Effects of transference work in the context of therapeutic alliance and quality of object relations.

Objective: Transference interpretation is considered as a core active ingredient in dynamic psychotherapy. In common clinical theory, it is maintained that more mature relationships, as well as a strong therapeutic alliance, may be prerequisites for successful transference work. In this study, the interaction between quality of object relations, transference interpretation, and alliance is estimated. Method: One hundred outpatients seeking psychotherapy for depression, anxiety, and personality disorders were randomly assigned to 1 year of weekly sessions of dynamic psychotherapy with transference interpretation or to the same type and duration of treatment, but without the use of transference interpretation. Quality of Object Relations (QOR)–lifelong pattern was evaluated before treatment (P. H?glend, 1994). The Working Alliance Inventory (A. O. Horvath & L. S. Greenberg, 1989; T. J. Tracey & A. M. Kokotovic, 1989) was rated in Session 7. The primary outcome variable was the Psychodynamic Functioning Scales (P. H?glend et al., 2000), measured at pretreatment, posttreatment, and 1 year after treatment termination. Results: A significant Treatment Group × Quality of Object Relations × Alliance interaction was present, indicating that alliance had a significantly different impact on effects of transference interpretation, depending on the level of QOR. The impact of transference interpretation on psychodynamic functioning was more positive within the context of a weak therapeutic alliance for patients with low quality of object relations. For patients with more mature object relations and high alliance, the authors observed a negative effect of transference work. Conclusion: The specific effects of transference work was influenced by the interaction of object relations and alliance, but in the direct opposite direction of what is generally maintained in mainstream clinical theory. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Therapists’ attachment, patients’ interpersonal problems and alliance development over time in inpatient psychotherapy.

The focus of this study is the investigation of the relation between patients’ interpersonal problems, therapists’ attachment representations, and the development of the therapeutic alliance over time. The authors investigated weekly alliance ratings of 281 psychotherapy inpatients, treated by 12 psychotherapists. Alliance quality was measured with the Inpatient Experience Scale. Multilevel regression models showed that patients’ interpersonal problems were associated with the level of alliance quality. Therapists’ attachment security was not related to alliance development, but higher attachment preoccupation of therapists was associated with lower levels of alliance quality. In addition, an interaction effect between therapists’ degree of attachment preoccupation and patients’ interpersonal problems explained variations of the alliance development curve over time. Limitations of the study are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patient interpersonal impacts and the early therapeutic alliance in interpersonal therapy for depression.

The therapeutic alliance consistently predicts positive psychotherapy outcomes. Thus, it is important to uncover factors that relate to alliance development. The goal of this study was to examine the association between patient interpersonal characteristics and alliance quality in interpersonal therapy for depression. Data derive from a subsample (n = 74) of a larger naturalistic database of outpatients treated at a mood disorders clinic of a university-affiliated psychiatric hospital. Following Session 3 of treatment, therapists completed the Impact Message Inventory (Kiesler & Schmidt, 1993) to assess patients' interpersonal impacts on them. Also following Session 3, patients completed the Working Alliance Inventory (Horvath & Greenberg, 1989) to assess alliance quality. As predicted, patients' affiliative interpersonal impacts, as perceived by their therapists, were positively associated with alliance quality, controlling for baseline depression severity. Although unrelated to the initial hypotheses, patients concurrently taking psychotropic medications reported better alliances than patients receiving psychotherapy only. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Testing a model of change in the experiential treatment of depression.

In this study, we measured emotional processing and the alliance across 3 phases of therapy (beginning, working, and termination) for 74 clients who each received brief experiential psychotherapy for depression. Using path analysis, we proposed and tested a model of relationships between these 2 processes across phases of therapy and how these processes relate to predict improvement in the domains of depressive and general symptoms, self-esteem, and interpersonal problems after experiential treatment. Both therapy processes significantly increased across phases of therapy. Controlling for both client processes at the beginning of therapy, working phase emotional processing was found to directly and best predict reductions in depressive and general symptoms, and it could directly predict gains in self-esteem. Within working and termination phases of therapy, the alliance significantly contributed to emotional processing and indirectly contributed to outcome. Surprisingly, beginning therapy alliance (measured after Session 1) also directly predicted all outcomes. Furthermore, only clients’ beginning therapy process predicted reductions in interpersonal problems. Therefore, although the proposed theory of change was supported, clients’ beginning therapy processes may constrain clients’ success in experiential treatment and in particular their outcomes in some problem domains related to depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Identification and analyses of periodontal pathogens in Taiwan by microbiological tests

