Chapter

Barber, J. P., Muran, J.C., McCarthy, K.S., Keefe, R.J. (2013). Research on Psychodynamic Therapies. In M. J. Lambert (Ed.). Bergin and Garfield's Handbook of Psychotherapy and Behavior Change (6th ed.) (pp. 443-494). New-York, NY: John Wiley & Sons, Inc.

January 2013

In book: Bergin and Garfield's Handbook of Psychotherapy and Behavior Change (pp.443-494)
Chapter: Research on Psychodynamic Therapies
Publisher: John Wiley & Sons
Editors: MJ Lambert

Authors:

Jacques Barber

Adelphi University

Kevin Mccarthy

Chestnut Hill College

Jack R Keefe

Long Island University

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?

Measuring working alliance and technical alliance from the perspective of healthcare professionals working with people with mild intellectual disabilities: adaptation, factor structure and reliability

Article

Full-text available

Nov 2022
J INTELL DISABIL RES

Background The establishment of a valuable and meaningful working alliance between people with mild intellectual disabilities (IDs) and healthcare professionals is critically important for improving both the quality of life and impact of therapy for people with mild IDs. Measuring the working alliance as a treatment or support component is therefore of utmost relevance. In light of the increased use of eHealth tools, it is also essential to measure the alliance using these tools, which is referred to as technical alliance. There was a lack of validation of these two measurements for healthcare professionals working with people with mild IDs, which this study sought to address. Method Both the validated Working Alliance Inventory – Short Form – MID (WAI-SF-MID) and Technical Alliance Inventory – Short Form – MID (TAI-SF-MID) for general patient populations were adapted for healthcare professionals working with people with mild IDs. A two-step approach was conducted to systematically adapt both measurements with an expert group of healthcare professionals. Confirmatory factor analysis was conducted to test a three-factor structure for both the WAI-SF-MID (N = 199) and the TAI-SF-MID (N = 139), and internal consistency was determined for both scales. Results An acceptable-to-good model fit was found for both the WAI-SF-MID and the TAI-SF-MID; confirmatory factor analysis confirmed a three-factor model for both measurements. Cronbach’s alpha and McDonald’s omega were excellent for both total scales (≥0.90) and acceptable to good for sub-scales of both versions. Conclusion Both the WAI-SF-MID and the TAI-SFMID are promising measurements for determining healthcare professionals’ perspective on the (digital) working alliance with people with mild IDs.

Psychodynamic Psychotherapies

Chapter

May 2017

Psychodynamic psychotherapies (PDP) is an umbrella term for a variety of therapeutic modalities that have evolved out of the psychoanalytic/psychodynamic tradition, each theorizing a trajectory of human development that includes an etiology of and treatment for psychopathology. PDPs have in common the belief that people have an unconscious mind that influences thoughts and behaviors outside of the individual’s awareness. These processes operate from birth till death and are responsible for adaptive and maladaptive functioning at the level of interpersonal relationships and daily living. The psychodynamic therapist creates a case formulation for the individual seeking treatment, which incorporates a formal diagnosis with an understanding of the underlying dynamic factors contributing to the individual’s suffering. From this case formulation a treatment plan is created specific to the individual. During treatment, the therapist develops a strong working alliance while utilizing psychodynamic-specific techniques targeted at bringing insight into these unconscious thoughts and behaviors. Greater self-understanding enables greater choice ability and flexibility in functioning. In contrast to prevalent views, empirical research has found support for the efficacy of PDP in the treatment of mental disorders, including but not limited to: depression, anxiety disorders, somatic disorders, and personality disorders. In general, PDP was found more effective than control conditions and not different from active treatments. PDP effects have been shown to remain stable post treatment.

Psychodynamic Therapy: Short-Term

Article

Dec 2015

Short-term dynamic therapy (STDP) comprises a group of interventions based on psychoanalytic principles that have been adapted for use in treatments of limited duration. The prototypic definition of STPD includes the following aspects: the theory of psychopathology explaining the disorder and treatment techniques employed (e.g., clarification, interpretation, and confrontation) that are psychoanalytic in origin; the selection of patients on the basis of their ability to withstand intensive psychotherapy; treatment that is time-limited and focused on a specific issue or conflict; and treatment aimed to provide symptom relief or limited personality or character change. STPD was developed by a subgroup of psychoanalysts who were trying to increase the efficiency of psychodynamic therapy, to bring its power to short-term settings (seeing patients once or twice a week, sitting up), and therefore to make the treatment available to a potentially broader group of patients. Subsequent changes in health care financing and reimbursement and increased awareness of data supporting its efficacy have driven increased interest in STDP.

"If those tears could talk, what would they say?" Multi-method analysis of a corrective experience in brief dynamic therapy

Article

May 2016
PSYCHOTHER RES

We analyzed master theorist/therapist Hanna Levenson's six-session work with "Ann" in American Psychological Association's Theories of Psychotherapy video series to determine if and how this client had a corrective experience in Brief Dynamic Therapy. First, we identified indicators of a corrective experience in the therapist's and client's own words. Complementing this analysis, we used observational coding to identify, moment by moment, narrative-emotion markers of shifts in Ann's "same old story"; the frequency, type, and depth of immediacy; and the client's and therapist's behavioral contributions to the working alliance. Additionally, we qualitatively analyzed Levenson's session-by-session accounts of the therapy from two sources. Convergent evidence from these multi-method analyses suggested how the intertwined relational and technical change processes seemed to bring about this client's corrective experience. Through consistent attention to the alliance and increasingly deep immediacy, Levenson created a safe space for Ann to "bring down the wall"-by allowing herself to cry and be deeply understood and cared for in a way that she had never before experienced. Concurrently, Ann began seeing herself quite differently, signified by self-identity narrative change. Then, following Session 4, she took Levenson's suggestion to risk behaving more authentically with a friend and with her romantic partner.

The efficacy of short-term psychodynamic psychotherapy for depression: A meta-analysis update

Article

Dec 2015
CLIN PSYCHOL REV

Acceptance and Commitment Therapy (ACT) Informed Coaching: Examining Outcomes and Mechanisms of Change

Thesis

Full-text available

Jan 2018

Rachael Skews

This thesis presents a programme of research designed to examine the impact of Acceptance and Commitment Therapy (ACT) informed performance and development coaching. A preliminary repeated measures study tested the impact of a brief ACT-informed coaching intervention on coachee general mental health, generalised self-efficacy, life satisfaction, intrinsic motivation, goal-directed thinking, goal attainment, and psychological flexibility with 53 UK adults. Data were collected at four time points over 5 weeks. Analyses revealed significant increases in general mental health, life satisfaction, goal-directed thinking, and goal attainment. A randomised controlled trial (RCT) study tested the impact of a more substantial ACT-informed coaching intervention on coachee work performance, general mental health, generalised self-efficacy, job satisfaction, job motivation, goal- directed thinking, goal attainment, and psychological flexibility with 126 senior managers in the UK Civil Service. Participants were randomly allocated to either an ACT-informed coaching intervention (n = 65) or a waitlist control condition (n = 61). Data were collected at four time points over 13 weeks. Analyses showed significant increases in general mental health, generalised self-efficacy, goal-directed thinking, goal attainment, and psychological flexibility in the ACT group compared to the control condition. Consistent with ACT theory, analyses indicated that increases in psychological flexibility mediated improvements in general mental health, generalised self-efficacy, goal-directed thinking, and goal attainment. A final parallel mediation study compared the effects of psychological flexibility and working alliance (a plausible alternative mediator) using data from the coaching arm of the RCT study. These analyses revealed that significant increases in psychological flexibility mediated increases in generalised self-efficacy, goal-directed thinking, and goal attainment. Despite significant increases in working alliance over time, no mediation effects for increases in study variables were found. Overall, findings suggest that ACT-informed coaching is an effective approach to performance and development coaching, and psychological flexibility mediates the beneficial impact of the ACT coaching intervention.

Therapists’ Interventions as a Predictor of Clients’ Emotional Experience, Self-Understanding, and Treatment Outcomes

Article

Full-text available

Aug 2019

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).

Psychotherapie

Article

Jan 2019

Mark Helle

Dieses Lehrbuch stellt die zentralen Modelle und Konzepte der Psychotherapie vor und vermittelt einen kompakten Überblick über das nötige Grundlagenwissen: Was ist Psychotherapie? Welche Ansätze gibt es? Wie steht es um deren Wirksamkeit? Neben den Grundlagen werden konkrete psychotherapeutische Behandlungsprozesse anhand ausgewählter Fallbeispiele anschaulich gemacht. Außerdem gibt es Anregungen für die Vertiefung ausgewählter Themengebiete. Der Inhalt • Geschichte der Psychotherapie • Psychodynamische Verfahren • Humanistische Psychologie und Humanistische Psychotherapie • Systemische Therapie • Verhaltenstherapie • Forschung in der Psychotherapie • Berufs- und sozialrechtliche Grundlagen der Psychotherapie Die Zielgruppen Studierende und Lehrende der Psychologie, der Medizin sowie sozial- und gesundheitswissenschaftlicher Fächer Der Autor Dr. Mark Helle ist Professor für Klinische Psychologie an der Hochschule Magdeburg-Stendal und praktizierender Psychotherapeut.

Humanistische Psychologie und Humanistische Psychotherapie

Chapter

May 2019

Mark Helle

Ausgangspunkt bildet zunächst die Klärung des Begriffs „Humanismus“. Es folgen Ausführungen zur Humanistischen Psychologie als sog. Dritte Kraft. Ferner wird der Einfluss der beiden philosophischen Strömungen „Existenzphilosophie“ und „Phänomenologie“ auf die Humanistische Psychologie herausgearbeitet. Es werden das Menschenbild und das daraus abgeleitete Störungsverständnis der Humanistischen Psychologie erläutert, um dann, im zweiten Teil dieses Kapitels, ausgehend von C. Rogers, die Gesprächspsychotherapie und ihre Weiterentwicklungen mit „Focusing“ nach Gendlin, „Emotionsfokussierte Therapie“ nach Greenberg und „Prätherapie“ nach Prouty vorzustellen. Mit der Gestalttherapie nach F. Perls und der Logotherapie nach V. Frankl werden zwei weitere ausgewählte Vertreter und deren therapeutische Ansätze beschrieben. Das Kapitel endet mit Ausführungen zur Wirksamkeit der humanistisch-psychotherapeutischen Verfahren.

Systemische Therapie

Chapter

May 2019

Mark Helle

Ausgangspunkt dieses Kapitels bilden die ersten familientherapeutischen Ansätze in den USA der 1950er-Jahre. Es schließt sich eine Übersicht an, in der die verschiedenen systemtheoretischen Grundlagen, die sich wahlweise der Kybernetik 1. Ordnung und ab den 1980er-Jahren der Kybernetik 2. Ordnung zuordnen lassen. Es folgt eine Einführung in die Grundlagen der Systemischen Therapie. Hier werden das Menschenbild, die ätiologischen Grundannahmen und das Verständnis der therapeutischen Grundhaltungen beschrieben. Das Unterkapitel „Praxis der Systemischen Therapie“ vermittelt eine Übersicht über das reichhaltige Methodenrepertoire. Diese Ausführungen schließen mit einer Fallvignette. Zum Ende des Kapitels wird der Frage der Wirksamkeit vor dem Hintergrund des aktuellen Forschungsstands nachgegangen und ein Ausblick in die Zukunft der Systemischen Therapie gewagt. Ein besonderer Fokus wird hier auf die Vor- und Nachteile einer Integration in das Gesundheitssystem gelegt.

