Chapter 4 Interpretation in Short-Term Therapy

Abstract

There is much theoretical and clinical literature on the role of interpretation in psychoanalysis, psychoanalytic psychotherapy, and brief dynamic psychotherapy, but little supporting research data. Using 112 audiotaped sessions from 38 patients in supportive-expressive time-limited treatment, the present study hypothesized that therapists would modify the object and temporal content and frequency of their interpretations in relation to the level of patient functioning. The results did not support this hypothesis. Therapists were not less active with more interpretations for higher functioning patients, nor were they more active with fewer interpretations for lower functioning patients. Therapists were more active and made more genetic interpretations with married patients, regardless of level of patient functioning. The findings are discussed in terms of their implications for supportive-expressive psychodynamic therapy.     

Psychoanalytisch-orientierte Fokaltherapie der sozialen Phobie

Although psychodynamic therapy is one of the most frequently applied forms of psychotherapy to treat anxiety disorders in clinical practice, evidence for the efficacy of psychodynamic therapy in anxiety disorders is unsatisfactory. This is especially true with regard to randomized controlled trials of psychodynamic psychotherapy in anxiety disorders. Psychodynamically oriented treatment manuals for anxiety disorders presently exist for generalized anxiety disorder and panic disorder. For social phobia (or social anxiety disorder), however, no manual for psychodynamic treatment has yet been published. Social phobia is a very frequent mental disorder characterized by an early onset, a chronic course, severe psychosocial impairments and high socio-economic costs and at the same time in spite of these facts one of the mental disorders which are scarcely diagnosed and treated. In this article, a manual for a 30-session (5 exploratory and 25 therapy sessions) short-term psychodynamic treatment of social phobia is presented. The treatment is based on Luborsky’s supportive-expressive (SE) therapy. In the first part, the general principles of SE therapy are presented. In the second part, a manual specifically adapted to the treatment of social phobia is described. This manual includes specific additional treatment elements that have clinically proved to be useful in the therapy of social phobia. The treatment manual is presently used in a large-scale randomized controlled multi-center study comparing short-term psychodynamic psychotherapy and cognitive-behavioral therapy in the treatment of social phobia.     

Changes in personality pathology after pharmacotherapy and combined therapy for depressed patients

The central question addressed by this article is whether courses of treatment consisting of pharmacotherapy or pharmacotherapy combined with psychotherapy (combined therapy) produce different changes in personality pathology at follow-up after 40 weeks. We also examined whether recovery from depression has an influence on outcome. The study population consisted of 128 outpatients in whom personality pathology and severity of depression were determined at the start of the study. For 72 patients, personality pathology and severity of depression were determined again after 40 weeks. Of the group of 72 patients, 25 patients received only pharmacotherapy for 6 months, and 47 patients received combined treatment (pharmacotherapy and psychodynamic supportive psychotherapy). The antidepressant protocol provides for three successive steps in case of intolerance or inefficacy: fluoxetine, amitriptyline, and moclobemide. The combined therapy condition consisted of 16 sessions of Short Psychodynamic Supportive Psychotherapy in addition to pharmacotherapy. In the combined therapy condition there was a significant reduction in personality pathology in patients who recovered from depression but also in patients who had not. In the pharmacotherapy condition the significant decrease was restricted to patients who recovered from depression. The results were most striking for Cluster C psychopatology. Patients with cluster B pathology changed the least. Depressed patients with comorbid personality pathology appear to benefit most from a combination of pharmacotherapy and a form of short, psychodynamic, supportive psychotherapy.     

The use of the Core Conflictual Relationship Theme method in describing and comparing gestalt and rational emotive behavior therapy with adolescents

The Core Conflitual Relationship Theme (CCRT) method (Luborsky, 1977) is used to study recurrent relationship patterns in therapy and may be employed as a measure of transference as well. We found only one article in the literature in which it was applied to a mode of psychotherapy, other than psychodynamic (Turner, 1992). In addition, there are only a few articles in the literature that refer to the CCRT method with children and adolescents. In this paper, we applied the CCRT method to two videotaped individual sessions of young adolescent boys, one in gestalt therapy and the other in rational emotive behavior therapy. Results showed that both boys revealed similar core relational theme profiles, but that their respective therapists each dealt differently with these relationship conflicts. In this pilot use of the CCRT with adolescent therapy, we were able to describe relationship patterns and delineate key differences between the two treatment modalities.Stacey Agin, a gradduate student in School Psychology at New York University, submitted this paper for partial fulfillment of the requirements for the Doctorate of Psychology. Iris E. Fodor is a professor of Applied Psychology at New York University and is director of the School Psychology program. She is known for her work on integrating cognitive and gestalt therapies. We gratefully acknowledge the cooperation of Raymond DiGiuseppe, Ph.D. Violet Oaklander, Ph.D. and Michael Bernard, Ph.D. in allowing us to utilize their videotaped psychotherapy sessions for the purposes of this study.     

