Bias in psychotherapist ratings of client transference and insight.

The psychology literature at large considers rater bias to be a substantial source of error in observer ratings. Yet, it is typically ignored by psychotherapy researchers using participant (psychotherapist/client) ratings. In particular, interrater variability, or differences between raters' overall tendency to rate others favorably or unfavorably, has been a largely ignored source of error in studies that use psychotherapists and/or clients as raters. Ignoring rater bias can have serious consequences for statistical power and for interpretation of research findings. Rater bias may be a particular problem in psychotherapy research, as psychotherapists are often asked to rate subjective variables that require much rater inference. Consequently, we examined the extent to which rater bias is a factor in psychotherapist ratings of client transference and insight, by comparing psychotherapist variance from these ratings to psychotherapist variance in ratings of client-perceived emotional intelligence, using Hierarchical Linear Modeling. Results suggest that bias may be a substantial source of error in psychotherapist process and relationship ratings, accounting for, on average, 38% of the total variance in scores, and 30% after accounting for perceived emotional intelligence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The efficacy of psychodynamic psychotherapy.

Empirical evidence supports the efficacy of psychodynamic therapy. Effect sizes for psychodynamic therapy are as large as those reported for other therapies that have been actively promoted as “empirically supported” and “evidence based.” In addition, patients who receive psychodynamic therapy maintain therapeutic gains and appear to continue to improve after treatment ends. Finally, nonpsychodynamic therapies may be effective in part because the more skilled practitioners utilize techniques that have long been central to psychodynamic theory and practice. The perception that psychodynamic approaches lack empirical support does not accord with available scientific evidence and may reflect selective dissemination of research findings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Supportive-expressive psychodynamic therapy for cocaine dependence: A closer look.

Using data from the National Institute on Drug Abuse Collaborative Cocaine Treatment Study, this article focuses on the outcomes of patients who received supportive-expressive (SE) psychodynamically oriented psychotherapy (plus group drug counseling; GDC). Short-term SE for cocaine dependent individuals, while not the most efficacious treatment examined in the study (individual drug counseling [IDC] plus GDC was), produced large improvements in cocaine use. In addition, there was evidence that SE was superior to IDC on change in family/social problems at the 12-month follow-up assessment, particularly for those patients with relatively more severe difficulties in this domain at baseline. For patients who achieved abstinence early in treatment, SE produced comparable drug use outcomes to IDC, with mean drug use scores numerically lower for SE at all of the follow-up assessments (9, 12, 15, and 18 months). SE patients who achieved initial abstinence decreased cocaine use from a mean 10.1 day per month at baseline to a mean of 1.3 days at 12 months. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

When it comes to evaluating psychodynamic therapy, the devil is in the details.

Comments on the original article, "The efficacy of psychodynamic psychotherapy," by J. Shedler (see record 2010-02208-012). As Shedler noted, some researchers have reflexively and stridently dismissed psychodynamic therapy (PT) as ineffective without granting outcome studies on this modality a fair hearing. We applaud Shedler’s efforts to bring PT into the scientific mainstream and hope that his article encourages investigators to evaluate claims regarding PT’s efficacy with a more objective eye. Nevertheless, as Shedler also observed, one reason for the scientific community’s premature dismissal of PT is traceable to some psychodynamic practitioners’ historical antipathy toward controlled research and propensity to overstate PT’s efficacy. Regrettably, Shedler falls prey to the latter error by glossing over key methodological details, ignoring crucial findings that run counter to his position, and overstating the quality and quantity of the evidence base for PT. Because of space constraints, we focus only on a handful of the more serious shortcomings of Shedler’s analysis (a more complete review of these issues is available from the first author on request). (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Brief psychodynamic and cognitive therapy regarding acute treatment.

