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)     

Describing the face of transference: Psychodynamic therapists' recollections about transference in cases of successful long-term therapy.

This study used the consensual qualitative research method to address questions about therapists' perceptions of transference in long-term therapy: How does transference operate? How is transference dealt with and resolved? What problems do therapists encounter with transference? Eleven dynamically oriented therapists were interviewed by phone about a successful case in which transference was an important part of treatment. On the basis of therapists' recollections, findings suggested that transference operated in a complex manner in terms of source, valence, themes, and the events influencing it; therapists used a wide range of techniques (nonanalytic and analytic) to deal with transference; working alliance, real relationship, and client emotional insight importantly influenced the resolution of transference; and a variety of countertransference reactions and mistakes were encountered when dealing with transference. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Transference, insight, and the course of time-limited therapy.

This study examined (a) the interactive role of therapist-rated transference and insight (in first session and first quarter of treatment) in predicting the outcome of time-limited therapy and (b) the course of therapist-rated transference and insight in more and less successful cases. The sample consisted of 33 completed cases. Although neither transference nor insight alone predicted outcome, the interaction of transference and emotional insight was significantly related to both client- and therapist-rated outcome. The course of negative transference and overall amount of transference differentiated more successful from less successful cases. In more successful cases, transference increased during the first three quarters of treatment and then declined, whereas in less successful cases, transference continued to increase throughout treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Exploring a psychotherapeutic change sequence: Relating process to intersessional and posttreatment outcome.

Process was related to intermediate and posttreatment outcomes for 34 patients undergoing multimodal group therapy. Exploratory time series analysis suggested that process variable effects differed with the phase of the therapy. It appeared that an emotionally warm bond occurred between patient and therapist in the sessions prior to therapist-rated improvement. A patient rating of insight followed in subsequent sessions. A negative feedback loop between patient symptom levels and therapist negative patient-directed feelings was demonstrated. Patient dysphoria in later therapy sessions seemed to reflect an earlier therapeutic failure. Ego strength directly exerted its positive influence on outcome in later sessions. The relation between in-therapy process trends and overall outcome supported these findings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Theory-based research for understanding the process of dynamic psychotherapy.

Research is reviewed on 6 theoretical propositions central to psychodynamic psychotherapy: (1) The establishment of an alliance is important to successful outcome; (2) the patient displays a central relationship theme (transference); (3) transference interpretations are helpful; (4) the therapist aims at accurate interpretations of the transference; (5) the patient gains understanding of self and the relationship pattern; and (6) the patient's improvement is reflected in changes in the relationship pattern, although the pattern is still evident. We suggest concepts that are in need of research development: internalization, resistance, working through, self-understanding and insight, and the therapist's adherence to recommended techniques. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Two aspects of the therapeutic alliance: Differential relations with depressive symptom change.

Objective: The therapeutic alliance has been linked to symptom change in numerous investigations. Although the alliance is commonly conceptualized as a multidimensional construct, few studies have examined its components separately. The current study explored which components of the alliance are most highly associated with depressive symptom change in cognitive therapy (CT). Method: Data were drawn from 2 published randomized, controlled clinical trials of CT for major depressive disorder (n = 105, mean age = 40 years, female = 62%, White = 82%). We examined the relations of 2 factor-analytically derived components of the Working Alliance Inventory (WAI; Horvath & Greenberg, 1986, 1989) with symptom change on the Beck Depression Inventory—II (BDI–II; Beck, Steer, & Brown, 1996) that occurred either prior to or subsequent to the examined sessions. WAI ratings were obtained at an early and a late session for each therapist–patient dyad. Results: Variation in symptom change subsequent to the early session was significantly related to the WAI factor that assesses therapist–patient agreement on the goals and tasks of therapy but not to a factor assessing the affective bond between therapist and patient. In contrast, both factors, when assessed in a late session, were significantly predicted by prior symptom change. Conclusions: These findings may reflect the importance, in CT, of therapist–patient agreement on the goals and tasks of therapy. In contrast, the bond between therapist and patient may be more of a consequence than a cause of symptom change in CT. The implications of these results and directions for future research are discussed. (PsycINFO Database Record (c) 2011 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.     

The missed session: A neglected aspect of psychodynamic psychotherapy.