Ist psychodynamische Kurztherapie eine wirksame Behandlungsform bei psychischen Störungen?

To test the efficacy of short-term psychodynamic psychotherapy (STPP) in specific psychiatric disorders, a meta-analysis of more recent studies was performed. Its importance is grounded on the inconsistent results of previous meta-analyses regarding short-term psychodynamic psychotherapy (STPP) and the controversial discussion regarding the efficacy of psychodynamic therapy in general. In a computer-based search, studies of STPP published between 1970 and 2004 were identified. Studies of interpersonal therapy were excluded and rigorous inclusion criteria were applied. Seventeen studies fulfilled these criteria. Effect sizes were calculated for target problems, general psychiatric symptoms, and social functioning. In order to examine the stability of outcome, effect sizes were assessed separately for end of therapy and for follow-up assessment. The effect sizes of STPP were compared to those of waiting list control patients, treatments as usual, and of other forms of psychotherapy. STPP yielded significant and large pre-post effect sizes, which were not only stable, but tended to increase at follow-up. The effect sizes of STPP significantly exceeded those of waiting list and treatments as usual, but no differences were found between STPP and other forms of psychotherapy. STPP proved to be an effective treatment in different psychiatric disorders. However, further research of STPP in specific psychiatric disorders is needed, including a study of the active ingredients of STPP. Effectiveness studies should be included.     

Therapist orientation,supervisor match,and therapeutic interventions: Implications for session quality in a psychotherapy training PRN

Background: Theoretical orientation is a multifaceted construct that is integral to the process of psychotherapy and psychotherapy training. While some research has been conducted on personal identification with particular schools of psychotherapy, techniques used in psychotherapy sessions, and match between trainees and supervisors in training, there is insufficient information regarding how these may interact with one another. Aim: This study, conducted in a practice research network of trainee therapists, was designed to test whether these variables may be related to one another in predicting session quality. Method: The sample comprised 328 sessions from 26 clients and 11 therapists, with the clients completing session quality measures and therapists completing measures of technique immediately post‐session. Results: Using multilevel linear modelling, the data showed varied results. For behavioural therapy and person‐centred therapy, techniques and orientation were unrelated to session quality in the sample. However, process‐experiential, psychodynamic, and cognitive therapy techniques were all involved in interactions with therapist and/or supervisor orientations. Conclusions: These results suggest that the impact of specific psychotherapy techniques sometimes depends on the orientation of the therapist and/or supervisor. For instance, sessions high in cognitive therapy techniques were only associated with positive outcome when both the therapist and supervisor were highly cognitively oriented. Though preliminary, these results suggest that orientation may be an important variable to consider in training and supervision, especially in the context of other variables.     

Psychoanalytisch-orientierte Fokaltherapie der Depression bei Krebskranken

Emotional distress connected to a cancer disease may result in comorbid mental and especially depressive disorders. Although psychodynamic therapy is one of the most frequently applied forms of psychotherapy of depression in cancer patients there is a lack of empirical studies which meet the criteria of evidence-based psychotherapy research. This is especially true with regard to randomized controlled trials of psychodynamic psychotherapy. As far as we know no manual for psychodynamic treatment of cancer patients has yet been published. In this article a manual for a 20-session short-term psychodynamic treatment is presented. The treatment is based on Luborsky’s supportive-expressive (SE) therapy. The SE treatment manual of depressions in cancer patients presented here is an adaptation of the general SET manual as well as the SE manual for depression. In the first part the general principles of SE therapy are presented. In the second part a manual specifically adapted to the treatment of depressive cancer patients is described. The treatment manual is presently being used in a large-scale randomized controlled multi-centered study comparing short-term psychodynamic psychotherapy and treatment as usual.     

