Clinical implications of research on brief dynamic psychotherapy II. How the therapist helps or hinders therapeutic progress.

In this second of a two-part article, we describe how the therapist's interpretations promote therapeutic progress. Any therapist behavior that is in accord with the patient's plan will be helpful to the patient, but interventions that are at cross purposes with the patient's plan will not be helpful. The implications of the plan concept for brief dynamic therapy are described and contrasted with other key technical, concepts such as transference interpretations, therapeutic alliance, and interpretive activity. The importance of understanding the patient's plan and intervening in accord with it are illustrated in several case vignettes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapist immediacy in brief psychotherapy: Case study I.

The authors examined immediacy (i.e., discussions about the here-and-now therapeutic relationship) in a 12-session case of individual interpersonal psychotherapy. Therapist immediacy during immediacy events most often focused on parallels between external relationships and the therapy relationship, encouraging expression of immediate feelings, processing termination, therapist expressing disappointment/sadness/hurt and inquiring about the client's reactions. Client involvement was slightly higher before and after than during immediacy events. On the positive side, therapist immediacy seemed to help the client express her immediate feelings about the therapist more openly, feel closer to the therapist, and become less defended. On the negative side, the client felt somewhat awkward and pressured when the therapist used immediacy. Limitations and implications for practice and research are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Disturbances and silences in the patient's speech in psychotherapy.

"Linguistic measures of the patient's anxiety in therapeutic interviews can be useful in several areas of research… . On empirical and theoretical grounds, speech disturbance and silence seem to be expressive attributes that are useful as anxiety indices… . Data from 2 cases show that the 2 measures discriminate 'some thing' between-sessions and within-sessions for a given patient. Motivational phase judgments have been proposed as useful criteria for validating the Speech-Disturbance Ratio and Silence Quotient as anxiety measures. Detailed knowledge of the dynamic context of the interview is necessary to make such judgments of criteria since manifest content is of limited value in this regard… . Preliminary results of the proposed validation procedure indicate that the present approach is fruitful." (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Brief dynamic psychotherapy in community mental health settings: Providing a holding environment on a short-term basis.

Because of funding limitations, Community Mental Health therapists must often apply brief therapy techniques to an inappropriate clientele. Previously developed techniques hasten treatment by means of the therapist actively focusing interpretations on either preoedipal or oedipal issues. An actively focused technique would be inappropriate for most Community Mental Health patients, however, because it would not effectively address their strong dependency needs. Active focusing would not provide the holding environment which is crucial in treating dependent patients. More appropriate is a moderate amount of focusing in the context of tolerant, unfocused listening to provide a holding environment. This approach is illustrated with case examples. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of Short-term dynamic psychotherapy: Evaluation and techniques.

Reviews the book, Short-term dynamic psychotherapy: Evaluation and techniques (2nd edition) by Peter E. Sifneos (1988). The book focuses specifically, if not exclusively, on short-term anxiety-provoking psychotherapy (STAPP). This mode of treatment is restricted to patients whose psychopathology results from an oedipal conflict, who have had meaningful relationships with another during early childhood, who have the capacity to relate flexibly and expressively with the psychotherapist, who have above-average intelligence and psychological sophistication, and who are motivated for change and not simply symptom relief. The book is organized into three sections: four chapters concern the psychiatric evaluation, seven relatively brief chapters review and illustrate techniques for doing STAPP, and two chapters focus on the results of treatment. In general, this is not a volume for the beginning reader of short-term treatment. It does not overview the entire field but details only one specific type of treatment, which is appropriate for only a limited group of patients. Additionally, the reader will need some understanding of dynamic theory in order to appreciate fully the book's sophistication. These points aside, the book affords the reader an opportunity to see one type of short-term treatment in detail with realistic and sound case material presented in a comprehensible and informative manner. (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)     

Social problem solving and depressive symptoms over time: A randomized clinical trial of cognitive-behavioral analysis system of psychotherapy, brief supportive psychotherapy, and pharmacotherapy.

Objective: Depression is associated with poor social problem solving, and psychotherapies that focus on problem-solving skills are efficacious in treating depression. We examined the associations between treatment, social problem solving, and depression in a randomized clinical trial testing the efficacy of psychotherapy augmentation for chronically depressed patients who failed to fully respond to an initial trial of pharmacotherapy (Kocsis et al., 2009). Method: Participants with chronic depression (n = 491) received cognitive-behavioral analysis system of psychotherapy (CBASP; McCullough, 2000), which emphasizes interpersonal problem solving, plus medication; brief supportive psychotherapy (BSP) plus medication; or medication alone for 12 weeks. Results: CBASP plus pharmacotherapy was associated with significantly greater improvement in social problem solving than BSP plus pharmacotherapy, and a trend for greater improvement in problem solving than pharmacotherapy alone. In addition, change in social problem solving predicted subsequent change in depressive symptoms over time. However, the magnitude of the associations between changes in social problem solving and subsequent depressive symptoms did not differ across treatment conditions. Conclusions: It does not appear that improved social problem solving is a mechanism that uniquely distinguishes CBASP from other treatment approaches. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Comment: Integrating methodologies in the scientific study of interpersonal psychotherapy: A reaction to Therapist immediacy in brief psychotherapy: Case study I and case study II.