The effectiveness of transference interpretation in the psychodynamic psychotherapy of patients with borderline personality disorder has been highly controversial. Both highly expressive approaches that stress the value of transference interpretation and supportive strategies that eschew transference work have been advocated in the literature. We review this literature and identify three emerging trends in thought: (1) Primarily interpretive approaches should be reserved for patients with greater levels of ego strength. (2) Whichever technique is used, a strong therapeutic alliance is the foundation of treatment. (3) Expressive and supportive techniques should not be juxtaposed as polarized opposites; supportive interventions often pave the way for transference interpretation. Our psychotherapy process study revealed that transference interpretations tended to have greater impact--both positive and negative--than other interventions made with patients with borderline personality disorder. We conclude that such factors as neuropsychologically based cognitive dysfunction, a history of early trauma, patterns of object relations involving interpersonal distance, masochistic tendencies, and anaclitic rather than introjective psychopathology are among the patient characteristics that influence the impact of transference interpretation on the therapeutic alliance. Bias toward expressive technique and countertransference issues appear to be relevant to the therapist's difficulty in shifting to a more supportive approach when indicated.     

Change in working alliance, social support, and psychological symptoms in brief therapy.

Many interpersonal therapists use the working alliance as a vehicle for client change and as a corrective experience for clients to learn new relationship skills. 34 19–28-yr-old clients in brief therapy completed measures of social support and psychological symptoms at pretest and termination and a measure of working alliance after the third session and at termination. Path analysis suggested that improvement in the working alliance was significantly related to improvement in social support and that improvement in social support was significantly related to symptom reduction. The working alliance appears to have an important indirect connection to symptom reduction, through the mediating influence of increased support. After the effects of improved alliance were controlled, increased support was still related to decreased symptoms; however, after the effects of social support were controlled, the relation between change in alliance and symptoms was not significant. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patient pretreatment interpersonal problems and therapeutic alliance in short-term cognitive therapy.

The growing consensus regarding the importance of interpersonal process in psychotherapy, as well as of interpersonal factors in self-definition, has underscored the relevance of examining patient interpersonal functioning as it relates to the development of the therapeutic alliance. This study examined the relationship of patient pretreatment interpersonal functioning, as measured by the Inventory of Interpersonal Problems and the Millon Clinical Multiaxial Inventory (MCMI), to the therapeutic alliance, as measured early in treatment by a patient self-report version of the Working Alliance Inventory. On the basis of an interpersonal circumplex interpretation, the results generally indicated that friendly-submissive interpersonal problems were positively related to the development of aspects of the alliance and that hostile-dominant problems were negatively related to the development of aspects of the alliance early in short-term cognitive therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relational interpretations.

We review studies of relational interpretations as predictors of psychotherapy outcome and alliance. Investigations examining frequency of interpretations and outcome have yielded mixed findings. However, studies specifically of transference interpretations have converged toward the conclusion that high rates of transference interpretations can lead to poor outcome, particularly for patients with low quality of object relations. Several studies of the quality of interpretations have yielded consistent findings suggesting that relatively more favorable treatment outcomes are produced when therapists accurately address central aspects of patients' interpersonal dynamics. Few studies that have examined the relation between interpretations and the therapeutic alliance or tested the common clinical notion that interpretations have their greatest impact in the context of a positive alliance. Practice implications based upon this research literature are proposed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Skills training in affective and interpersonal regulation followed by exposure: A phase-based treatment for PTSD related to childhood abuse.

Fifty-eight women with posttraumatic stress disorder (PTSD) related to childhood abuse were randomly assigned to a 2-phase cognitive-behavioral treatment or a minimal attention wait list. Phase 1 of treatment included 8 weekly sessions of skills training in affect and interpersonal regulation; Phase 2 included 8 sessions of modified prolonged exposure. Compared with those on wait list, participants in active treatment showed significant improvement in affect regulation problems, interpersonal skills deficits, and PTSD symptoms. Gains were maintained at 3- and 9-month follow-up. Phase 1 therapeutic alliance and negative mood regulation skills predicted Phase 2 exposure success in reducing PTSD, suggesting the value of establishing a strong therapeutic relationship and emotion regulation skills before exposure work among chronic PTSD populations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Personality, Interpersonal, and Motivational Predictors of the Working Alliance in Group Cognitive-Behavioral Therapy for Partner Violent Men.