To be in touch

This study examined the constellation of interaction structures – repetitive patterns of interactions between patient and therapist over the course of treatment – that emerged in the psychodynamic therapy (PDT) of a child diagnosed with borderline personality disorder and treated by two doctoral student therapists. Identification of these interaction structures can inform therapists of what might be expected from patients with particular symptom or behaviour patterns and how interactions change over time. This study also examined each session’s adherence to three session prototypes: PDT, cognitive-behavioural therapy (CBT) and reflective functioning (RF) process. The Child Psychotherapy Q-Set (CPQ) is a 100-item instrument that assesses the processes within a single psychotherapy session. Items reflect a wide range of therapist attitudes and behaviours, patient attitudes and behaviours and interactions between therapist and patient. Experts used the CPQ to define PDT, CBT and RF process session prototypes. The results suggested that four distinct interaction structures could be identified and that their constellations differed between the two therapists and also differed over time within each treatment. Therapists were more structured and accommodating early on in their treatments and more interpretive later. Prototypical PDT process was more prominent in the sessions than RF process, which in turn was more prominent than CBT process. Unique therapeutic processes are at work in every dyad, despite holding the patient and theoretical orientation constant. An effective treatment in one dyad might not work in another due to therapist-specific and dyad-specific effects.     

Editorial

With the aim of increasing knowledge about processes of change in psychodynamic individual child psychotherapy, sessions that could be called turning points were analysed.     

Psychological Intervention in a Case of Bulimia Nervosa: A Case Report

This paper presents a case report detailing the use of an enhanced form of enhanced cognitive behavior therapy (CBT) and other techniques that were employed when faced with impediments in adhering to manualized CBT-E. Ms. S, 22 years old unmarried female pursuing MBBS final year, belonging to upper middle socioeconomic status and urban domicile was provided with 28 weekly sessions of psychotherapy to simultaneously address the patient’s symptoms and try to effect change across multiple domains. A single case design was adopted. Therapy was conducted over 9 months. A total of 28 sessions were taken, with the frequency of two sessions/week initially, and then moving onto one session/week. Pre and Post assessments using Binge Eating Scale, BDI-II, height and weight measurements and frequency of binging episodes using visual analogue scale were done. On measures of pre and post assessment there was 87 % improvement in Binging Episodes, 82 % improvement on Binge Eating Scale and client had 3 kg weight gain with reduction in depression as assessed on BDI-II. The gains were maintained at 1 month follow up. The use and deviations from CBT E, therapy process, role of family and challenges to intervention will be discussed in this case report.     

Are psychodynamic and psychoanalytic therapies effective?: A review of empirical data

There is a need for empirical outcome research in psychodynamic and psychoanalytic therapy. However, both the approach of empirically supported therapies (EST) and the procedures of evidence‐based medicine (EBM) have severe limitations making randomised controlled trials (RCTs) an absolute standard. After a critical discussion of this approach, the author reviews the empirical evidence for the efficacy of psychodynamic psychotherapy in specific psychiatric disorders. The review aims to identify for which psychiatric disorders RCTs of specific models of psychodynamic psychotherapy are available and for which they are lacking, thus providing a basis for planning further research. In addition, results of process research of psychodynamic psychotherapy are presented. As the methodology of RCTs is not appropriate for psychoanalytic therapy, effectiveness studies of psychoanalytic therapy are reviewed as well. Studies of psychodynamic psychotherapy published between 1960 and 2004 were identifed by a computerised search using Medline, PsycINFO and Current Contents. In addition, textbooks and journal articles were used. Twenty‐two RCTs were identifed of which 64% had not been included in the 1998 report by Chambless and Hollon. According to the results, for the following psychiatric disorders at least one RCT providing evidence for the efficacy of psychodynamic psychotherapy was identifed: depressive disorders (4 RCTs), anxiety disorders (1 RCT), post‐traumatic stress disorder (1 RCT), somatoform disorder (4 RCTs), bulimia nervosa (3 RCTs), anorexia nervosa (2 RCTs), borderline personality disorder (2 RCTs), Cluster C personality disorder (1 RCT), and substance‐related disorders (4 RCTs). According to results of process research, outcome in psychodynamic psychotherapy is related to the competent delivery of therapeutic techniques and to the development of a therapeutic alliance. With regard to psychoanalytic therapy, controlled quasi‐experimental effectiveness studies provide evidence that psychoanalytic therapy is (1) more effective than no treatment or treatment as usual, and (2) more effective than shorter forms of psychodynamic therapy. Conclusions are drawn for future research.     

Psychodynamische Kurzzeittherapie bei dependenter und vermeidender Persönlichkeitsstörung

Although dependent and avoidant personality disorders are frequent in patient populations, there are only few studies in which the efficacy of psychotherapeutic interventions for these two personality disorders was reviewed. The purpose of this study was to examine whether psychodynamic short-term therapy based on the model of the cyclic maladaptive pattern (CMP) is effective for reducing the mental impairment of patients diagnosed with a dependent or an avoidant personality disorder. Data were collected via a self-report scale (Symptom-Checklist, SCL) and expert ratings by therapists [Global Assessment of Functioning (GAF) Scale and Severity of Impairment-Score (Beeinträchtigungsschwere-Score, BSS)]. In the study 20 patients received 25 sessions of outpatient therapy. Mental impairment decreased significantly from the beginning to the end of the therapy; moreover this decrease remained stable over a 2-year period following completion of the therapy. The findings show that psychodynamic short-term therapy can lead to an enduring improvement in the mental health of patients with a dependent or an avoidant personality disorder.     