Psychotherapie in Deutschland

Chapter

May 2019

Mark Helle

Die Berufe des Psychologischen Psychotherapeuten und Kinder- und Jugendlichenpsychotherapeuten wurden mit der Verabschiedung des Psychotherapeutengesetzes im Jahre 1998 geschaffen und sind von daher recht neue Errungenschaften. Zunächst werden die berufsrechtlichen Grundlagen dieser beiden Berufe erläutert, um sie dann gegenüber den ärztlichen Psychotherapeuten und den Heilpraktikern abzugrenzen. Es schließen sich Ausführungen zur Psychotherapie als kassenärztliche Leistung an. Es wird ein historischer Einblick in die Aufnahme der Psychotherapie in den Leistungskatalog der gesetzlichen Krankenkasse gegeben. Zudem werden die drei unterschiedlichen psychotherapeutischen Kategorien „Psychotherapieverfahren“, „Psychotherapiemethoden“ und „psychotherapeutische Techniken“ erläutert. Das Kapitel schließt mit der kritischen Feststellung, dass durch die sozialrechtlichen Regelungen die berufsrechtlich gegebene psychotherapeutische Vielfalt aktuell und langfristig bedroht ist.

Psychodynamische Verfahren

Chapter

May 2019

Mark Helle

Im Zentrum dieses Kapitels stehen zunächst die theoretischen Beiträge Sigmund Freuds. Es folgt die Darstellung der weiteren zentralen psychodynamischen Strömungen, nämlich der Ich-Psychologie, Objektbeziehungstheorie und Selbstpsychologie. Unter der Überschrift „Neuere Entwicklungen“ werden die beiden Ansätze „Theorie der Intersubjektivität“ und „Relationale Psychoanalyse“ beschrieben. Ferner werden die Grundlagen der mentalisierungsbasierten Psychotherapie vermittelt. Um einen Einblick in die Breite und Heterogenität der psychodynamischen Verfahren zu geben, werden einige Schüler Freuds und deren therapeutische Ansätze vorgestellt. Es folgen Ausführungen zur Operationalisierten Diagnostik (OPD), wobei ein Schwerpunkt auf die Unterscheidung zwischen Konflikt- und Strukturpathologie gelegt wird. Das Kapitel schließt mit der Darstellung der Rahmenbedingungen psychodynamischer Verfahren in der kassenärztlichen Versorgung sowie der aktuellen Einschätzung der Wirksamkeit.

Psychotherapie: Von den Anfängen bis heute

Chapter

May 2019

Mark Helle

Ausgangspunkt bilden die zentralen Fragen, was Psychotherapie nach unserem heutigen Verständnis kennzeichnet und wann der Beginn der modernen Psychotherapie anzusetzen ist. Ausgehend von der Tatsache, dass psychisch abweichendes Verhalten die Menschheit schon immer begleitet hat, wird herausgearbeitet, dass eben so lang die unterschiedlichsten Interventionsformen existieren, um diese Abweichungen zu beeinflussen. Der faktische Beginn der modernen Psychotherapie ist im Grunde nicht eindeutig festzulegen, vielmehr handelt es sich immer um eine Rekonstruktion. Moderne Psychotherapie lässt sich daher weniger anhand konkreter Interventionen, sondern eher über deren zugrundeliegende psychologische Erklärungsansätze definieren. Das Kapitel endet mit einem Blick auf die heute bestehende Vielfalt, die sich in die vier Grundorientierungen „psychodynamische Verfahren“, „systemische Verfahren“, „humanistisch-psychologische Verfahren“ und „kognitiv-behaviorale Verfahren“ unterteilen lässt.

Forschung in der Psychotherapie

Chapter

May 2019

Mark Helle

Dieses Kapitel gibt einen Überblick, welchen Beitrag die Forschung zum aktuellen Verständnis von Psychotherapie leisten konnte und welche Antworten die Psychotherapieforschung auf ausstehende Fragen zu geben hat. Ausgangspunkt bildet eine historische Perspektive auf die Entwicklung der Psychotherapieforschung anhand ausgewählter Forschungsbeiträge. Im zweiten Teil wird geprüft, welche Ergebnisse die Psychotherapieforschung zu zentralen Fragen, wie Therapiedauer, Merkmale eines guten Psychotherapeuten, Verschlechterungen und Nebenwirkungen einer Psychotherapie, beitragen kann. Zum Abschluss findet eine kritische Zusammenfassung statt, aus der hervorgeht, dass die Inhalte und Methoden der Psychotherapieforschung nicht ausschließlich von einem reinen Erkenntnisinteresse geleitet, sondern von Professionalisierungsbestrebungen und Marktorientierung beeinflusst sind. Das Kapitel schließt mit einem Ausblick auf für die Psychotherapieforschung wünschenswerte Weiterentwicklungen.

Verhaltenstherapie

Chapter

May 2019

Mark Helle

Ausgangspunkt bildet die historische Entwicklung der Verhaltenstherapie, die in drei Phasen bzw. Wellen unterteilt wird. Während in der 1. Welle Erkenntnisse des Behaviorismus erstmalig in den klinischen Kontext übertragen wurden, ist die 2. Welle von einem Fokus auf kognitive Phänomene gekennzeichnet und in der 3. Welle stehen achtsamkeitsbasierte Techniken und akzeptanzbasierte Strategien im Vordergrund. Diese drei Strömungen bilden heute das Gerüst, aus dem sich die Verhaltenstherapie mit all ihrer Heterogenität formt. Es folgen Ausführungen zur Diagnostik, wobei ein besonderes Augenmerk auf die horizontale und vertikale Verhaltensanalyse gelegt wird.

Investigating the Mutual Changing of Patient's and Therapist's Self-States: An Integrative Clinical Research Study of a Single Case

Article

Full-text available

Dec 2018

Investigación del cambio mutuo de los estados del self del paciente y del terapeuta: Un estudio de investigación clínica integradora de un caso único El presente estudio presenta un examen integrador de método mixto de un solo caso utilizando la TPA, o la Escala de asimilación de experiencias problemáticas de dos personas (APES). A partir del modelo de asimilación (Stiles, 2011; Stiles et al., 1991), el TPA integra el pensamiento relacional-psicodinámico con un análisis empírico para crear una herramienta clínica que rastrea y codifica simultáneamente los procesos de cambio en psicoterapia. El TPA expande el APES siguiendo los cambios en la calidad del movimiento entre los estados del self, en un continuo que va desde la disociación a la dialéctica, tanto dentro del paciente como del terapeuta. Por lo tanto, permite una observación de los procesos intrapsíquicos e intersubjetivos complejos que ocurren en la terapia, y una relación simultánea de estos procesos con las variables de resultado sintomáticas y las variables de proceso. El estudio de caso actual investigó 26 sesiones de terapia de una mujer de 30 años que recibió un tratamiento orientado psicodinámicamente basado en evidencia para la depresión. Las sesiones se codificaron cuantitativamente y luego los jueces clínicos las analizaron cualitativamente, utilizando el procedimiento de seguimiento y calificación de TPA. Se encontró una mejora en la calidad del movimiento entre estados del self, a medida que avanzaba el proceso terapéutico. Además, el cambio mutuo (es decir, la congruencia temporal) entre la calidad del movimiento del paciente y del terapeuta entre los estados del self aumentó durante el último tercio del tratamiento. Los resultados del estudio tienen implicaciones clínicas y empíricas para comprender cómo se genera el cambio terapéutico, como un proceso que ocurre tanto intrapsíquicamente como en el contexto de una relación intersubjetiva diádica.

Exploring therapeutic action in psychoanalytic psychotherapy: Attachment to therapist and change

Thesis

Full-text available

Nov 2014

Peter Lilliengren

There are several theoretical notions of how psychoanalytic psychotherapy work, but only limited empirical evidence to support any of them. The overall aim of this thesis was to explore therapeutic action in psychoanalytic psychotherapy from different perspectives (patient, therapist, and observer), using different methodological approaches (qualitative and quantitative). Study I explores 22 young adult patients’ views of therapeutic action with qualitative, grounded theory methodology. The analysis resulted in a conceptual model indicating that talking openly in the context of a safe therapeutic relationship led to new relational experiences and expanding self-awareness. Hindering factors included difficulties “opening up”, experiencing the therapist as too passive and that something was missing in therapy, leading to an experience of mismatch. Study II investigates 16 experienced therapists’ views of therapeutic action. The results indicated that the development of a close, safe and trusting relationship was perceived as the core curative factor. This interacted with the patient making positive experiences outside the therapy setting and the therapist challenging the patients’ thinking about the self. Patients’ fears about close relationships emerged as the sole hindering factor from the therapists’ perspective, perceived as creating distance in the therapeutic relationship and leading to maintenance of patients’ problems. The results of study I and II suggest that the quality of patients’ attachment to their therapist may be important for treatment process and outcome. In order to examine attachment to therapist using quantitative methodology, a new observer-rating scale (Patient Attachment to Therapist Rating Scale; PAT-RS) was developed. Study III involves an initial examination of the psychometric properties of PAT-RS. Three raters rated a total of 70 interviews. The results indicated good inter-rater reliability for three of the subscales (Security, ICC = .74; Deactivation, ICC = .62; Disorganization, ICC = .74), while one had poor (Hyperactivation, ICC = .34). Correlations with measures of the therapeutic alliance, mental representations, and symptom distress were moderate and in the in the expected directions, suggesting construct validity for the reliable subscales. Study IV investigates the relationships between secure attachment to therapist, patient-rated alliance and outcome. A series of linear mixed-effects models, controlling for between-therapist variability and length of therapy, indicated that secure attachment to therapist at termination was related to improvements in symptoms, global functioning and interpersonal problems. The relationships with symptom change and increased functioning was maintained after the therapeutic alliance was accounted for. Further, a suppression effect was found, indicating that secure attachment to therapist at termination predicted continued improvement in functioning during follow-up, whereas the alliance predicted deterioration when both variables were modeled together. The overall result of this thesis indicates that the development of a secure attachment to the therapist may be an important mechanism of change in psychoanalytic psychotherapy. This is discussed in relation to common and specific factors in psychotherapy, as well as in established theoretical notions of therapeutic action in the psychoanalytic discourse. Implications for the measurement of secure attachment to therapist and its differentiation from the therapeutic alliance are considered. Based on the results, two tentative process models that may be useful for clinical practice and future research are proposed: a broaden-and-built cycle of attachment security development and change and a react-and-disconnect cycle of attachment insecurity maintenance. Future research should investigate the temporal development of attachment to therapist and its relation to the therapeutic alliance and outcome more closely. Specific strategies that foster a secure attachment to therapist, as well as interventions for dissolving insecure strategies, should be identified and integrated in the theory and practice of psychoanalytic psychotherapy.

