in the context of a dyadic intersubjective relationship.
... Although warranting additional research, these findings indicate that interpretations of interpersonal issues between the therapist and the client can be unexpected events that transpire during sessions. Although transference interpretations are considered to be one of the central processes of psychodynamic therapy, previous studies assessing clients' responses towards verbal interpretations of transference have yielded inconclusive findings, and some have demonstrated a negative response to transference interpretations (Barber et al., 2013). Several studies reported a negative association between frequency of transference interpretations and outcome (Connolly et al., 1999;Høglend, 1993;Ogrodniczuk et al., 2000;Piper et al., 1991), especially in clients with more mature object relations (Hersoug et al., 2014). ...
Article
Despite accumulating theoretical and empirical knowledge in the field of process research in psychotherapy, not much is known about individuals' expectations of the mechanisms that produce change in psychotherapy. In this article we present the Expectations of Active Processes in Psychotherapy Scale (EAPPS), aimed to assess and quantify psychotherapy process expectations derived from current process constructs. Two studies with a total of 381 participants were conducted in order to assess the scale factor structure, reliability, and validity. Exploratory factor analysis indicated a seven-factor structure, which consisted of dimensions related to the patient-therapist relationship, the secure exploration of sensitive personal contents, and specific functions of the therapeutic process. The derived factors were found to have satisfactory internal consistency and test-retest reliability, and were correlated with clinically relevant variables as well as other expectations scales, thus supporting the scale's convergent validity. The EAPPS can allow an in-depth examination of the effects of psychotherapy process expectations on therapy outcomes, as well as their mediating effects through patients' ongoing evaluations of the therapeutic process.
... Given that psychodynamic, cognitive-behavioral, and humanistic therapies could operate through different mechanisms, it is important to examine a more homogenous range of treatment. It makes sense to study psychodynamic techniques because of the rich history of psychodynamic therapy dating back to the time of Freud, and because of the evidence supporting the effectiveness of psychodynamic psychotherapy (Barber, Muran, McCarthy, & Keefe, 2013). ...
Article
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.
... Despite the data supporting the efficacy of these existing treatments (e.g., Barber, Muran, McCarthy, & Keefe, 2013), effects tend to be small and particularly unstable in the longer term (Cristea et al., 2017). PD patients are notoriously hard to treat because, in addition to the within-diagnosis heterogeneity and comorbidities, they often have histories of complex trauma that lead to insecure attachment patterns and to earlier dropout (Barnicot et al., 2012). ...
Article
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Personality disorders (PDs) come in a large variety of presentations, severely affect the individual's social and emotional functioning, and are notoriously complex to treat. To make treatments for individuals with PDs more potent, there is a need to better understand how and why these treatments work. The articles assembled for this special section propose potential mechanisms of change within PD patients that may be addressed in future process-outcome research. Although the studies are exploratory and were limited by their scope and heterogeneity of their samples, they illustrate the importance of process research as nomothetic and idiographic building blocks toward a multifaceted understanding of change processes in PDs and their treatment. In this discussion, the authors aim to foster interest in the potential mechanisms of change in PD treatments and inspire further research by providing several methodological considerations for future process-outcome research and its potential clinical implications.