Six‐month follow‐up of two mother–infant psychotherapies: Convergence of therapeutic outcomes

Fifty‐eight mothers and infants participating in two infant–mother psychotherapeutic interventions in a comparative infant–mother clinical intervention study were followed six months after treatment ended. One treatment was an infant‐led psychotherapy, Watch, Wait, and Wonder (WWW). The other was a more traditional mother–infant psychodynamic psychotherapy (PPT). Infants ranged in age from 10 to 30 months at the outset of treatment, which took place in weekly sessions over approximately five months. Results indicated that positive effects observed from the beginning to the end of treatment in both treatment groups in infant symptoms, parenting stress, and mother–infant interaction were maintained or improved further at six‐month follow‐up. Additionally, decreased maternal depression, gains in infant cognitive development and emotion regulation, and improved infant–mother attachment security or organization had been observed posttreatment only in the WWW group. Interestingly, between the posttreatment to follow‐up period the PPT group also showed such gains. Thus, for these variables it would be more accurate to say that the outcomes were similar for the two treatment groups but change emerged at a different pace. Nevertheless, an advantage persisted in the WWW group in relation to mothers' comfort dealing with infant behaviors and their ratings of parenting stress which improved more in this group from the end of treatment to follow‐up. The direct inclusion of the infant as an initiator in WWW was set forth as an explanation of differentially timed treatment effects. ©2002 Michigan Association for Infant Mental Health.     

Gegenübertragung im stationären Therapie-Setting

Background

Countertransference is seen as an instrument of research into a patient’s unconscious and is therapeutically useful in furthering psychodynamic work. For inpatient psychodynamic psychotherapy, where patients are treated by a team of psychotherapists, countertransference is much more complex and makes consideration and integration of different countertransference feelings necessary. Using the first German translation of the countertransference questionnaire (CTQ, Zittel Conclin and Westen, the countertransference questionnaire, 2005) an attempt was made to identify differences in countertransference phenomena in a team of psychotherapists and to show the impact countertransference has on therapy outcome.

Materials and methods

A total of t multiprofessional teams of psychotherapists (15 physicians, 5 psychologists and 9 body and art therapy psychotherapists) took part in the study and completed the CTQ for 137 patients (100 female, 37 male) at the beginning and at the end of inpatient psychotherapy. In addition, the patients completed two questionnaires, the Symptom Check List Revised 90-R (SCL-90) for the severity of symptoms and the Assessment of DSM-IV Personality Disorders Questionnaire (ADP-IV) for personality disorders.

Results

Body and art therapy psychotherapists expressed more positive, protective and involved countertransference feelings whereas psychotherapists for single and group therapy expressed more aggressive and hopeless feelings. Countertransference has an impact on therapy outcome and feelings of a lack of interest, aggression and resignation at the beginning of therapy can point to a poor outcome. Patients with personality disorders activate more negative countertransference reactions than patients without personality disorders but at the same time they may also evoke parent-like feelings of protection.

Conclusions

Using the CTQ it is possible to differentiate countertransference phenomena in a team of psychotherapists treating inpatients with psychodynamic psychotherapy. The timely perception and integration of countertransference feelings has a positive influence on the therapeutic process and therapy outcome.     

Indikation zu Psychoanalyse und analytischer Psychotherapie

Based on the diagnostic process in the initial interview, which is an intersubjective encounter, the various developmental steps for establishment of the indications for psychoanalysis are presented. Freud and his followers, who were initially oriented to the psychiatric diagnosis, were later oriented to the criteria of approachability, analysability and in particular on the aptitude for psychoanalysis. The criterion of aptitude was not only elaborated from the perspective of Ego psychology but was also relevant for all high frequency non-terminated psychoanalyses which followed the basic psychoanalytical principles of “afocality”. This has so far characterized the standard procedure of all psychoanalytic schools. Due to the experiences of psychoanalysts with early disturbed, structurally Ego-disturbed neuroses and personality disorders, the extent of lability of the mental structure and by turning to countertransference analysis, the person of the psychoanalyst become more important for the assessment of the indications. In Germany the integration of psychotherapy, which is financially supported by healthcare insurance, ultimately leads to differential indication assessments between high frequency psychoanalysis or analytical psychotherapy, modified psychoanalytical psychotherapy and less frequent psychodynamic procedures.     