Supportive-Expressive Dynamic Psychotherapy

Chapter

Full-text available

Apr 2017

Combining pharmacotherapy and psychotherapy or monotherapy for major depression? A meta-analysis on the long-term effects

Article

Jan 2016

Background: The present meta-analysis aimed to examine to what extent combined pharmacotherapy with psychotherapy results in a different response to treatment compared to psychotherapy or pharmacotherapy alone in adults with major depression at six months or longer postrandomization. Methods: A systematic literature search resulted in 23 randomized controlled trials with 2184 participants. Combined treatment was compared to either psychotherapy or anti-depressant medication alone in both the acute phase and the maintenance phase. Odds ratios of a positive outcome were calculated for all comparisons. Results: In acute phase treatment, combined psychotherapy with antidepressants outperformed antidepressants alone at six months or longer postrandomization in patients with major depressive disorder (OR=2.93, 95%CI 2.15-3.99, p<0.001). Heterogeneity was zero (95%CI 0-57%, p>0.05). However, combined therapy resulted in equal response to treatment compared to psychotherapy alone at six months or longer postrandomization. As for the maintenance treatment, combined maintenance psychotherapy with antidepressants resulted in better-sustained treatment response compared to antidepressants at six months or longer postrandomization (OR=1.61, 95%CI 1.14-2.27, p<0.05). Heterogeneity was zero (95%CI 0-68%, p>0.05). Conclusions: Combined therapy results in a superior enduring effect compared to antidepressants alone in patients with major depression. Psychotherapy is an adequate alternative for combined treatment in the acute phase as it is as effective as combined treatment in the long-term.

Changes in causal attributions and relationship representations: Are they specific or common mechanisms in the treatment of depression?

Article

Dec 2015

Background: The goal of the study was to examine two central theory-driven mechanisms of change, causal attributions and relational representations, to account for symptomatic improvement in psychodynamic treatment and supportive clinical management, combined with either pharmacotherapy or placebo, in a randomized control trial (RCT) for depression. Method: We used data from an RCT for depression, which reported non-significant differences in outcome among patients (N=149) who received supportive-expressive psychotherapy (SET), clinical management combined with pharmacotherapy (CM+MED), or clinical management with placebo pill (CM+PBO) (Barber et al., 2012). Mechanism and outcome measures were administered at intake, mid-treatment, end of treatment, and at a 4-month follow-up. Results: Improvements in causal attributions and in relational representations were found across treatments. Changes in causal attributions did not predict subsequent symptomatic level when controlling for prior symptomatic level. In contrast, decrease in negative relational representations predicted subsequent symptom reduction across all treatments, and increase in positive relational representations predicted subsequent symptom reduction only in SET. Limitations: The study is limited by its moderate sample size. Additional studies are needed to examine the same questions using additional treatment orientations, such as cognitive treatments. Conclusions: Findings demonstrate that changes in negative relational representations may act as a common mechanism of change and precede symptom reduction across psychodynamic therapy and supportive case management combined with either pharmacotherapy or placebo, whereas an increase in positive relational representation may be a mechanism of change specific to psychodynamic therapy.

Adhesion and dropout in psychoanalytic psychotherapy from the perspective of adolescents

Article

Apr 2022
Psicolog Clin

There are several factors associated with the high dropout rates in adolescent psychotherapy, but there are only a few studies that address this topic from these patients' perspective. This study aimed to analyze, based on adolescents' view, reasons that made them dropout or remain in psychoanalytic psychotherapy. A qualitative, exploratory and cross-sectional study was conducted. In it, 23 adolescents with an indication of psychoanalytic psychotherapy took part. After seven months, on average, 12 remained on treatment and 11 interrupted. An individual and semi-structured interview was conducted with each participant and subsequently the data was analyzed based on the thematic analysis method. Two themes were identified in the group that remained in psychotherapy: 'Therapeutic Relationship' and 'Changes Resulting from Psychotherapy', and three themes in the interviews of the group that dropped out: 'Therapeutic Relationship', 'Adolescent Defenses and Resistances' and 'Therapeutic Alliance with Those in Charge'. The results point to the centrality of therapeutic relationship in young people's experience, as well as the importance of keeping a good alliance with parents in order to remain in psychotherapy.

Process expectations: Differences between therapists, patients, and lay individuals in their views of what works in psychotherapy

Article

Oct 2019

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.

Mentalization in Child Psychodynamic Psychotherapy

Article

Full-text available

Aug 2019

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.

Intervention training using peer role‐play and standardised patients in psychodynamic psychotherapy trainees

Article

May 2019

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.

Successful and Less Successful Psychotherapies Compared: Three Therapists and Their Six Contrasting Cases

Article

Full-text available

Apr 2019

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.

Differential Effects of Alliance and Techniques on Panic-Specific Reflective Function and Misinterpretation of Bodily Sensations in Two Treatments for Panic

Article

Feb 2019

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.

Development of a scale quantifying expectations regarding active processes in therapy: The Expectations of Active Processes in Psychotherapy Scale (EAPPS)

Article

May 2018
PSYCHIAT RES

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.

Mechanisms of Change in Treatments of Personality Disorders: Commentary on the Special Section

Article

Full-text available

Jan 2018
J PERS DISORD

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.

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

Article

Jan 2018

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 potential of predictive analytics to provide clinical decision support in depression treatment planning

Article

Oct 2017

Ronald C. Kessler

Purpose of review: To review progress developing clinical decision support tools for personalized treatment of major depressive disorder (MDD). Recent findings: Over the years, a variety of individual indicators ranging from biomarkers to clinical observations and self-report scales have been used to predict various aspects of differential MDD treatment response. Most of this work focused on predicting remission either with antidepressant medications versus psychotherapy, some antidepressant medications versus others, some psychotherapies versus others, and combination therapies versus monotherapies. However, to date, none of the individual predictors in these studies has been strong enough to guide optimal treatment selection for most patients. Interest consequently turned to decision support tools made up of multiple predictors, but the development of such tools has been hampered by small study sample sizes. Design recommendations are made here for future studies to address this problem. Summary: Recommendations include using large prospective observational studies followed by pragmatic trials rather than smaller, expensive controlled treatment trials for preliminary development of decision support tools; basing these tools on comprehensive batteries of inexpensive self-report and clinical predictors (e.g., self-administered performance-based neurocognitive tests) versus expensive biomarkers; and reserving biomarker assessments for targeted studies of patients not well classified by inexpensive predictor batteries.

The MATRIX, a novel tool exploring dynamic psychotherapy: Preliminary psychometric properties

Article

Full-text available

Aug 2017

Most measures in the field of psychodynamic psychotherapy are bound to a specific theory, and usually focus only on patient processes or therapist interventions. The MATRIX is a newly developed research tool that focuses on events within both the patient and the therapist individually, as well as on dyadic events, and provides the simple and meaningful coding of content for therapy session transcripts in psychotherapy. The present study describes the inter-rater reliability and construct validity of the MATRIX. Reliability of the MATRIX was assessed by applying it to 805 fragments of psychodynamic-oriented psychotherapy sessions. Three independent experts coded fragments, and the tool was examined for reliability. Validity in identifying the theoretical inclinations was assessed by applying the MATRIX to 30 segments (containing 1309 fragments) of sessions that reflect different theoretical orientations. Findings evinced high inter-rater reliability for all dimensions. The MATRIX was found to have high degree of validity for differentiating the theoretical inclinations of segments of sessions. The MATRIX is a reliable and valid measure that may enable moment-to-moment, quantitative, analysis of psychodynamic psychotherapy.

The Components of Psychoanalysis: Factor Analyses of Process Measures of 27 Fully Recorded Psychoanalyses

Article

Full-text available

Jul 2017

In an empirical study of psychoanalytic processes, the authors identify therapist, patient, and interaction factors from 2 instruments totaling 31 items based on clinicians' evaluation of 540 sessions from 27 completely recorded psychoanalyses. The 2 instruments, developed over 30 years studying recorded psychoanalyses, are the Analytic Process Scales (APS; Waldron, Scharf, Hurst, Firestein, & Burton, 2004b) and the Dynamic Interaction Scales (DIS; Waldron, Gazzillo, Genova, & Lingiardi, 2013). This article reports the authors' simplification of the complex patterns produced by the items via factor analysis. Guided by past process-outcome literature (Lambert, 2013), therapist, patient, and interaction items were factor analyzed in 3 separate analyses. Three patient factors emerged: the patient's experience of the world, the patient's experience of the analyst, and a factor the authors call patient dynamic competence. Components contributed by the therapist reduced to therapist's relational competence and therapist's dynamic competence. Interaction items produced just 1 factor, interaction quality. The authors describe the items contributing to each of these 6 factors and the correlations among these factors to permit the reader to better understand how they interact. Moreover, 2 second-order factors emerged which show what the authors describe as a parallel process between patient and analyst, allowing for a conceptualization of the intricate process of analyst and patient working together, with differing foci, in a potentially mutually enriching way. (PsycINFO Database Record

Prediction and Moderation of Improvement in Cognitive-Behavioral and Psychodynamic Psychotherapy for Panic Disorder

Article

Full-text available

Jun 2017

Objective: To identify variables predicting psychotherapy outcome for panic disorder or indicating which of 2 very different forms of psychotherapy-panic-focused psychodynamic psychotherapy (PFPP) or cognitive-behavioral therapy (CBT)-would be more effective for particular patients. Method: Data were from 161 adults participating in a randomized controlled trial (RCT) including these psychotherapies. Patients included 104 women; 118 patients were White, 33 were Black, and 10 were of other races; 24 were Latino(a). Predictors/moderators measured at baseline or by Session 2 of treatment were used to predict change on the Panic Disorder Severity Scale (PDSS). Results: Higher expectancy for treatment gains (Credibility/Expectancy Questionnaire d = -1.05, CI95% [-1.50, -0.60]), and later age of onset (d = -0.65, CI95% [-0.98, -0.32]) were predictive of greater change. Both variables were also significant moderators: patients with low expectancy of improvement improved significantly less in PFPP than their counterparts in CBT, whereas this was not the case for patients with average or high levels of expectancy. When patients had an onset of panic disorder later in life (≥27.5 years old), they fared as well in PFPP as CBT. In contrast, at low and mean levels of onset age, CBT was the more effective treatment. Conclusions: Predictive variables suggest possibly fruitful foci for improvement of treatment outcome. In terms of moderation, CBT was the more consistently effective treatment, but moderators identified some patients who would do as well in PFPP as in CBT, thereby widening empirically supported options for treatment of this disorder. (PsycINFO Database Record

The Process of Change in Accelerated Experiential Dynamic Psychotherapy (AEDP): A Case Study Analysis

Article

Full-text available

Apr 2017

El proceso de cambio en la psicoterapia dinámica experiencial acelerada (AEDP por su sgla en inglés): un análisis de estudio de caso La psicoterapia dinámica experiencial acelerada (AEDP, por sus siglas en inglés) es un tratamiento altamente integrador que incorpora elementos psicoterapéuticos psicodinámicos a corto plazo y centrados en la emoción, experimentales en el proceso, así como la teoría del apego. El estudio actual empleó un diseño de estudio multicaso de métodos mixtos para describir cómo se desarrolla el proceso de cambio en un caso “exitoso” y “no exitoso” de AEDP, según lo definido por el cambio confiable (RC) en el Cuestionario de Resultados-30.2 (OQ- 30; Lambert, Vermeersch, Brown y Burligame, 2004). Simultáneamente, varios resultados adicionales (afectan la experiencia y el apego adulto), variables de relación terapéutica (alianza de trabajo [WA], relación real [RR] y apego del paciente al terapeuta) y una descripción cualitativa del proceso de terapia (Cuestionario de eventos importantes [IEQ]; Cummings, Martin, Hallberg y Slemon, 1992) se evaluaron en 3 puntos de tiempo durante el curso de la terapia. En general, las observaciones clínicas en este estudio son consistentes con la teoría de cambio de AEDP, que predice que el alivio de los síntomas va acompañado de cambios en el afecto y el apego inseguro, y que estos cambios ocurren dentro de una fuerte relación terapéutica que es real, colaborativa y segura. Además, los análisis cualitativos sugieren que el advenimiento de una experiencia emocional correctiva (PEC) puede haber servido como un catalizador para el cambio en la díada de terapia “exitosa”. Por el contrario, una disminución confiable en el acuerdo sobre las tareas de la terapia y la disminución del afecto positivo (PA) y el afecto negativo (NA) pueden haber obstaculizado el cambio temprano en el caso “sin éxito”.