In this reaction article, the author concentrates on selected methodological components characterizing both Kasper, Hill, and Kivlighan's (see record 2008-13167-001) and Hill, Sim, Spangler, Stahl, Sullivan, and Teyber's (see record 2008-13167-002) respective case studies of therapist immediacy in brief psychotherapy. In tandem, the foci and methodology of these investigations break new ground in the scientific study of interpersonal psychotherapy, and more generally they serve as paradigmatic illustrations of the form that psychotherapy research can take if it is to be truly more meaningful and useful for practitioners. Emphasis is placed on the investigators' integration of single-case research, elements of change process research, and quantitative and qualitative methods in a way that enables highly intensive examination of this core intervention in interpersonal psychotherapy. Specific elements and implications of each of these methodological components are briefly discussed, which also creates a context for addressing the issue of discovery versus verification as this pertains to the present studies. Some underlying philosophical considerations are also briefly touched on along the way. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinical exchange: Integrating psychotherapy and psychopharmacology-the case of the certified nursing assistant.

The Clinical Exchange invites eminent clinicians of diverse persuasions to share, in ordinary language, their clinical formulations and treatment plans of the same psychotherapy patient-one not selected or nominated by those therapists-and then to discuss points of convergence and contention in their recommendations. This special exchange focuses on the integration of psychotherapy and psychopharmacology in the case of Ms. M, a 64-year-old divorced woman presenting for treatment of depression complicated by an extensive history of medical illnesses, noncompliance with psychiatric treatment, and relationship dysfunction. Physician-therapists David Bienenfeld (integrative psychodynamic and cognitive- behavioral orientation), Paulette Marie Gillig (integrative self psychology and cognitive- behavioral), Steven I. Kramer (psychodynamic and supportive), and David Mintz (psychodynamic) are the featured commentators. Finally, Zia Wahid and Hasrat Khan, the case contributors, provide a few closing comments. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Some implications of psychotherapy research for therapeutic practice.

Implications for practice and research are drawn from a survey of psychotherapy research findings, condensed into 6 broad conclusions: (1) psychotherapy causes clients to become better or worse adjusted than controls; (2) control Ss improve with time as a result of informal therapeutic encounters; (3) therapeutic progress varies with therapist warmth, empathy, adjustment, and experience; (4) client-centered therapy is the only interview-oriented method that has been validated by research; (5) traditional therapies are seriously limited in effectiveness and are relevant for a small minority of disturbances; and (6) behavior therapies have considerable promise for enhancing therapeutic effectiveness and should be utilized or experimented with more widely. (2 p. ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Leading researchers' consensus on psychotherapy research findings: Implications for the teaching and conduct of psychotherapy.

We examined leading international psychotherapy researchers' views on psychotherapy outcome research. Participants completed a questionnaire on which they rated level of research evidence for or against various assertions about psychotherapy processes and outcomes. Participants rated how confident they were that the assertions were supported by psychotherapy research. Strong, or relatively strong, consensus was achieved on several of the questionnaire items. Areas for which relative uniformity of opinion does or does not exist have potential implications for the teaching and conduct of psychotherapy and for the science-practice interface in psychotherapy. Additionally, consensus about psychotherapy findings can be used as a yardstick by which to measure practicing clinicians' knowledge of the research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Preliminary relationships between adherence and outcome in dynamic deconstructive psychotherapy.

This study examined adherence to specific psychotherapeutic techniques as a predictor of outcome in dynamic deconstructive psychotherapy (DDP), a new psychodynamic therapy for treatment-resistant clients with borderline personality disorder (BPD). Ten clients dually diagnosed with BPD and alcohol use disorders underwent 12 months of DDP. Outcome indexes included measures of borderline symptoms, depression, dissociation, social support, alcohol misuse, parasuicide, and institutional care. Independent raters coded videorecorded sessions on adherence to DDP techniques, using a scale developed for this study, as well as therapeutic alliance and standard cognitive–behavioral and psychodynamic techniques. The adherence instrument demonstrated excellent interrater and test–retest reliability. Adherence to DDP techniques was positively related to improvement in BPD symptoms (ρ = .64) and most secondary outcomes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of transference work, the therapeutic alliance, and their interaction in reducing interpersonal problems among psychotherapy patients with Cluster C personality disorders.

The aim of the present study was to examine whether transference work, the therapeutic alliance, and their interaction predicted a reduction in interpersonal problems at treatment termination. Forty-nine patients with Cluster C personality disorders from a randomized controlled trial investigating the effectiveness of short-term dynamic psychotherapy and cognitive therapy were included. Transference work was measured with the Inventory of Therapeutic Strategies (Gaston & Ring, 1992), while the therapeutic alliance was measured with the Helping Alliance Questionnaire (Luborsky, Crits-Christoph, Alexander, Margolis & Cohen, 1983). Less emphasis on transference work predicted overall reduced interpersonal problems, whereas the effects of the therapeutic alliance did not reach statistical significance. An interaction effect was also demonstrated, indicating that greater emphasis on transference work performed on patients with lower therapeutic alliance ratings was associated with a smaller reduction in interpersonal problems at termination. However, the results also indicate that a low dose of transference work may be beneficial in reducing interpersonal problems. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Changes in clients' attachment styles over the course of time-limited dynamic psychotherapy.