Cognitive–behavioral therapy (CBT) and psychodynamic psychotherapy either in their pure forms or possibly synthesized as a form of eclectic therapy appear to be the 2 most commonly utilized forms of psychotherapy, both having levels of empirical support. As the majority of outpatient therapy in America appears to be very brief, 1 reasonable assumption is that treatment is often sought for resolution of acute episodes. A relevant question for practice and clinical training is what are the potential implications with brief psychodynamic and cognitive therapy for this type of treatment? This brief commentary will address the following: (a) the current general differential empirical status of each approach; (b) distinctions between acute treatment and traditional brief therapy and current common treatment patterns; and (c) the general clinical mechanisms for change for each approach and their potential implications regarding acute treatment and clinical supervision. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Methods and mechanisms in the efficacy of psychodynamic psychotherapy.

Comments on the original article, "The efficacy of psychodynamic psychotherapy," by J. Shedler (see record 2010-02208-012). Shedler summarized a large body of research that shows psychodynamic therapy to have a substantial effect size, comparable to that for many empirically supported treatments. This is an important finding, in part refuting the concerns raised by Bornstein (2001, 2002) regarding the future of psychodynamic approaches had there been no substantial changes in how practitioners and researchers approached the science to demonstrate efficacy. Further, Shedler showed that the efficacy of psychoanalytic psychotherapy is due to therapeutic methods commonly employed in cognitive behavior therapy (CBT), one of the most frequently cited empirically supported approaches for a wide range of psychological conditions. From a methodological perspective, there are some important limitations to the claim of psychodynamic psychotherapy’s comparable efficacy to other empirically supported approaches. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapist interpretation, patient-therapist interpersonal process, and outcome in psychodynamic psychotherapy for avoidant personality disorder.

[Correction Notice: An erratum for this article was reported in Vol 43(3) of Psychotherapy: Theory, Research, Practice, Training (see record 2006-12148-017). The correct legend for Figure 1 on page 500 should read as follows: Figure 1. The SASB circumplex model, cluster version, interpersonal surfaces. Adapted from Benjamin (1993), Interpersonal diagnosis and treatment of personality disorders. New York: Guilford Press, copyright Guilford Press, and from: Benjamin (1987), Use of the SASB dimensional model to develop treatment plans for personality disorders, I: Narcissism. Journal of Personality Disorders, 1, 43-70, copyright Guilford Press.] The authors examined the link between interpretive techniques, the therapeutic relationship, and outcome in psychodynamic psychotherapy. Two independent teams of judges each coded one early session from patients diagnosed with avoidant personality disorder. Results revealed (a) an inverse association between concentration of interpretation and favorable patient outcome; (b) that small amounts of disaffiliative patient-therapist transactions before, during, and after interpretations were reliably or meaningfully associated with negative patient change; and (c) concentration of interpretation was positively associated with disaffiliative therapy process before and during interpretation and negatively associated with affiliative patient responses to interpretation. The results suggest that therapists who persisted with interpretations had more hostile interactions with patients and had patients who reacted with less warmth than therapists who used interpretations more judiciously. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Levels of interpretation in dynamic psychotherapy.

Interpretation of patterns and warded-off ideas and feelings may be focused at many levels of content. These content areas range from the relatively recent stressors and immediate responses to stress to the deepest levels of warded-off, unconscious scenarios, agendas, self-concepts, and role relationship models. This range from external events to the psychological manifestations of unconscious drives may also be interpreted in terms of the usual triangle of insight, involving the current situation, the therapy situation, and past situations during developmental periods. A system for describing such levels of interpretation is described. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A manual-based psychodynamic therapy for treatment-resistant borderline personality disorder.

The authors introduce a manual-based treatment, labeled dynamic deconstructive psychotherapy, developed for those patients with borderline personality disorder who are most difficult to engage in therapy, such as those having co-occurring substance use disorders. This treatment model is based on the hypothesis that borderline pathology and related behaviors reflect impairment in specific neurocognitive functions, including association, attribution, and alterity that form the basis for a coherent and differentiated self. Dynamic deconstructive psychotherapy aims to activate and remediate neurocognitive self-capacities by facilitating elaboration of affect-laden interpersonal experiences and integration of attributions, as well as providing novel experiences in the patient-therapist relationship that promote self-other differentiation. Treatment involves weekly individual sessions for a predetermined period of time and follows sequential stages. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Do personality problems improve during psychodynamic supportive–expressive psychotherapy? Secondary outcome results from a randomized controlled trial for psychiatric outpatients with personality disorders.