Effectiveness of Integrative Imagery- and Trance-Based Psychodynamic Therapies: Guided Imagery Psychotherapy and Hypnopsychotherapy

Article

Full-text available

Feb 2017

In a naturalistic study, we examined the effectiveness of two integrative psychodynamic psychotherapies—Guided Imagery Psychotherapy (GIP) and Hypnopsychotherapy (HY) – in an outpatient setting. A mixed sample of patients was assessed at the beginning of therapy (N = 300) and after 30 months (N = 97), using the IIP, the IPO-16, the FLZM, and the PMS as well as health economic measures. The BSI was employed at the beginning of therapy and every 6 months after that. Therapists rated CGI-S and GAF at the beginning and end of therapy. There was no control group. Improvements were found on all measures for GIP and for all but 1 measure for HY. Effect sizes ranged from d = .12 to d = 1.76. The percentage of patients who changed reliably ranged from 18% to 82.5%. We statistically controlled for the number of treatment sessions and whether the treatment had been completed within 30 months. For the BSI, improvement was found within the first 6 months of treatment and again within the following 18 to 24 months—indicating a regressive but steady alleviation of symptom distress over the course of longer treatments. In conclusion, under naturalistic conditions, GIP and HY have been shown to be effective with regards to different outcome modalities.

The role of avoidant and obsessive-compulsive personality disorder traits in matching patients with major depression to cognitive behavioral and psychodynamic therapy: A replication study

Article

Aug 2016

Background: Barber and Muenz (1996) reported that cognitive behavior therapy (CBT) was more effective than interpersonal therapy (IPT) for depressed patients with elevated levels of avoidant personality disorder, while IPT was more effective than CBT in patients with elevated levels of obsessive-compulsive personality disorder. These findings may have important clinical implications, but have not yet been replicated. Methods: We conducted a study using data from a randomized clinical trial comparing the efficacy of CBT and short-term psychodynamic supportive psychotherapy in the outpatient treatment of depression. Results: We found no evidence indicating that avoidant patients may benefit more from CBT compared to short-term psychodynamic supportive therapy (SPSP). Conclusions: Our results indicate that treatment effect does not depend on the level of avoidance, or obsessive-compulsiveness personality disorders further examine the influence of personality disorders on the effectiveness of CBT or psychodynamic therapy in the treatment of depression.

Knowing-in-Relation: How Experienced Therapists Integrate Different Sources of Knowledge in Actual Clinical Practice

Article

Full-text available

Jul 2016

The present article elaborates on the concept of psychotherapy integration by approaching the issue from the perspective of clinician activity within therapy sessions. Secondary analysis of qualitative data on in-session behavior and posttreatment reflections of highly experienced, pluralistically informed therapists was carried out. The concept of “knowing-in-relation” emerged as a means of representing the moment-to-moment integration of knowledge and practice that was observed. It is argued that integration may be considered as an evolving, processual activity, as well as an implementation of specific integrative models.

Uncovering Interaction Structures in a Brief Psychodynamic Psychotherapy / Desvelando Estruturas de Interação em uma Psicoterapia Psicodinâmica Breve

Article

Full-text available

May 2016

Estruturas de interação designam os funcionamentos repetitivos da díade paciente-terapeuta ao longo do tratamento. O constructo é operacionalizado pela aplicação repetida do Psychotherapy Process Q-Set (PQS) às sessões de psicoterapia. Estudos nesta linha de investigação até agora focalizaram somente tratamentos de longa duração. Esta investigação examina se estruturas de interação podem ser detectadas empiricamente em psicoterapias breves. Todas as sessões (N = 31) de um caso bem-sucedido de psicoterapia psicodinâmica breve foram codificadas com o PQS. A aplicação de análise fatorial do tipo Q com rotação varimax revelou cinco estruturas de interação: resistência, aliança, enfrentado a depressão, expectativa de mudança, e introspecção e escuta. A análise da variação destas estruturas ao longo do tratamento mostrou que as mesmas não são lineares, podem estar positiva ou negativamente salientes em diferentes sessões, ou predominar em alguma etapa do tratamento.

Uncovering Interaction Structures in a Brief Psychodynamic Psychotherapy

Article

Full-text available

Aug 2016

Fernanda Serralta

Interaction structures refers to the repetitive ways of interaction between the patient-therapist dyad over the course of treatment. This construct is operationalized by the repeated application of the Psychotherapy Process Q-Set (PQS) to psychotherapy sessions. Studies in this line of research have so far focused only on long-term treatment. The present study examines whether interaction structures can be detected empirically in short-term psychotherapies. All sessions (N = 31) of a successful case of brief psychodynamic psychotherapy were coded with the Psychotherapy Process Q-Set (PQS). The application of Q type factor analysis procedures with varimax rotation revealed five interaction structures: resistance, alliance, facing depression, expectation of change, and introspection and hearing. The analysis of variation of these structures over the course of the treatment showed that these interactions are nonlinear, may be positively or negatively protruding in different sessions, or be predominant at some treatment phase.

Relational Turn and Psychotherapy Research

Article

Mar 2016

Psychoanalytic authors have traditionally been skeptical of nomothetic studies, in which group averages obscure the uniqueness of individual cases. Several relational psychoanalytic authors have expressed more pronounced skepticism, affirming, for example, that given the uniqueness of each therapist-patient dyad, systematic empirical research is particularly problematic. In this article we highlight the potential synergy between relational thinking and today's psychotherapy research, by exploring some of the ways in which the work of relational authors has influenced relational psychotherapy research, shifting the focus of study from validation of the models of treatment to the study of the clinical variables such as: countertransference, therapist empathy, self-disclosure, rupture and resolution in therapeutic alliance, intersubjective negotiation, and the patient-therapist attachment relationship. In conclusion, the aim of this article is to facilitate the dialogue between relational psychoanalysis and the field of psychotherapy research, by exploring ways in which these two different worlds can reciprocally stimulate and enrich one another.

Psychotherapeutic Evening Clinic

Article

Feb 2016

New treatment settings. Psychosomatic psychotherapeutic evening clinic as innovative treatment model Abstract There is a gap of psychotherapeutic treatment intensity between the full-day inpa- tient or day-clinic psychotherapy programs within hospitals and outpatient psychother apy according to the national guidelines for psychotherapy in Germany. This article in troduces the new model of a psychosomatic psychotherapeutic evening clinic that has been established at the University Hospital Heidelberg. In addition to a detailed descript- n of the developmental process, the structural framework and the contents of therapy are reported. The first clinical experiences with the new setting are illustrated with a case example. Patients participate in a therapy program on three late afternoons/early evenings per week where they receive a combination of group and individual psychotherapy. Overall, the new clinical setting is experienced as positive by both patients and therapists. Possibilities for further development as well as potential risks are discussed.

The quest for connection in interpersonal and therapeutic relationships

Article

Full-text available

Jan 2016
PSYCHOTHER RES

Hadas Wiseman

Objective: This paper focuses on the need for connection as a common core theme at the heart of both close relationships and therapeutic relationships and explores ways to connect these two research domains that have evolved as separate fields of study. Bowlby's attachment theory provides a strong conceptual and empirical base for linking human bonds and bonds in psychotherapy. Method: The growing body of research intersecting attachment and psychotherapy (1980-2014) is documented, and meta-analytic studies on attachment-outcome and attachment-alliance links are highlighted. Results: Five ways of studying attachment as a variable in psychotherapy are underscored: as moderator, as mediator, as outcome, client-therapist attachment match, and as process. By integrating conceptualizations and methods in studying relational narratives of client-therapist dyads (Core Conflictual Relationship Theme), measures of alliance, and client attachment to therapist during psychotherapy, we may discover unique client-therapist relational dances. Conclusions: Future fine-grained studies on how to promote core authentic relational relearning are important to clinicians, supervisors and trainers, who all share the common quest to alleviate interpersonal distress and enhance wellbeing. Directions for advancing research on interpersonal and therapeutic relationships are suggested. Learning from each other, both researchers of close relationships and of psychotherapy relationships can gain a deeper and multidimensional understanding of complex relational processes and outcomes.

In Cognitive Therapy for Depression, Early Focus on Maladaptive Beliefs May Be Especially Efficacious for Patients With Personality Disorders

Article

Full-text available

Jan 2016

Objective: Patients with major depressive disorder (MDD) and a comorbid personality disorder (PD) have been found to exhibit relatively poor outcomes in cognitive therapy (CT) and other treatments. Adaptations of CT focusing heavily on patients' core beliefs have yielded promising findings in the treatment of PD. However, there have been no investigations that have specifically tested whether increased focus on maladaptive beliefs contributes to CT's efficacy for these patients. Method: CT technique use from an early CT session was assessed for 59 patients (33 without PD, 26 with PD-predominantly Cluster C) who participated in a randomized controlled trial for moderate to severe MDD. Scores were calculated for directive CT techniques (CT-Concrete) and a set of belief-focused items (CT-Belief) as rated by the Collaborative Study Process Rating Scale. Robust regressions were conducted to estimate relations between scores on each of these measures and change in depressive and PD symptoms. A PD status by CT-Belief use interaction tested the hypothesis that therapist use of CT-Belief techniques would exhibit a stronger association with symptom change in the PD group relative to the non-PD group. Results: As hypothesized, a significant interaction between PD status and use of CT-Belief techniques emerged in the prediction of depressive and PD symptom change. Among PD patients, higher early CT-Belief interventions were found to predict significantly greater improvement. CT-Belief use did not predict greater symptom change among those without PD. Conclusions: Early focus on CT-Belief interventions may facilitate changes in depression and PD symptoms for patients with MDD-PD comorbidity. (PsycINFO Database Record

Therapist defense mechanisms and training level: An exploratory study

Article

Sep 2014

Of all the variables studied in psychotherapy research, the therapists them selves appear to constitute the strongest predictors of the therapeutic process and results. We currently, however, have very little research data to explain this effect. To date, no research has yet focused specifically on the defenses employed by psychotherapists during their sessions. This study sought to evaluate two principal factors: (1) the absolute frequency of defense mechanisms employed by therapists during therapy sessions and relative frequency of the different defense mechanisms used; (2) the effect of psychotherapy training on the frequency of the therapist's defense mechanisms. The study sample was comprised of 12 therapists, divided into the three following categories: novice, experienced (training completed), and expert. The therapy consisted of brief psychodynamic intervention (BPI) conducted over four sessions. The therapist's defense mechanisms were measured by means of the Defense Mechanism Rating Scales (DMRS, Perry, et al., 2004). The results have demonstrated that all therapists employ several different defense mechanisms, corresponding to different levels of experience. Furthermore, novice therapists have been shown to use no more defense mechanisms than those who are more experienced. Finally, the defensive level of the therapist was found to have no effect on the intervention's results. This study paves the way for a promising line of research, validating the merit in studying processes of regulating a therapist's affect during psychotherapy sessions, which can sometimes prove extremely intense.