Psychodynamische Kurzzeittherapie mit erlebnisaktivierenden Interventionen

This short-term therapy model with experiential interventions is based on the basic assumptions of psychodynamic psychotherapy. The focus of treatment is the current psychosocial situation, in which dysfunctional emotional patterns are elicited by specific triggers. These emotional patterns are evidence of anconscious intrapsychic conflict, which has biographically relevant precursors. This conflict and the associated dysfunctional relationships are explored in a supportive therapeutic relationship, formulated in cooperation with the patient and then made accessible in an experience-activating process in the present. The effect is, in addition to the reduction of clinical symptoms, the improvement in managing relationships and improved social competence. The transference is noticed, but it is only addressed if it has a lasting compromising effect on the therapeutic relationship. This therapy model is especially suitable for psychotherapy with time limits of 25–40 hours.     

Recognizing the infant as subject in infant-parent psychotherapy

Drawing on Winnicott's view of infants as subjects entitled to an intervention in their own right, infants as the referred patient have been seen in infant-parent psychotherapy for 20 years at the Royal Children's Hospital, Melbourne, Australia. This is a radically different view of infant symptomatology than viewing it as only expressing an aspect of the mother's unconscious. The clinical pathway differentiates the therapy from much parent-infant psychotherapy. The author describes the theoretical model of a twofold approach to understanding the infant's experience through interactive dialogue between therapist and infant, and sharing this understanding with the parents, and illustrates it with cases of failure-to-thrive infants. She discusses two criticisms: first, that infant-parent psychotherapy may undermine the parents and, second, that brief parent-infant psychotherapy does not alter parents' insecure attachment status. Videotaped sessions often show rapid improvement; parents generally feel relieved. This approach potentially shapes not only parents' and infants' representations, but also their implicit knowledge of relationships-partly, it is suggested, through activating the mirror neuron system to bring about implicit memory change. Change may therefore be longer lasting than psychoanalytic theory presently conceives. The approach is relevant in an outpatient setting: gains were maintained long term in 90% of out-patient cases.     

A systematic review of the effectiveness of psychoanalysis,psychoanalytic and psychodynamic psychotherapy with adults with intellectual and developmental disabilities: progress and challenges

Objectives: This systematic review aimed to critically appraise the literature on the efficacy and effectiveness of psychoanalysis, psychoanalytic and psychodynamic psychotherapy in adults with intellectual and developmental disabilities (IDD). Method: A systematic search of electronic databases was carried out. The methodological quality of the studies was assessed using a quality assessment tool and comparisons were made with a review of the quality of research on the effectiveness of cognitive behavioural therapy (CBT) for people with IDD. Results: The search yielded 13 papers which provided evidence for the effectiveness but not efficacy of psychoanalytic and psychodynamic psychotherapy; but none were found for psychoanalysis. The quality of the research was generally poor compared to the current research on the effectiveness of CBT. Conclusions: Positive outcomes have been indicated for psychoanalytic and psychodynamic psychotherapy with people with IDD. Larger scale, more controlled research is necessary to advance the evidence base.     

Der ausreichend gute Therapeut

Psychotherapists show a great variation in their ability to achieve positive outcomes in therapy. Specifically, they vary in terms of their ability to identify and repair ruptures in the therapeutic alliance. Alliance ruptures are a frequent phenomenon but often go undetected; however, repairing alliance ruptures represents a great opportunity to improve the psychotherapy process and therapy outcome. Empirical research suggests that patient feedback should be included in the psychotherapy process to be able to detect alliance ruptures better. From a psychodynamic point of view, a “sufficiently good” therapist is a therapist who can acknowledge the countertransference-based limitations in evaluating the therapeutic alliance with patients and the need to use feedback in order to detect and repair inevitable alliance ruptures. The consequences for research, practice and psychotherapy training are considered.     

Assessing the impact of group treatment for aggressive inpatients

The purpose of this research was to determine if psychodynamic group psychotherapy decreases the occurrence of physical assault by male group members. The design of the study was a randomized clinical trial. Patients assigned to the control group received the customary clinical care. Patients assigned to the Group Therapy attended a psychodynamic psychotherapy group to help them cope with their aggressive impulses. Both quantitative and qualitative measures were used. Group members showed decreased expression of anger at followup, increased effort to control anger at followup, and decline in aggressive behavior. Control subjects demonstrated no change in level of angry feelings, increased expression of anger at follow-up, decrease in effort to control anger at follow-up, and no change in aggressive behavior. A model for conducting a psychodynamic psychotherapy group for assaultive men was developed which describes process and content aspects as well as leader interventions by group phase.