Recent studies have demonstrated that the working alliance predicts treatment outcome for partner violent men. This study examined the influence of personality and interpersonal characteristics, motivational readiness to change, and demographic factors on working alliance formation among a sample of men (N = 107) participating in a cognitive-behavioral group treatment program for partner violence. Motivational readiness to change was the strongest predictor of the working alliance. Psychopathic personality characteristics also emerged as a strong (negative) predictor of the working alliance. Lower levels of borderline personality characteristics and interpersonal problems, self-referred status, married status, and higher age and income predicted higher working alliance ratings. The results support recent clinical efforts to address motivational readiness in programs for partner violent men. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predictors of success in emotionally focused marital therapy

This study examined client variables expected to predict success in emotionally focused marital therapy (EFT), now the second most validated form of marital therapy after the behavioral approaches. The relationship of attachment quality, level of emotional self-disclosure, level of interpersonal trust, and traditionality to the therapy outcome variables, marital adjustment, intimacy, and therapist ratings of improvement, was examined. These variables were chosen for their relevance to the theory and practice of EFT and to intimate relationships in general. Overall, therapeutic alliance predicted successful outcome; the task dimension of the alliance in particular predicted couples' satisfaction. More specifically, one dimension of female partners' trust, their faith in their partner, predicted couples' satisfaction at follow-up. Females' faith also significantly predicted males' level of intimacy at follow-up. Males who were most likely to be nondistressed at termination indicated higher levels of proximity seeking on an attachment measure at intake, and older males and males whose partners had higher levels of faith in them were more likely to be nondistressed at follow-up. Traditionality was not found to be significantly related to outcome. Couples who made the most gains at follow-up also indicated lower initial marital satisfaction and included males who indicated lower levels of use of attachment figure on the attachment measure at intake. Males who made the largest gains at termination were older and were rated as less expressive by their partner on self-disclosure measures at intake. Age was the only variable significantly related to males' gains in satisfaction at follow-up. Implications for the practice of marital therapy and future research are delineated.     

The mediating role of insight for long-term improvements in psychodynamic therapy.

Objective: According to psychoanalytic theory, interpretation of transference leads to increased insight that again leads to improved interpersonal functioning over time. In this study, we performed a full mediational analysis to test whether insight gained during treatment mediates the long-term effects of transference interpretation in dynamic psychotherapy. Method: This study is a randomized clinical trial with a dismantling design. One hundred outpatients seeking psychotherapy for depression, anxiety, personality disorders, and interpersonal problems were randomly assigned to 1 year of weekly sessions of dynamic psychotherapy with transference interpretation or to the same type and duration of treatment with the same therapists but without the use of transference interpretation. Interpersonal functioning and insight were measured pretreatment, posttreatment, and 1 year and 3 years after treatment termination. Results: Contrary to common expectation, patients with a life-long pattern of low quality of object relations and personality disorder pathology profited more from therapy with transference interpretation than from therapy with no transference interpretation. This long-term effect was mediated by an increase in the level of insight during treatment. Conclusions: Insight seems to be a key mechanism of change in dynamic psychotherapy. Our results bridge the gap between clinical theory and empirical research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Role of perfectionism and personality disorder features in response to brief treatment for depression.

Using data from the Treatment of Depression Collaborative Research Program (TDCRP), the authors compared the role of patients' perfectionism and features of personality disorder (PD) in the outcome of brief treatment for depression. Data were extracted as to patients' intake levels of symptoms; perfectionism; and PD features, measured as continuous variables, as well as their symptoms at termination; their contribution to the therapeutic alliance; and their satisfaction with social relations. Poorer therapeutic outcome was demonstrated for patients with elevated levels of perfectionism and odd-eccentric and depressive PD features. Patients' contribution to therapeutic alliance and satisfaction with social relations were predicted by perfectionism but not by PD features. Results highlight the central role played by patients' personality in the course of brief treatment for depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Prediction of dropping out in time-limited, interpretive individual psychotherapy.

Predictors of dropping out were investigated for patients who participated in time-limited, interpretive individual psychotherapy in a randomized clinical trial. A sample of 22 dropouts was compared with a sample of 22 matched completers on pretherapy and therapy process variables. A modified Vanderbilt Psychotherapy Process Scale was used to assess patient hostility and patient and therapist exploration and focus on transference. Pretherapy predictors, which included demographic, diagnostic, and initial disturbance outcome variables, did not significantly differentiate the two groups. Therapeutic alliance, dynamic and supportive work, patient exploration, and focus on transference significantly differentiated dropouts from completers. For dropouts, there was a weaker alliance, less work, less exploration, and greater focus on transference. Examination of the last session of dropouts revealed a nonproductive pattern characterized by resistance and transference interpretation. Implications and limitations associated with the study are considered. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Attachment, group attraction and self-other agreement in interpersonal circumplex problems and perceptions of group members.