State of the Art Praxisorientierte Psychotherapieforschung

Article

Full-text available

Dec 2015

This paper provides an overview and recent developments in the field of practice oriented psychotherapy research and describes examples of the application of mixed methods designs including quantitative and qualitative research. Pro’s and Con’s of the integration of socialscience, humanities and natural science are discussed in order to reflect recent developments in psychotherapy research.

Measuring Verbal Psychotherapeutic Techniques—A Systematic Review of Intervention Characteristics and Measures

Article

Full-text available

Nov 2015

Language is one of the most important “tools” of psychotherapists. The working mechanisms of verbal therapeutic techniques, however, are still marginally understood. In part, this is due to the lack of a generally acknowledged typology as well as a gold standard for the assessment of verbal techniques, which limits the possibility of conducting studies focusing this topic. The present study reviews measures used in clinical research which assess directly observable dimensions of verbal interventions in a reliable manner. All measures were evaluated with respect to their theoretical foundation, research goals, assessment modes, and various psychometric properties. A systematic search in databases (PubMed, PsycInfo, PsycArticles, PSYNDEX, Web of Science, Embase) followed by an additional “snowballing” search covering the years 1940–2013 yielded n = 179 publications eligible for review. Within these publications, 34 measures were identified showing great heterogeneity regarding the aspects under study. Only two measures reached the highest psychometric standards and can be recommended for clinical use without any reservation. Central problems include deficiencies in the systematization of techniques as well as their partly ambiguous and inconsistent definitions. To promote this field of research, it will be important to achieve a consensus concerning the terminology, conceptions and measures of verbal interventions.

Proposal to Develop a Clinical Practice Guideline on Emotion Regulation: Final Report (from American Psychological Association Working Group on Transdiagnostic/Change Process: Emotion Regulation)

Research

Full-text available

Jan 2024

The American Psychological Association Advisory Steering Committee for Development of Clinical Practice Guidelines created a working group to consider the feasibility of, and appropriate methods for, developing an APA clinical practice guideline for interventions that address a transdiagnostic change process, rather than a categorical disorder. Specifically, the working group was asked to determine whether development of a clinical practice guideline focused on emotion regulation was worth pursuing at this time, given the state of the scientific literature, feasibility, and considerations of clinical need and utility. The working group identified a set of goals for a clinical practice guideline based on the idea that if a guideline could mostly achieve these goals, it would be an advance for the field and worth the investment to try to develop a clinical practice guideline based on a transdiagnostic change process or principle. Goals: 1) Inform providers, patients and their families, payers and other stakeholders about what the empirical data indicate regarding the efficacy of treatments targeting emotion regulation 2) Enhance clinical utility of a clinical practice guideline so we learn more than typical guidelines tell us about: ● What works, for whom, and under what circumstances ● What is known about widely-used treatments for which there is not rigorous evidence concerning efficacy ● What is known about change processes or principles underlying the effects of efficacious treatments After careful consideration of the opportunities and challenges likely to arise in developing a clinical practice guideline on emotion regulation, the working group recommends developing and publishing three review protocols that would lead to a clinical practice guideline with three components: Review 1. Systematic review of the efficacy data leading to recommendations, following the current best practices to reduce bias (and acknowledgement of biases not addressed with this approach). This would include the Population, Intervention, Comparator, Outcomes, Timing, and Setting (PICOTS) questions to assess applicability based on current best practices, and would include the usual review of literature on harms, patient preferences, etc. Note: Only in unusual cases when there is a good reason a priori to think that a given subgroup will have a unique response to a treatment will subgroup analyses, cohort or other studies (that don’t meet best practices to reduce bias) be included. In these cases, careful attention to likely confounds and differences in the analytic approach will need to be considered if these studies are used to guide recommendations. Review 2. Summary of current knowledge (with appropriate caveats about the quality of evidence) for select treatments that were not included in Review 1, when the treatments are both widely used and studies meet stringent, pre-specified inclusion and exclusion criteria. Review 3. Summary of current knowledge (with appropriate caveats about the quality of evidence) for literature on change processes or principles based on systematic inclusion and exclusion criteria to determine (observational) studies that rigorously try to account for confounding. This report outlines the working group’s process, rationale for a guideline on emotion regulation, review of challenges likely to arise when developing a guideline of this nature and how recognition of these challenges guided the current proposal. Next the proposal and rationale for the three reviews are discussed, along with consideration of how to manage scope and why the working group believes developing this guideline would be very challenging, but ultimately feasible. We close with recommendations for future research in the hopes that the available literature will one day better match the urgent clinical needs.

Examining Changes in Personality Following Shamanic Ceremonial Use of Ayahuasca

Preprint

Full-text available

Nov 2020

The present study examines the association between the ceremonial use of ayahuasca – a decoction combining the Banistereopsis caapi vine and N,N Dimethyltryptamine-containing plants – and changes in personality traits as conceived by the Five-Factor model (FFM); as well as the degree to which demographic characteristics, baseline personality, and acute post-ayahuasca experiences affect personality change. Method: Participants recruited from three ayahuasca healing and spiritual centers in South and Central America (N=256) completed self-report measures of personality at three timepoints (Baseline, Post, 3-Month Follow-up). Informant-report measures of the FFM were also obtained (N=110). Results: Linear mixed models were used to examine changes in personality and the moderation of those changes by covariates. The most pronounced change was a reduction in Neuroticism d self-reportT1-T2 =1.00; d self-reportT1-T3 =.85; d informant-reportT1-T3 =.62), reflected in self- and informant-report data. Moderation of personality change by baseline personality, acute experiences, and purgative experiences was also observed.

Psychoanalysis

Chapter

Full-text available

Jan 2017

The great psychotherapy debate: The evidence for what makes psychotherapy work: Second edition

Book

Jan 2015

The second edition of The Great Psychotherapy Debate has been updated and revised to expand the presentation of the Contextual Model, which is derived from a scientific understanding of how humans heal in a social context and explains findings from a vast array of psychotherapies studies. This model provides a compelling alternative to traditional research on psychotherapy, which tends to focus on identifying the most effective treatment for particular disorders through emphasizing the specific ingredients of treatment. The new edition also includes a history of healing practices, medicine, and psychotherapy, an examination of therapist effects, and a thorough review of the research on common factors such as the alliance, expectations, and empathy.

Psychotherapy in Two-Plus-One Sessions: Outcomes of a Randomized Controlled Trial of Cognitive–Behavioral and Psychodynamic–Interpersonal Therapy for Subsyndromal Depression

Article

Full-text available

Apr 1999

A total of 116 clients with a range of subsyndromal depression received 3 therapy sessions: 2 sessions 1 week apart followed by a 3rd session 3 months later (the 2 + 1 model). Clients were stratified for severity on the Beck Depression Inventory (BDI) as stressed, subclinical, or low-level clinically depressed. In a 2 × 2 design, they received either cognitive–behavioral (CB) or psychodynamic–interpersonal (PI) therapy, either immediately or after a 4-week delay. An initial advantage for the immediate condition disappeared once the delayed-condition clients received treatment. Improvement rates at the end of treatment were 67% (stressed), 72% (subclinical), and 65% (low-level clinically depressed). There were no significant differences between CB and PI treatment methods, with the exception at 1-year follow-up, when the BDI showed a significant advantage for CB. Implications for designing very brief planned interventions are discussed.

Effects of Treatment Duration and Severity of Depression on the Effectiveness of Cognitive–Behavioral and Psychodynamic–Interpersonal Psychotherapy

Article

Full-text available

Jun 1994

A total of 117 depressed clients, stratified for severity, completed 8 or 16 sessions of manualized treatment, either cognitive–behavioral psychotherapy (CB) or psychodynamic–interpersonal psychotherapy (PI). Each of 5 clinician-investigators treated clients in all 4 treatment conditions. On most measures, CB and PI were equally effective, irrespective of the severity of depression or the duration of treatment. However, there was evidence of some advantage to CB on the Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). There was no evidence that CB’s effects were more rapid than those of PI, nor did the effects of each treatment method vary according to the severity of depression. There was no overall advantage to 16-session treatment over 8-session treatment. However, those presenting with relatively severe depression improved substantially more after 16 than after 8 sessions.

Toward the delineation of therapeutic change principles

Article

Full-text available

Nov 1980

Marvin Goldfried

Documents a growing discontent among therapists of varying orientations. Psychoanalytic, behavioral, and humanistically oriented clinicians are starting to raise serious questions about the limits of their respective approaches and are becoming more open to contributions from other paradigms. The trend resembles a crisis of the type described by T. S. Kuhn (1970) in his work on scientific revolutions. Some of the political, economic, and social forces apt to affect the likelihood of ever reaching a consensus within the field are noted, and an approach to the delineation and study of commonalities across various orientations is presented. (2 p ref)

Toward personalized psychotherapy: The importance of the trait-like / state-like distinction for facilitating therapeutic change

Article

Full-text available

Jul 2020

Sigal Zilcha-Mano

For the past hundred years, mechanisms of change have been the black box of psychotherapy. Thousands of studies failed to produce consistent findings, even concerning factors considered crucial for treatment success by theoretical models and decades of clinical experience. This article introduces the distinction between trait-like (TL) and state-like (SL) components of any mechanism of change (the TLSL distinction) as a potential key to the black box of psychotherapy. TL refers to individual differences between patients; SL refers to changes occurring within the patient over the course of treatment. The TLSL distinction explains why past research, which conflated the two, has produced conflicting results, and predicts the conditions under which consistent results can be obtained. Data collected so far show support for the importance of the TLSL distinction and point the way toward personalized treatment. The TL components create the individual's signature pathology and strengths map, and determine the SL changes that represent the patient-specific mechanisms most critical for optimizing treatment efficacy for each individual. The TLSL distinction has the potential to explain not only how psychotherapy works, but also how changes of any type occur in the wake of intervention, life events, and other factors. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Therapeutic Alliance, Cultural Competence and Minority Status in Premature Termination of Psychotherapy

Article

Full-text available

Jul 2018

Premature termination is a pervasive barrier to effective implementation of outpatient psychotherapy that frequently results in poorer outcomes for clients as well as poor resource allocation for clients, therapists, and society. Despite its high prevalence and cost, premature termination remains poorly understood, especially from the clients’ perspective. The current study addressed some gaps in the literature using a national online survey design that permitted investigation of a broad range of potential predictors of premature termination. Participants were 278 respondents from Amazon.com’s Mechanical Turk who completed an online survey about their treatment history, their most recent outpatient therapy experience and therapist, termination status, reasons for terminating prematurely (if applicable), treatment satisfaction, and demographics. Results indicated that being a woman, identifying as a sexual minority, and having a therapist low in perceived multicultural competence were associated with increased risk of premature termination. However, the best predictors of premature termination were a weak therapeutic alliance and symptoms of depression. These results support previous research that shows both client and therapist variables contribute to premature termination. Potential interventions that can be implemented by providers or agencies to reduce premature termination are discussed, along with limitations of the study and recommendations for future research.