Missed sessions, whether initiated by the patient, therapist, or nature, are events in psychotherapy, not non-events. When appropriately handled, missed sessions provide valuable opportunities for therapeutic exploration. A clear cancellation policy, discussed early in therapy, offers a frame within which therapist and patient may understand the meanings of the missed session. An awareness of transference and countertransference contributes to therapeutic implementation of the cancellation policy and resulting maintenance of exploratory space. Therapists whose cancellation policies are unclear, too rigid, or too lenient render the therapy unsafe. Addressing the financial implications of a missed session before attending to motivations and feelings surrounding it is a clinical mistake. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An empirical study of the natural history of time-limited psychotherapy for stress response syndromes.

30 White female patients (aged 21–53 yrs) received individual, time-limited (12 sessions), dynamic psychotherapy following the death of a parent. Treatment followed the principles for the treatment of stress response syndromes and included focused use of suggestion, interpretation, clarification, abreaction, and work to resolve impending defenses and transference reactions. The patients' 11 therapists completed the 34-item Therapist Action Scale to indicate actions used in therapy. Results show that of the 6 dimensions that varied significantly over the course of the 12 sessions, Transference and Termination showed the most dramatic change across time, changing from a relatively low emphasis early in psychotherapy to the 2nd highest action in the final session. Findings indicate systematic variation in therapist actions. The way changes occurred across sessions depended on the kind of actions the therapist took. The last session was not representative of other sessions in the treatment. (30 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Children''s emerging regulation of conduct: restraint, compliance, and internalization from infancy to the second year

Receptor-mediated endocytosis of circulating collagen is a major physiological scavenger function of the liver endothelial cell and an important catabolic event in the complete turnover of this abundant connective tissue protein. In the present study, transport of collagen through the endocytic pathway was investigated in cultured liver endothelial cells. Collagen conjugated to fluorescein isothiocyanate, to allow detection of the ligand by fluorescence and immunoelectron microscopy, was found sequentially in three different organelles that compose the basic degradative endocytic pathway of eukaryotic cells: early endosomes, late endosomes, and terminal lysosomes. Early endosomes were identified as vesicles positive for early endosome antigen 1 (EEA1). Late endosomes were distinguished as structures positive for the late endosomal/lysosomal marker rat lysosomal membrane glycoprotein 120, but negative for EEA1 and lysosomally targeted BSA-gold. Lysosomes were defined by their content of BSA-gold, injected 24 hours before isolation of cells. Coated pits and coated vesicles mediated an extremely rapid internalization. Shortly after internalization and during the first 20 minutes, ligand was found in early endosomes. From 20 minutes on, ligand started to appear in late endosomes (23%), and by 2 hours the transfer was largely complete (82.5%). Only 2.5% of ligand was transferred to the lysosomes after 2 hours, and this number slowly increased to 21% and 53% after 6 and 16 hours, respectively. We conclude that 1) EEA1 is a useful marker for tracing early events of endocytosis in liver endothelial cells; 2) in contrast to the rapid internalization, transit of internalized ligand through early sorting endosomes generally takes from 20 minutes to 2 hours; and 3) exit from the late endosomes is very slow, requiring several hours.     

Investigating the devaluation explanation for negative anticipatory contrast.

This study addressed whether negative anticipatory contrast results in a decrease in the value of the low-valued substance. Rats responded in training conditions designed to produce negative contrast. They then responded in test sessions in which the low-valued substance from the training sessions was the reinforcer for an operant response. Despite the finding of contrast in the training conditions, the low-valued substance was a more effective reinforcer early in testing after training conditions in which it had been followed by access to the high-valued substance than after training conditions in which it had not. The findings question the devaluation explanation for contrast but may be similar to other findings of reversals of "preference." (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Le niveau de satisfaction des cas d'abandon dans un service universitaire de psychologie.

The purpose of this study was to compare the satisfaction level of drop-out cases and completers in a university psychology clinic. We also investigated the reasons given for dropping out of treatment and the subsequent help-seeking behaviour of these patients. The sample consisted of 43 drop-out cases and a comparison group of 15 patients who remained in treatment for 20 sessions. The drop-out cases were divided into three groups: spontaneous dropouts (n = 15), early drop-outs (n = 15), and late drop-outs (n = 13). The results indicated a significant difference between the satisfaction level of drop-out cases and completers. It was also found that the main reasons given for quitting treatment were mostly related to the amount of help received and unconfirmed expectancies. These findings are discussed, as are methodological issues raised by this study. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: Findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program.