This study utilized a theory-specific measure to examine client relational change over the course of time-limited dynamic psychotherapy in 84 Ss (aged 26–64 yrs). Specifically, this study examined change and stability in clients' attachment style. Categorical and dimensional ratings attachment styles were obtained. Pretreatment and posttreatment measures of attachment styles were then examined in association with Global Assessment Scale (GAS) scores and symptoms. Results show that at posttreatment, a significant number of clients were evaluated as having changed from an insecure to a secure attachment style. Additionally, the sample as a whole demonstrated significant changes toward increased secure attachment. Significant relationships were also found among changes in attachment style, GAS scores, and symptom levels. Implications for psychodynamic/interpersonal psychotherapy research and practice are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Decision making and psychotherapy integration: Theoretical considerations, preliminary data, and implications for future research.

In recent years, a number of publications have called for investigation of how psychotherapists make treatment decisions in clinical practice. This recommendation is particularly salient for psychotherapy integration, as studies have consistently shown that a plurality of American clinicians consider themselves to be either "eclectic" or "integrative" in theoretical orientation. Yet, the research on clinician decision making in psychotherapy is in its infancy. This article examines the need for decision-making research in psychotherapy integration, as well as aspects of psychotherapy integration that are targets for research and possible theoretical frameworks for understanding decision-making processes of integrative psychotherapists. A preliminary study provides data from practicing psychotherapists to illustrate these points. Finally, implications and directions for future research are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Research summary on the therapeutic relationship and psychotherapy outcome.

Factors that influence client outcome can be divided into four areas: extratherapeutic factors, expectancy effects, specific therapy techniques, and common factors. Common factors such as empathy, warmth, and the therapeutic relationship have been shown to correlate more highly with client outcome than specialized treatment interventions. The common factors most frequently studied have been the person-centered facilitative conditions (empathy, warmth, congruence) and the therapeutic alliance. Decades of research indicate that the provision of therapy is an interpersonal process in which a main curative component is the nature of the therapeutic relationship. Clinicians must remember that this is the foundation of our efforts to help others. The improvement of psychotherapy may best be accomplished by learning to improve one's ability to relate to clients and tailoring that relationship to individual clients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment integrity in psychotherapy research: Analysis of the studies and examination of the associated factors.

Treatment integrity refers to the degree to which an intervention is delivered as intended. Two studies evaluated the adequacy of treatment integrity procedures (including establishing, assessing, evaluating, and reporting integrity; therapist treatment adherence; and therapist competence) implemented in psychotherapy research, as well as predictors of their implementation. Randomized controlled trials of psychosocial interventions published in 6 influential psychological and psychiatric journals were reviewed and coded for treatment integrity implementation. Results indicate that investigations that systematically addressed treatment integrity procedures are virtually absent in the literature. Treatment integrity was adequately addressed for only 3.50% of the evaluated psychosocial interventions. Journal of publication and treatment approach predicted integrity implementation. Skill-building treatments (e.g., cognitive-behavioral) as compared with non-skill-building interventions (e.g., psychodynamic, nondirective counseling) were implemented with higher attention to integrity procedures. Guidelines for implementation of treatment integrity procedures need to be reevaluated. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Efficacy of brief strategic family therapy in modifying Hispanic adolescent behavior problems and substance use.

This study investigated the efficacy of brief strategic family therapy (BSFT) with Hispanic behavior problem and drug using youth, an underrepresented population in the family therapy research literature. One hundred twenty-six Hispanic families with a behavior problem adolescent were randomly assigned to 1 of 2 conditions: BSFT or group treatment control (GC). Results showed that, compared to GC cases, BSFT cases showed significantly greater pre- to post-intervention improvement in parent reports of adolescent conduct problems and delinquency, adolescent reports of marijuana use, and observer ratings and self reports of family functioning. These results extend prior findings on the efficacy of family interventions to a difficult to treat Hispanic adolescent sample. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Integrating outcome research and clinical reasoning in psychotherapy planning.

This article reviews the strengths and weaknesses of outcome research and clinical reasoning as bases of treatment planning and presents a synthesis in which these two types of information complement each other. The author proposes that therapy planning should begin with a review of the relevant outcome literature and also that divergence from research-based guidelines might be warranted under several conditions, including (a) when the client is demographically or culturally dissimilar to the study samples, (b) when assessment suggests a mismatch between the etiologies of the client's disturbance and the processes addressed by empirically supported treatments, and (c) when use of such treatments is followed by a lack of progress that signals the advisability of midcourse correction. (PsycINFO Database Record (c) 2010 APA, all rights reserved)