Effects of Training in Time-Limited Dynamic Psychotherapy: Changes in Therapist Behavior

Article

Full-text available

Jun 1993

Sixteen therapists participated in a year-long manualized training program as part of the Vanderbilt II study of time-limited dynamic psychotherapy. Changes in therapist behavior were measured with the Vanderbilt Therapeutic Strategies Scale (an adherence measure), the Vanderbilt Psychotherapy Process Scale (VPPS), and interpersonal process codings using the Structural Analysis of Social Behavior (SASB). The training program successfully changed therapists' technical interventions in line with the manualized protocol. After training, there was increased emphasis on the expression of in-session affect, exploration of the therapeutic relationship, an improved participant-observer stance, and greater use of open-ended questions. There was also an indication of unexpected deterioration in certain interpersonal and interactional aspects of therapy as measured by the VPPS and SASB ratings. These results question the assumption that greater control of the therapy variable is straightforwardly achieved with manuals and adherence scales. Changing or dictating specific therapist behaviors to achieve technical adherence may alter other therapeutic variables in unexpected and even counterproductive ways.

Comprehensive compilation of randomized controlled trials (RCTs) involving psychodynamic treatments and interventions

Research

Full-text available

Jun 2017

Peter Lilliengren

This is a list of all RCTs ever conducted on psychodynamic/psychoanalytic treatments and interventions. The inclusion criteria are the widest possible: the list includes studies of long-term and short-term therapy, the treatment may be in individual, group or other format (Internet-based self-help for example), the condition targeted may be a psychiatric condition or other defined problem and the patient population targeted may be adults, youth or children. Studies of integrative treatments with a major psychodynamic component have also been included, but established treatments that are typically not considered dynamic (although they may overlap to some extent, e.g. EMDR, IPT, Schema therapy) have not been included. The list has been assembled from references included in (or excluded from) published meta-analyses, as well as through manual searches in PubMed, PsycINFO, Google Scholar and others. The list is regularly updated and if you are aware of any study meeting the inclusion criteria that is currently not on the list - please let me know!

Is the Alliance Really Therapeutic? Revisiting This Question in Light of Recent Methodological Advances

Article

Full-text available

May 2017

Sigal Zilcha-Mano

The therapeutic value of alliance is a contested supposition. Although many theorists and researchers believe that alliance is therapeutic in itself, others see it as a byproduct of effective treatment or as a common nonspecific factor enabling the truly effective ingredients of treatment to work. For many years, the debate was confined mainly to the domain of theory, and no studies were available to confirm which of these approaches is correct. The only empirical evidence that existed was studies showing a correlation between alliance and outcome, and advocates of the above conflicting opinions used the same correlation to prove the validity of their position. Over the last few years, however, a revolution has taken place in alliance research, which brings this theoretical debate into the realm of the empirical. Several recent alliance studies have applied advanced methodologies to achieve this aim. Based on an integration of these studies, the present article proposes a new model for understanding the potential therapeutic role of alliance as sufficient to induce change by itself. The model stresses the importance of differentiating between patients’ general tendencies to form satisfying relationships with others, which affect also the relationship with the therapist (“trait-like” component of alliance), and the process of the development of changes in such tendencies through interaction with the therapist (“state-like” component of alliance). The former enables treatment to be effective; the latter makes alliance therapeutic. Based on the literature, this article attempts to determine which of these components is the predictor of treatment outcome.

Empirical investigation of the cognitive mediational paradigm for research on counseling.

Article

Full-text available

Apr 1986

Examined relations among counselor and client cognitions, behaviors, and ratings in 29 counseling sessions involving 10 different counselor–client pairs, using stimulated recall and content analysis. Clients were university students; there were 4 counselors with 7–25 yrs' experience and 3 who were counseling interns. The design of the study permitted assessments of the impact of counselor experience (novice vs experienced) and stage of counseling (early, middle, and end) on these variables. Consistency in various parts of the sequential chain of counselor intention (counselor behavior, client perceptions of counselor intention and behavior, client cognitive processing, and client behavior) was lower for interpersonal cognitive than for interpersonal behavioral or intrapersonal cognitive–behavioral links. Consistency across different elements in this chain was observed to account for a significant proportion of the variance in counselor ratings of session effectiveness. Consistent, interpretable patterns observed across counselor intentions, counselor behaviors, and client cognitive processing are discussed. Relatively few effects of stage of counseling or of counselor experience were observed. (32 ref)

Significant change events in psychodynamic psychotherapy: Is cognition or emotion more important?

Article

Full-text available

Mar 2017

Objective: Significant change events are helpful moments within a psychotherapy session that have been shown in previous research to relate strongly to outcome. They are special moments and therefore provide rich data for research into understanding therapeutic process. This study investigated clinical and linguistic features of these helpful moments using and comparing both human ratings and computerized text analysis strategies. Method: Significant change events versus non-event passages were studied within 1195 word blocks of transcribed psychotherapy for 20 participants with diagnoses of comorbid depression and personality disorder. Significant events were determined manually by independent raters using the Helpful Aspects of Therapy (HAT) form linked to the Helpful Aspects of Experiential Therapy Content Analysis System (HAETCAS). Mergenthaler's Therapeutic Cycles Model (TCM)-computerized text analysis, identified significant events via linguistic markers. The Linguistic Inquiry and Word Count (LIWC) differentiated emotional and cognitive components. Results: Significant events included statements reflecting emotional and cognitive awareness and insight, and moments of alliance strengthening. These events were saturated with both positive and negative emotion words, particularly anger and sadness, and more cognitive insight words. Conclusions: Significant moments of psychotherapeutic movement featured high therapeutic alliance. There was evidence of the integration or working through of positive and negative emotional content with cognitive insight - meaning both emotion and cognition were important in these interchanges. Practitioner points: This study found that significant events in therapy were characterized by high levels of both emotional and cognitive language, and alliance strengthening. Linguistic analysis methods provide important data on psychotherapeutic processes which can be useful in guiding clinicians and improving treatment outcomes.

Psychotherapy Relationships That Work: Evidence-Based Responsiveness

Book

Full-text available

Jan 2019

John C. Norcross

The two-volume third edition of this book identifies effective elements of therapy relationships (what works in general) as well as effective methods of tailoring or adapting therapy to the individual patient (what works in particular). Each chapter features a specific therapist behavior (e.g., alliance, empathy, support, collecting feedback) that demonstrably improves treatment outcomes or a nondiagnostic patient characteristic (e.g., reactance, preferences, culture, attachment style) by which to effectively tailor psychotherapy. Each chapter presents operational definitions, clinical examples, comprehensive meta-analyses, moderator analyses, and research-supported therapeutic practices. New chapters in this book deal with the alliance with children and adolescents, the alliance in couples and family therapy, and collecting real-time feedback from clients; more ways to tailor treatment; and adapting treatments to patient preferences, culture, attachment style, and religion/spirituality.

Brief Psychotherapy for Posttraumatic Stress Disorders

Article

Full-text available

Oct 1989

A large-scale study of the effectiveness of psychotherapeutic methods for the treatment of posttraumatic stress disorders was conducted. The sample consisted of 112 persons suffering from serious disorders resulting from traumatic events (bereavement, acts of violence, and traffic accidents) that had taken place not more than 5 years before. Trauma desensitization, hypnotherapy, and psychodynamic therapy were tested for their effectiveness in comparison with a waiting-list control group. The results indicated that treated cases were significantly lower in trauma-related symptoms than the control group. (C) 1989 by the American Psychological Association

Progress Feedback and the OQ-System: The Past and the Future

Article

Full-text available

Dec 2015
PSYCHOTHERAPY

Lambert Michael

A serious problem in routine clinical practice is clinician optimism about the benefit clients derive from the therapy that they offer compared to measured benefits. The consequence of seeing the silver lining is a failure to identify cases that, in the end, leave treatment worse-off than when they started or are simply unaffected. It has become clear that some methods of measuring, monitoring, and providing feedback to clinicians about client mental health status over the course of routine care improves treatment outcomes for clients at risk of treatment failure (Shimokawa, Lambert, & Smart, 2010) and thus is a remedy for therapist optimism by identifying cases at risk for poor outcomes. The current article presents research findings related to use of the Outcome Questionnaire-45 and Clinical Support Tools for this purpose. The necessary characteristics of feedback systems that work to benefit client's well-being are identified. In addition, suggestions for future research and use in routine care are presented. (PsycINFO Database Record

Differential Outcome of Short-Term Dynamic Psychotherapy and Systematic Desensitization in the Treatment of Anxious Out-Patients A Preliminary Report

Article

Full-text available

Jan 1978
PSYCHOL BELG

Factor Structure of the Working Alliance Inventory

Article

Full-text available

Sep 1989

The Working Alliance Inventory (WAI) was completed after the 1st psychotherapy session by 84 university counseling center clients and 15 therapists rating their work with 123 clients. The factor structure of these responses was examined using confirmatory factor analysis. A model with 1 general factor, a model with 3 specific factors, and a bilevel model of the factor structure were examined. The bilevel factor structure, with a General Alliance factor as its primary factor and 3 secondary specific factors, fit the data best. The items most indicative of the 3 specific factors were selected to form a 12-item short form of the WAI.

The Mentalizing Approach to Psychopathology: State of the Art and Future Directions

Article

May 2020

Mentalizing is the capacity to understand others and oneself in terms of internal mental states. It is assumed to be underpinned by four dimensions: automatic–controlled, internally–externally focused, self–other, and cognitive–affective. Research suggests that mental disorders are associated with different imbalances in these dimensions. Addressing the quality of mentalizing as part of psychosocial treatments may be helpful for individuals with various mental disorders. We suggest that mentalizing is a helpful transtheoretical and transdiagnostic concept to explain vulnerability to psychopathology and its treatment. This review summarizes the mentalizing approach to psychopathology from a developmental socioecological evolutionary perspective. We then focus on the application of the mentalizing approach to personality disorders, and we review studies that have extended this approach to other types of psychopathology, including depression, anxiety, and eating disorders. We summarize core principles of mentalization-based treatments and preventive interventions and the evidence for their effectiveness. We conclude with recommendations for future research. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 16 is May 7, 2020. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Relational Concepts in Psychoanalysis

Book

Jun 2009

Stephen A. Mitchell

Panic-focused psychodynamic psychotherapy–extended range

Chapter

Jan 2019

Process research in psychodynamic psychotherapy: interventions and the therapeutic relationship

Chapter

Jan 2019

The professional and personal characteristics of effective psychotherapists: a systematic review

Article

May 2019

Objective: Psychotherapists differ notably in the outcomes their patients achieve, and the characteristics that may explain these differences have attracted increasing interest. We systematically review studies on therapist pre-treatment characteristics predicting patient outcomes. Method: Systematic searches on databases for psychotherapy research, clinical psychology, and medical science for the years 2000–2018 identified published research examining therapist characteristics and psychotherapy outcomes. Of 2041 studies, 31 met inclusion criteria. Results: Findings show a few direct effects of therapist intrapersonal variables (e.g., self-relatedness, attachment) and several interaction effects with other constructs (e.g., patient pathology) on outcome. There is little support for the relevance of self-rated social skills. However, more consistent evidence has recently emerged for performance-based measurements of professional interpersonal skills, especially when elicited in challenging situations. Patient outcomes were also predicted by therapists’ self-rated professional characteristics, such as their experienced difficulties in practice, coping mechanisms, and attitudes towards therapeutic work, indicating that therapist self-perception also matters, although not always in the direction expected. Conclusions: More effective therapists seem characterized by professionally cultivated interpersonal capacities, which are likely rooted in their personal lives and attachment history. Research guidelines are proposed for moving this field forward (including larger samples, multilevel modeling, and in-depth qualitative work).