Studies involving patients with personality disorders (PDs) have not focused on improvement of core aspects of the PD. The authors examined changes in quality of object relations, interpersonal problems, psychological mindedness, and personality traits in a sample of 156 patients with Diagnostic and Statistical Manual of Mental Disorders (4th ed.) PD diagnoses being randomized to either manualized or nonmanualized dynamic psychotherapy. Effect sizes adjusted for symptomatic change and reliable change indices were calculated. The authors found that both treatments were equally effective at reducing personality pathology. Only in neuroticism did the nonmanualized group do better during the follow-up period. The largest improvement was found in quality of object relations. For the remaining variables, only small and clinically insignificant magnitudes of change were found. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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)     

An augmented model of brief psychodynamic interpersonal therapy for patients with nonepileptic seizures.

Nonepileptic seizures (NES) are one of the most common functional (medically unexplained) symptoms seen by neurologists. Although most experts consider psychotherapy the treatment of choice, few therapeutic approaches have been described in detail. Given that NES occur in the context of many different psychopathologies, it remains uncertain whether there is 1 intervention that can benefit all comers or whether it is necessary to offer individualized psychotherapy. This article describes an approach grounded in psychodynamic interpersonal therapy but augmented with elements of cognitive–behavioral therapy, somatic trauma therapy, and the involvement of caregivers and family members. The approach was developed in the setting of a specialist psychotherapy service for patients with functional neurological disorders presenting to British hospital-based neurologists. The authors have previously shown that it is associated with significant improvements in psychological functioning, health-related functioning, and a symptom count. Three case reports illustrate how the treatment can be adapted to meet different patients' needs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The amygdala's role in long-term declarative memory for gist and detail.

In humans, the emotional nature of stimuli appears to have a complex influence on long-term declarative memory for those stimuli: Whereas emotion enhances memory for gist, it may suppress memory for detail. On the basis of prior studies, the authors hypothesized that the amygdala helps mediate the above 2 effects. Long-term memory for gist and for visual detail of aversive and neutral scenes was assessed in 20 subjects with unilateral amygdala damage and 1 rare subject with bilateral amygdala damage. Comparisons with 2 control groups (15 brain-damaged and 47 healthy) provided evidence that bilateral, but not unilateral, damage to the amygdala results in poorer memory for gist but superior memory for visual details. The pattern of findings provides preliminary support for the idea that the amygdala may help filter the encoding of relevant information from stimuli that signal threat or danger. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The supervisory encounter: A guide for teachers of psychodynamic psychotherapy and psychoanalysis.

Review of book: The Supervisory Encounter: A Guide for Teachers of Psychodynamic Psychotherapy and Psychoanalysis by Daniel Jacobs, Paul David and Donald J. Meyer, New Haven, CT: Yale University Press, 1985, 285 pp. Reviewed by Alan Z. Skolnikoff. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The real relationship in psychotherapy: Relationships to adult attachments, working alliance, transference, and therapy outcome.

The purpose of this study was to understand how the real relationship (RR) relates to important process and outcome variables from both the clients’ and therapists’ perspectives. Using a sample of 31 therapist/client dyads at a university counseling center, the authors examined the RR at the 3rd session of therapy and at termination. The results revealed that client adult attachment avoidance was negatively correlated with client RR, while client adult attachment anxiety was uncorrelated. Therapists’ ratings of negative transference were negatively correlated with therapist-rated RR and were uncorrelated with client-rated RR. Hierarchical linear modeling analyses were conducted to predict postintervention outcome from client and therapist perceptions of the RR. Therapists’ ratings of the RR accounted for a significant amount of variance in client posttreatment symptoms while controlling pretreatment symptoms. Client-rated RR total scores and client and therapist 3rd-session alliance scores were not significant predictors of postsymptom ratings. Implications of the usefulness of measuring the RR in psychotherapy are discussed, as are recommendations for future study. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychotherapy in long-term care: II. Evidence-based psychological treatments and other outcome research.