The relationship between therapeutic alliance and treatment outcome was examined for depressed outpatients who received interpersonal psychotherapy, cognitive-behavior therapy, imipramine with clinical management, or placebo with clinical management. Clinical raters scored videotapes of early, middle, and late therapy sessions for 225 cases (619 sessions). Outcome was assessed from patients' and clinical evaluators' perspectives and from depressive symptomatology. Therapeutic alliance was found to have a significant effect on clinical outcome for both psychotherapies and for active and placebo pharmacotherapy. Ratings of patient contribution to the alliance were significantly related to treatment outcome; ratings of therapist contribution to the alliance and outcome were not significantly linked. These results indicate that the therapeutic alliance is a common factor with significant influence on outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Negative affective spillover from daily events predicts early response to cognitive therapy for depression.

This study evaluated the predictive role of depressed outpatients' (N = 62) affective reactivity to daily stressors in their rates of improvement in cognitive therapy (CT). For 1 week before treatment, patients completed nightly electronic diaries that assessed daily stressors and negative affect (NA). The authors used multilevel modeling to compute each patient's within-day relationship between daily stressors and daily NA (within-day reactivity), as well as the relationship between daily stressors and next-day NA (next-day reactivity; affective spillover). In growth model analyses, the authors evaluated the predictive role of patients' NA reactivity in their early (Sessions 1-4) and late (Sessions 5-12) response to CT. Within-day NA reactivity did not predict early or late response to CT. However, next-day reactivity predicted early response to CT, such that patients who had greater NA spillover in response to negative events had a slower rate of symptom change during the first 4 sessions. Affective spillover did not influence later response to CT. The findings suggest that depressed patients who have difficulty bouncing back the next day from their NA reactions to a relative increase in daily negative events will respond less quickly to the early sessions of CT. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The transference and the zone of proximal development

The Zone of Proximal Development (ZPD) is discussed, a construct that, when introduced into psychoanalysis, advances understanding of the key clinical relationship between the intrapsychic and the interpersonal. Strands from several psychoanalytic formulations are brought together and forged into a coherent construct, which is then contrasted with the transference. It is shown how the ZPD provides the transference with its mutative potential. Just as the transference provides the motivation for the recruitment of objects to accomplish its purposes (repetition), the ZPD leads to the recruitment of objects in order to accomplish its purposes (to learn by ushering individuals into a speech and internalization community). Under the sway of the transference objects are sought so that early disregulating experiences can be repeated and an opportunity provided for a better resolution. The ZPD works in tandem with the transference, capitalizing on the impetus provided, allowing for the possibility of internalization, a beneficial outcome to transference repetition which otherwise would have no agent of conflict resolution. In analysis, when the transference and the ZPD enjoin smoothly, the potential outcome is "insight" in a broad sense. The processes of the ZPD define the optimal interpersonal context of psychoanalysis, one that allows the intrapsychic to be best reached by analytic interventions. Given the inevitability of mutual influences between analyst and analysand, the analyst strives simultaneously to be in the ZPD yet outside the transference with the analysand, a crucial tension that is a constant, precarious technical factor. This useful tension casts light on such procedural guides as optimal frustration and abstinence.     

Transference and race: An intersubjective conceptualization.

Discussions of race-based transference in the psychoanalytic literature have been infrequent. When present, such transference has been described from the Freudian or Kleinian perspective, as either a manifestation of intrapsychic conflicts or projection of unwanted mental content onto the racial other. These views, although helpful in some situations, exclude other possible meanings of interracial transference. This article describes an approach based on contemporary intersubjective theories in which race-related transference is seen as one aspect of a person's ongoing construction of experience and understanding of the unique meaning of race for each patient is emphasized. The far-reaching influence of the analyst's race and culture in the development of transference is then described, and it is argued that the analyst needs to be aware of the culture embeddedness of her or his therapeutic endeavors. Treatment issues are discussed with clinical examples. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Unique risk factors for bacteraemia in allogeneic bone marrow transplant recipients before and after engraftment