Dynamic Interpersonal Therapy for moderate to severe depression: a pilot randomized controlled and feasibility trial

Article

May 2019

Background Improving Access to Psychological Therapies (IAPT) services treat most patients in England who present to primary care with major depression. Psychodynamic psychotherapy is one of the psychotherapies offered. Dynamic Interpersonal Therapy (DIT) is a psychodynamic and mentalization-based treatment for depression. 16 sessions are delivered over approximately 5 months. Neither DIT's effectiveness relative to low-intensity treatment (LIT), nor the feasibility of randomizing patients to psychodynamic or cognitive-behavioural treatments (CBT) in an IAPT setting has been demonstrated. Methods 147 patients were randomized in a 3:2:1 ratio to DIT ( n = 73), LIT (control intervention; n = 54) or CBT ( n = 20) in four IAPT treatment services in a combined superiority and feasibility design. Patients meeting criteria for major depressive disorder were assessed at baseline, mid-treatment (3 months) and post-treatment (6 months) using the Hamilton Rating Scale for Depression (HRSD-17), Beck Depression Inventory-II (BDI-II) and other self-rated questionnaire measures. Patients receiving DIT were also followed up 6 months post-completion. Results The DIT arm showed significantly lower HRSD-17 scores at the 6-month primary end-point compared with LIT ( d = 0.70). Significantly more DIT patients (51%) showed clinically significant change on the HRSD-17 compared with LIT (9%). The DIT and CBT arms showed equivalence on most outcomes. Results were similar with the BDI-II. DIT showed benefit across a range of secondary outcomes. Conclusions DIT delivered in a primary care setting is superior to LIT and can be appropriately compared with CBT in future RCTs.

The Technique and Practice of Psychoanalysis

Book

May 2018

Ralph R. Greenson

The Working Alliance and the Transference Neurosis

Article

Apr 1965

Ralph R. Greenson

Mechanisms of change in mentalization-based treatment of BPD

Article

Apr 2006

There are very few less contentious issues than the role of attachment in psychotherapy. Concepts such as the therapeutic alliance speak directly to the importance of activating the attachment system, normally in relation to the therapist in individual therapy and in relation to other family members in family-based intervention, if therapeutic progress is to be made. In group therapy the attachment process may be activated by group membership. The past decade of neuroscientific research has helped us to understand some key processes that attachment entails at brain level. The article outlines this progress and links it to recent findings on the relationship between the neural systems underpinning attachment and other processes such as making of social judgments, theory of mind, and access to long-term memory. These findings allow intriguing speculations, which are currently undergoing empirical tests on the neural basis of individual differences in attachment as well as the nature of psychological disturbances associated with profound disturbances of the attachment system. In this article, we explore the crucial paradoxical brain state created by psychotherapy with powerful clinical implications for the maximization of therapeutic benefit from the talking cure. (c) 2006 Wiley Periodicals, Inc.

Major developments in methods addressing for whom psychotherapy may work and why

Article

Feb 2018

Sigal Zilcha-Mano

Significant progress has been achieved in the last decades in studying two central questions in psychotherapy research: what treatment works for which patient and why does treatment work. This paper delineates central developments in the methods used to study each of these questions. Through targeted examples, the paper discusses several phenomena and trends in psychotherapy research. Regarding the question of what works for whom, the discussion focuses on the progress from the search for one moderator to guide clinical decision-making to the search for a set of such moderators and their interactive effects, to best answer this question. To answer the question why treatment is effective, the paper reviews the progress from a single snapshot of a process variable to approaching causality, that is, temporal relationships, higher dependability, and closer attention to the dynamics of change in process variables. Finally, methodological developments made it possible to combine these two questions so as to better capture the richness and complexity of therapeutic work. Two central products of this integration are discussed and demonstrated through the case of the working alliance. Clinical or methodological significance of this article: Progress achieved in research regarding the methods used to examine which treatments work for which patients and why is reviewed, and some of the most promising paths toward personalized treatment integrating research on these two questions are suggested.

Towards an evidence-based unified psychodynamic protocol for emotional disorders

Article

Nov 2017
J AFFECT DISORDERS

Background In psychotherapy research unified, transdiagnostic and modular treatments have emerged. This is true for both cognitive-behavioral therapy and psychodynamic therapy. Recently, two unified psychodynamic protocols were presented, one for anxiety disorders, another for depressive disorders. Integrating the treatment principles for these two highly prevalent disorder groups into one protocol for "emotional disorders" may be useful for both clinical practice and training in psychotherapy. Methods After updating the evidence for psychodynamic therapy in anxiety and depressive disorders in terms of randomized controlled trials (RCTs) by a systematic search, the treatment elements applied in those RCTs providing evidence for the efficacy of psychodynamic therapy in depressive or anxiety disorders were reviewed and compared. Results Twenty-seven RCTs for anxiety or depressive disorders were identified. A review revealed a high overlap between the principles used for the psychodynamic treatment of anxiety and depressive disorders, reflecting the transdiagnostic nature of psychodynamic therapy. The overlap suggested to integrate the identified treatment principles into one unified psychodynamic protocol for "emotional disorders" (UPP-EMO). As a result, seven treatment principles or modules were distilled which can be flexibly applied depending on the patient´s symptoms and needs. In addition, a separate module addresses diagnostic assessment. Across modules, a focus on resources has been included. Limitations Despite being based on RCTs, UPP-EMO has not yet been examined in an RCT - which is planned as a next step. Conclusions As psychodynamic therapy is transdiagnostic in origin focusing on core underlying processes of mental disorders, acceptability of UPP-EMO among psychodynamic psychotherapists is likely to be high.

An update and overview of the empirical evidence for transference-focused psychotherapy and other psychotherapies for borderline personality disorder

Chapter

Jan 2012

The reliability and validity of a measure of self-understanding of interpersonal patterns.

Article

Oct 1999

Change in self-understanding of maladaptive interpersonal patterns has been an important mechanism of symptom change in theories of dynamic psychotherapy and has been specified as an important treatment outcome by psychotherapy clients. The current investigation evaluated the reliability and validity of a new self-report measure of Self-Understanding of Interpersonal Patterns (SUIP). The measure was administered to 3 clinical samples and a student sample. The measure demonstrated good internal consistency, test-retest reliability, and discriminant validity. The SUIP further demonstrated convergent validity with measures of analytical and self-improving personality traits in a clinical sample. Finally, there was significantly greater change in self-understanding in a dynamic psychotherapy as compared with a medication treatment condition, despite comparable symptom change across both treatment conditions.

A randomised controlled trial of Intensive Short-Term Dynamic Psychotherapy for treatment resistant depression: the Halifax Depression Study

Article

Mar 2017
J AFFECT DISORDERS

Background While short-term psychodynamic psychotherapies have been shown effective for major depression, it is unclear if this could be a treatment of choice for depressed patients who have not sufficiently responded to existing treatments and commonly have chronic and complex health issues. Method This superiority trial used a single blind randomised parallel group design to test the effectiveness of time-limited Intensive Short-Term Dynamic Psychotherapy (ISTDP) for treatment resistant depression (TRD). Patients referred to secondary care community mental health teams (CMHT) who met DSM-IV criteria for major depressive episode, had received antidepressant treatment 6 weeks, and had Hamilton Depression Rating Scale (HAM-D) scores of  16 were recruited. The effects of 20 sessions of ISTDP were judged through comparison against secondary care CMHT treatment as usual (TAU). The primary outcome was HAM-D scores at 6 months. Secondary outcomes included dichotomous measures of both remission (defined as HAM-D score  7) and partial remission (defined as HAM-D score  12). Results Sixty patients were randomised to 2 groups (ISTDP=30 and TAU=30), with data collected at baseline, 3, and 6 months. Multi-level linear regression modelling showed that change over time on both depression scales was significantly greater in the ISTDP group in comparison to TAU. Statistically significant between-group treatment differences, in the moderate to large range, favouring ISTDP, were observed on both the observer rated (Cohen’s d = 0.75) and self-report measures (Cohen’s d = 0.85) of depression. Relative to TAU, patients in the ISTDP group were significantly more likely after 6 months to achieve complete remission (36.0% vs. 3.7%) and partial remission (48.0% vs. 18.5%). Limitations It is unclear if the results are generalizable to other providers, geographical locations and cultures. Conclusions Time-limited ISTDP appears an effective treatment option for TRD, showing large advantages over routine treatment delivered by secondary care services.

Counselor and helpee perceptions of counselor intentions in relation to outcome in a single counseling session.

Article

Jul 1985

Determined whether counseling session could be predicted from different variables (i.e., counselor intentions, helpee's perceptions of counselor's intentions, match between counselor and helpee on intentions), focusing on counselors' and helpees' perceptions. Four 32–43 yr old experienced counselors each saw 4 undergraduate helpees for single 50 min counseling sessions. Counselors and helpees evaluated sessions and then reviewed videotapes during which counselors identified their intentions and helpees rated the helpfulness for each counselor turn. Results indicate that helpees perceived more intentions to support, focus, and clarify and less self-control and resistance than counselors had intended. The highest match between counselors and helpees occurred for getting information, setting limits, and clarifying. Helpees' ratings of helpfulness were highest for counselors' intentions involving needs, resistance, cognitions, and relationships, and lowest for setting limits, getting information, supporting, and focusing. Session outcome was related to different counselor and client perceptions, indicating that participants valued different events within sessions. (18 ref)

A power primer

Article

Jan 1991

J. Cohen

Effects of structured clinician training on patient and therapist perspectives of alliance early in psychotherapy

Article

Jan 2002
PSYCHOTHERAPY

This study investigates the effects of structured clinician training in a Therapeutic Model of Assessment (TMA) and Short-Term Psychodynamic Psychotherapy (STPP) on therapeutic alliance variables measured early in treatment. Thirty-four outpatients received psychotherapy from clinicians who had undergone structured training in a TMA and STPP. A 2nd group of 34 outpatients were assessed using a standard model of assessment and received general, nonstructured training in psychodynamic-eclectic treatment. Groups were matched on key demographic and clinical variables. Results demonstrated significant differences between the 2 groups on both patient- and therapist-rated alliance variables, with higher scores from those in the structured clinical training group. The impact that structured training and supervision may have on graduate clinicians' ability to form positive collaborative relationships with their patients is discussed.