This article is the 2nd of 2 that together examine 3 domains important to providing high-quality, evidence-based services to long-term care (LTC) facility residents: policy and advocacy, practical considerations, and outcome research. Older adults who reside in LTC facilities have a very high rate of mental health difficulties. Psychologists have been able to provide services to this population through Medicare since the late 1980s, and empirical findings on treatment approaches are important in guiding psychotherapists to more helpful intervention. The focus of this article is outcome research in LTC settings. This article emphasizes evidence-based psychological treatments (EBTs) but also examines other scientifically supported approaches and discusses the strengths and limitations of focusing on EBTs, as well as general issues in the relation between science and practice in the provision of psychotherapy in LTC settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effect of group climate on outcome in two forms of short-term group therapy.

The authors investigated the association between dimensions of perceived group climate (engagement, avoidance, and conflict) and treatment outcome in 2 forms of short-term group psychotherapy. They were particularly interested in the relationship between early group climate and outcome. They also examined whether average group climate and change in group climate were associated with outcome. Both engagement after Session 4 and engagement averaged over the course of therapy were directly associated with improvement. Significant interactions among the group climate dimensions were also found. These findings support the contention that aspects of the group environment influence patient benefit from psychotherapy groups. Possible explanations and implications of the findings are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Individual psychodynamic psychotherapy of schizophrenia: Empirical evidence for the practicing clinician.

Practicing psychodynamically oriented clinicians need empirical evidence to support the use of individual psychodynamic psychotherapy for the treatment of individuals with schizophrenia. The purpose of this article is to provide psychodynamically oriented clinicians with that needed empirical evidence. A review of the meta-analytic research on the use of individual psychodynamic psychotherapy was conducted. It is concluded that strong empirical support exists for the use of individual psychodynamic psychotherapy in the treatment of schizophrenia. In addition, several suggestions are made to help clinicians apply the meta-analytic evidence to their daily clinical work. Limitations of the available evidence are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Video-tape role induction for psychotherapy: Moving forward.

Role induction (RI) has been shown to decrease premature termination and to enhance the therapeutic alliance and symptom relief. We examine the effects of a video-tape RI on premature termination rates, outcome, and the process variable of therapeutic alliance. Sixty-eight clients and their therapists (N = 26) participated in the study. Each client completed baseline measures of symptom status before beginning the therapy. Clients were then randomly assigned to either a video-tape RI condition or a no videotape treatment-as-usual condition. After the first session of therapy, clients and therapists separately completed outcome and alliance measures. Providing a video-tape RI to clients as they entered therapy did not lead to better results in attendance, outcome, or process variables. Considering possibilities that lie beyond the design of this study, so as to understand these results, is encouraged in an effort to advance the field's thinking about RI and how it can best be harnessed for continued positive effects moving forward. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

The death of psychoanalysis and depth therapy.

Notes that numerous attempts have been made to explain the demise of psychoanalysis and depth psychotherapy, placing blame on secularism among analysts, insufficient empirical research, prolonged treatment time, monetary considerations, and managed care. The author considers the primary cause to be an implicit cultural movement to squelch serious inquiry into family dynamics and interpersonal relationships, particularly the physical, sexual, and emotional abuse of children. To revive the humane practice of depth psychotherapy, therapists must support research that emphasizes the importance of early psychosocial environmental influences on personality development. Clinicians must also challenge restrictive societal pressure, sacred illusions concerning family life, and their own psychological defenses in order to reestablish a legitimate practice of depth therapy that moves away from the medical model. (PsycINFO Database Record (c) 2010 APA, all rights reserved)