Graduate students (N=76) fulfilling a class requirement for interpersonal group participation completed measures of interpersonal problems and adult attachment at pretest. At the midpoint and at termination they completed measures of interpersonal problems and group attraction and provided interpersonal circumplex ratings of each fellow group member. As predicted, selected attachment insecurities were significantly correlated with interpersonal problems and group attraction. Attachment anxiety and avoidance, also as hypothesized, were associated with discrepancies in self-other perceptions. Whereas members with attachment avoidance tended to overestimate hostile and hostile-submissive problems, members with attachment anxiety were likely to overestimate interpersonal problems in the "friendly" half of the circumplex. Implications for the conceptualization of attachment-based distortions and interpersonal learning in group therapy are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Client interpersonal and cognitive styles as predictors of response to time-limited cognitive therapy for depression.

This study examined the relationship between cognitive and interpersonal styles and outcome among 24 clients who received time-limited cognitive therapy for depression. The authors hypothesized that this relationship would be mediated by therapeutic alliance. They found that clients' interpersonal style, particularly an underinvolved style, was predictive of treatment outcome. As predicted, the impact of this style on outcome was mediated through the therapeutic alliance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapist retrospective recall impasses in long-term psychotherapy: A qualitative analysis.

Twelve experienced therapists completed a questionnaire, and 8 of the 12 were then interviewed about their experiences with a therapeutic impasse that ended in the termination of therapy. Data were analyzed using a qualitative methodology. Results indicated that most of the clients were anxious and depressed with personality disorders and interpersonal problems. Therapists perceived impasses as having a profound negative impact on both clients and therapists. Variables associated with impasses in a majority of the cases were a client history of interpersonal problems, a lack of agreement between therapists and clients about the tasks and goals of therapy, interference in the therapy by others, transference, possible therapist mistakes, and therapist personal issues. Implications for training, practice, and research are provided. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapeutic alliance and clinical outcome in the NIMH Treatment of Depression Collaborative Research Program: Preliminary findings.

Investigated the effect of the therapeutic alliance on clinical outcome in the 7 most improved and 7 least improved cases in the 4 treatments investigated in a study (I. Elkin et al; see PA, Vols 72:20648 and 77:10249) of treatment of depression. The treatments were interpersonal therapy (IPT), cognitive-behavior therapy, imipramine plus clinical management, and placebo plus clinical management. Clinical observer ratings of alliance, using Vanderbilt Therapeutic Alliance Total Scale scores, were compared across and within treatment groups and were related to clinical status at termination. Despite selective, significant relationships between alliance and outcome across treatments, the alliance–outcome relationship was significant only for IPT within treatments. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment expectancies, patient alliance and outcome: Further analyses from the National Institute of Mental Health Treatment of Depression Collaborative Research Program.

Prior analyses from the National Institute of Mental Health Treatment of Depression Collaborative Research program indicated that patients' expectancies of treatment effectiveness (S. M. Sotsky et al., 1991) and the quality of the therapeutic alliance (J. L. Krupnick et al., 1996) predicted clinical improvement. These data were reanalyzed to examine the hypothesis that the link between treatment expectancies and outcome would be mediated by patients' contribution to the alliance. Among 151 patients who completed treatment, this hypothesis was suported, suggesting that patients who expect treatment to be effective tend to engage more constructively in session, which help bring about symptom reduction. Therapists' expectancies for patient improvement also predicted outcome, although this association was not mediated by the alliance. None of the expectancy scales interacted with alliance ratings in the prediction of clinical improvement. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapeutic Alliance and Treatment Adherence in Two Interventions for Bulimia Nervosa: A Study of Process and Outcome.

The relationship between therapeutic alliance, therapist adherence to treatment protocol, and outcome was analyzed in a randomized trial of cognitive-behavioral therapy (CBT) and interpersonal psychotherapy for bulimia nervosa. Independent observers rated audiotapes of full-length therapy sessions. Purging frequency was the primary outcome variable. There were no significant therapist or Therapist × Treatment effects on outcome. Although results showed high levels of alliance and adherence across treatments, CBT was associated with greater adherence. Across treatments and time points, better adherence was associated with enhanced alliance. Treatment condition and baseline purging frequency, but not adherence, predicted outcome. Early alliance predicted posttreatment purging frequency. In temporal analyses, prior symptom change assessed early in treatment was significantly related to subsequent adherence at midtreatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)