‘Mourning and melancholia

Article

S. Freud

Applying relationship anecdotes paradigm interviews to study client–therapist relationship narratives: Core conflictual relationship theme analyses

Article

Jan 2017

Objective: We describe client-therapist relational narratives collected in relationship anecdotes paradigm (RAP) interviews during psychotherapy and the application of the core conflictual relationship theme (CCRT) method. Changes in clients' and therapists' CCRT in relation to each other are examined and associations between their CCRTs and self-reported ruptures and repairs are explored. Method: Sixty-seven clients and 27 therapists underwent RAP interviews and completed self-report rupture and repair items at early, middle, and late psychodynamic psychotherapy. Client-therapist relationship narratives were rated on the CCRT and the relational interplay within dyads was explored qualitatively. Results: CCRT changes from early to late therapy showed that with time clients perceived the therapist (RO) and the self (RS) more positively, and the therapist perceived the self (RS) less negatively. Some associations were found between tension in the session and clients' and therapists' negative RO and RS. Therapists' reports of alliance repairs were associated with positive RO and RS. Conclusions: Relational narratives that clients and therapists tell in RAP interviews about meaningful interactions between them, enhance our understanding of clients' and therapists' inner experiences during interpersonal dances in the therapeutic relationship. Limitations and directions for future research are discussed, and implications for training are suggested.

Therapeutic alliance and adherence in cognitive therapy for depression

Article

Jan 2004

Melissa A Brotman

The relations between the therapeutic alliance, therapists' adherence to cognitive therapy (CT) techniques, and patients' responses to such techniques was examined in the reduction of depressive symptoms in a group of 51 patients receiving CT for depression. Several statistical methods were applied to examine the influence of in-session behaviors on symptom improvement. First, an attempt to replicate two earlier studies (R. J. DeRubeis & M. Feeley, 1990 and M. Feeley, R. J. DeRubeis, & L. A. Gelfand, 1999), using multiple regressions to assess the relation between in-session behaviors at session 2 and outcome, demonstrated a pattern opposite to prior findings. However, the repeated measures of the in-session behaviors over the first four sessions allowed more sophisticated analyses to be performed. Using longitudinal random coefficients analyses, therapist adherence predicted the rate of depressive symptom change from session 4 to the end of treatment at a trend level. Early measures of the therapeutic alliance did not lead to improvement at the end of treatment. In addition, therapist and patient concrete adherence aggregated across the first four sessions was predictive of symptom improvement in the following session, whereas the therapeutic alliance was not significantly related to short-term gains. Advantages of using longitudinal analyses over regressive approaches are reviewed, and implications for psychotherapy process research are discussed.

The standard edition of the complete psychological works of Sigmund Freud.)

Article

Jan 1953

Cognitive Therapy in the Treatment of Depression

Chapter

Jan 1984

The cognitive model of depression originated in a series of studies of clinical depression conducted by Beck in the late 1950s. Although these studies arose from the desire to secure empirical evidence in support of psychoanalytic theories of depression, the psychoanalytic model proved difficult to confirm empirically. Rather, the data suggested an alternate formulation, namely, that the depressed patient was characterized by a particular kind of thinking: he tended to regard himself as a “loser.” The dreams he reported, his early memories, his responses to projective tests, and the material he generated in a clinical setting all tended to reflect certain stereotyped themes: he saw himself as a person who was continually deprived, frustrated, and thwarted, whose prospects were dim, and who had little chance of improving them. Beck also observed that depressed patients made certain logical errors—among them overgeneralization, arbitrary inference, and selective abstraction. Beck concluded that the negative thinking typical of the depressed patient—his negative bias in interpreting events—might underlie his depressed moods. It followed that correcting this thinking might then improve the mood and other symptoms of depression (Beck, 1967/1972).

Comprehensive meta-analysis (Version 2.2.027) [Computer software]

Article

Jan 2005

Symposium on the theory of the therapeutic results of psycho-analysis

Article

E. Bibring

Mentalization based treatment of borderline personality disorder

Article

Jan 2004

Mentalizing is the process by which we make sense of each other and ourselves, implicitly and explicitly, in terms of subjective states and mental processes. It is a profoundly social construct in the sense that we are attentive to the mental states of those we are with, physically or psychologically. Given the generality of this definition, most mental disorders will inevitably involve some difficulties with mentalization, but it is the application of the concept to the treatment of borderline personality disorder (BPD), a common psychiatric condition with important implications for public health, that has received the most attention. Patients with BPD show reduced capacities to mentalize, which leads to problems with emotional regulation and difficulties in managing impulsivity, especially in the context of interpersonal interactions. Mentalization based treatment (MBT) is a time-limited treatment which structures interventions that promote the further development of mentalizing. it has been tested in research trials and found to be an effective treatment for BPD when delivered by mental health professionals given limited additional training and with moderate levels of supervision. This supports the general utility of MBT in the treatment of BPD within generic mental health services.

Psychoanalytic Process: Theory, Clinical Observation, and Empirical Research

Article

Mar 1988

Howard S Sudak

Pragmatic randomized controlled trial of long-term psychoanalytic psychotherapy for treatment-resistant depression: The Tavistock Adult Depression Study (TADS)

Article

Sep 2015

This pragmatic randomized controlled trial tested the effectiveness of long-term psychoanalytic psychotherapy (LTPP) as an adjunct to treatment-as-usual according to UK national guidelines (TAU), compared to TAU alone, in patients with long-standing major depression who had failed at least two different treatments and were considered to have treatment-resistant depression. Patients (N=129) were recruited from primary care and randomly allocated to the two treatment conditions. They were assessed at 6-monthly intervals during the 18 months of treatment and at 24, 30 and 42 months during follow-up. The primary outcome measure was the 17-item version of the Hamilton Depression Rating Scale (HDRS-17), with complete remission defined as a HDRS-17 score ≤8, and partial remission defined as a HDRS-17 score ≤12. Secondary outcome measures included self-reported depression as assessed by the Beck Depression Inventory - II, social functioning as evaluated by the Global Assessment of Functioning, subjective wellbeing as rated by the Clinical Outcomes in Routine Evaluation - Outcome Measure, and satisfaction with general activities as assessed by the Quality of Life Enjoyment and Satisfaction Questionnaire. Complete remission was infrequent in both groups at the end of treatment (9.4% in the LTPP group vs. 6.5% in the control group) as well as at 42-month follow-up (14.9% vs. 4.4%). Partial remission was not significantly more likely in the LTPP than in the control group at the end of treatment (32.1% vs. 23.9%, p=0.37), but significant differences emerged during follow-up (24 months: 38.8% vs. 19.2%, p=0.03; 30 months: 34.7% vs. 12.2%, p=0.008; 42 months: 30.0% vs. 4.4%, p=0.001). Both observer-based and self-reported depression scores showed steeper declines in the LTPP group, alongside greater improvements on measures of social adjustment. These data suggest that LTPP can be useful in improving the long-term outcome of treatment-resistant depression. End-of-treatment evaluations or short follow-ups may miss the emergence of delayed therapeutic benefit.

The therapeutic and working alliances

Article

Nov 1975
Int J Psychoanal Psychother

M Kanzer

The concepts of the "therapeutic alliance" (Zetzel, 1956) and "working alliance" (Greeson, 1965) are traced in their antecedents to Freud and other analysts and compared especially with Freud's "analytic pact." Differences both in theory and practice are elucidated with the aid of case material. While the therapeutic and working alliances are often used interchangeably, they are found to take up their positions at diametrically opposite points along a continuum defined by the analytic pact and show a marked tendency to depart from the guidance offered the traditional analysis by the fundamental rule. They should be regarded more as exercises in analytically oriented psychotherapy than parameters of the traditional technique. Nevertheless, as a basis for comparisons, it should be recognized that the latter technique: (1) does not formulate in theory many of the measures left for pragmatic fulfillment; (2) does not include genetic, structural and adaptive viewpoints that later developments require. Current tendencies to include the analyst's self-observations in relation to the total analytic process point up the growing influence of these more recent considerations.

First empirical evaluation of the link between attachment, social cognition and borderline features in adolescents

Article

Jul 2015

Several developmental models of borderline personality disorder (BPD) emphasize the role of disrupted interpersonal relationships or insecure attachment. As yet, attachment quality and the mechanisms by which insecure attachment relates to borderline features in adolescents have not been investigated. In this study, we used a multiple mediational approach to examine the cross-sectional interplay between attachment, social cognition (in particular hypermentalizing), emotion dysregulation, and borderline features in adolescence, controlling for internalizing and externalizing symptoms. The sample included 259 consecutive admissions to an adolescent inpatient unit (Mage=15.42, SD=1.43; 63.1% female). The Child Attachment Interview (CAI) was used to obtain a dimensional index of overall coherence of the attachment narrative. An experimental task was used to assess hypermentalizing, alongside self-report measures of emotion dyregulation and BPD. Our findings suggested that, in a multiple mediation model, hypermentalizing and emotion dysregulation together mediated the relation between attachment coherence and borderline features, but that this effect was driven by hypermentalizing; that is, emotion dysregulation failed to mediate the link between attachment coherence and borderline features while hypermentalizing demonstrated mediational effects. The study provides the first empirical evidence of well-established theoretical approaches to the development of BPD. Copyright © 2015. Published by Elsevier Inc.

Hope and Dread in Dread in Psychoanalysis

Book

Jan 1993

Stephen A Mitchell

A Secure base

Book

Jan 1988

John Bowlby

A Meeting of Minds: Mutuality in Psychoanalysis

Book

Jan 1996

Lewis Aron

Beware the Dodo Bird: The Dangers of Overgeneralization

Article

Feb 2002

Dianne L. Chambless

Luborsky et al.'s conclusion that there are no meaningful differences in the efficacy of various psychotherapies should be reconsidered for the following reasons: (a) errors in data analysis, (b) exclusion of research on many types of clients (e.g., children and adolescents), (c) faulty generalization to comparisons between therapies that have never been made, and (d) erroneous assumption that the average difference between all sorts of treatments for all sorts of problems can be assumed to represent the difference between any two types of treatment for a given problem. Concern for clients' welfare demands that psychologists be very wary of accepting the Dodo bird verdict.

The Dodo Bird Is Extinct

Article

Feb 2002

Larry E. Beutler

It may be quite inaccurate and certainly it is premature to identify the dodo bird as the mascot for psychotherapy research. The dodo bird is not as alive and well as some may wish. The complexity of determining the presence of specific effects has been underestimated and, more importantly, the evidence of specific effects in treatments have been largely ignored by those who adopt a dodo bird's perspective. The article by Luborsky et al. in this issue illustrates these misperceptions and exclusions. Here I review some of the evidence for the premature ascendence of the dodo bird and raise questions about the nature of current research methodologies for assessing the presence of specific effects and especially for disclosing differential treatment contributors to treatment outcome.

Clients' Deference in Psychotherapy

Article

Oct 1994

DL RENNIE

In the present study, 14 psychotherapy clients were interviewed about their recollections, assisted by tape replay, of an immediately preceding therapy session. A major category derived from a grounded theory analysis of the interview protocols was client's deference to the therapist, constituted of 8 lower level categories: concern about the therapist's approach, fear of criticizing the therapist, understanding the therapist's frame of reference, meeting the perceived expectations of the therapist, accepting the therapist's limitations, client's metacommunication, threatening the therapist's self-esteem, and indebtedness to the therapist. The P. Brown and S. Levinson (1987) model of politeness in discourse both informs and is informed by the results of this study, which are also discussed in terms of recent literature on the client's covert experience and in terms of their implications for the practice of therapy.

Barber, J. P., Muran, J.C., McCarthy, K.S., Keefe, R.J. (2013). Research on Psychodynamic Therapies. In M. J. Lambert (Ed.). Bergin and Garfield's Handbook of Psychotherapy and Behavior Change (6th ed.) (pp. 443-494). New-York, NY: John Wiley & Sons, Inc.

Abstract

No full-text available

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