A study of the risk factors associated with bacteraemia in 191 allogeneic bone marrow transplant (BMT) recipients (1991-1996) was performed. In contrast to risk factors commonly cited for cancer chemotherapy, mucositis, degree of conditioning toxicity of the gut and lungs, duration of neutropenia, and severity of neutropenia and monocytopenia were not associated with bacteraemia in the pre-engraftment period, during which the only significant risk factor was late stage underlying disease (P < 0.05). After engraftment, Hickman catheter infection, and severe acute and chronic graft-versus-host disease (GVHD) were found to be independently associated with bacteraemia by multivariate analysis (P < 0.001, <0.05 and <0.05, respectively). This might be explained by intense antimicrobial prophylaxis, early empirical treatment, and non-routine use of haemopoietic growth factors. No significant difference in mortality was detected between bacteraemic and non-bacteraemic patients in both periods. Allogeneic BMT recipients are therefore a group of patients distinct from other cancer patients receiving chemotherapy at risk of developing bacteraemia. The study findings prompt consideration of a management protocol incorporating early and routine use of haemopoietic growth factors before engraftment in high-risk patients with late stage underlying malignancies, routine antimicrobial prophylaxis for acute GVHD with intense immunosuppression, and intravenous immunoglobulin therapy for chronic GVHD. Further cost-benefit analyses are warranted.     

Blood transfusion. An independent risk factor for postinjury multiple organ failure

OBJECTIVE: To determine if blood transfusion is a consistent risk factor for postinjury multiple organ failure (MOF), independent of other shock indexes. DESIGN: A 55-month inception cohort study ending on August 30, 1995. Data characterizing postinjury MOF were prospectively collected. Multiple logistic regression analysis was performed on 5 sets of data. Set 1 included admission data (age, sex, comorbidity, injury mechanism, Glasgow Coma Scale, Injury Severity Score, and systolic blood pressure determined in the emergency department) plus the amount of blood transfused within the first 12 hours. In the subsequent 4 data sets, other indexes of shock (early base deficit, early lactate level, late base deficit, and late lactate level) were sequentially added. Additionally, the same multiple logistic regression analyses were performed with early MOF and late MOF as the outcome variables. SETTING: Denver General Hospital, Denver, Colo, is a regional level I trauma center. PATIENTS: Five hundred thirteen consecutive trauma patients admitted to the trauma intensive care unit with an Injury Severity Score greater than 15 who were older than 16 years and who survived longer than 48 hours. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The relationship of blood transfusions and other shock indexes with the outcome variable, MOF. RESULTS: A dose-response relationship between early blood transfusion and the later development of MOF was identified. Despite the inclusion of other indexes of shock, blood transfusion was identified as an independent risk factor in 13 of the 15 multiple logistic regression models tested; the odds ratios were high, especially in the early MOF models. CONCLUSIONS: Blood transfusion is an early consistent risk factor for postinjury MOF, independent of other indexes of shock.     

Emotional Processing During Experiential Treatment of Depression.

This study explored the importance of early and late emotional processing to change in depressive and general symptomology, self-esteem, and interpersonal problems for 34 clients who received 16-20 sessions of experiential treatment for depression. The independent contribution to outcome of the early working alliance was also explored. Early and late emotional processing predicted reductions in reported symptoms and gains in self-esteem. More important, emotional-processing skill significantly improved during treatment. Hierarchical regression models demonstrated that late emotional processing both mediated the relationship between clients' early emotional processing capacity and outcome and was the sole emotional-processing variable that independently predicted improvement. After controlling for emotional processing, the working alliance added an independent contribution to explaining improvement in reported symptomology only. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

On receiving the patient's transference: the symbolizing and desymbolizing countertransference

This is an empirical study of the therapist's experience of the patient delineating the boundaries between empathy and constructive and destructive forms of countertransference. The unique step was taken of focusing a video camera on the therapist in order to trace the therapist's nonverbal behavior during listening. The same therapist was observed first in a "not-so-difficult" and then a "difficult" session; the sessions could then be distinguished along dimensions of rhythmicity or arrhythmicity of nonverbal behavior. These observations suggested three modes of experiencing the patient: empathy marked by rhythmicity, a symbolizing countertransference marked by a transitory arrhythmicity, and a desymbolizing countertransference marked by continuous arrhythmicity. The congruence of these formulations based on direct observation of therapist behavior and ones derived from retrospective reconstructions of analysts in sessions (Schwaber, Jacobs, and Laskey) was explored and was found to enhance the validity of the proposed formulations.