Long-term effects of transference interpretation in dynamic psychotherapy of personality disorders.

BACKGROUND: Only a few treatment studies of personality disorders (PD) patients are on longer-term psychotherapy, general outcome measures are used, and follow-up periods are usually short. More studies of long-term therapies, using outcome measures of core psychopathology, are needed. METHOD: This study is a dismantling randomized controlled clinical trial, specifically designed to study long-term effects of transference interpretation. Forty-six patients with mainly cluster C personality disorders were randomly assigned to 1 year of dynamic psychotherapy with or without transference interpretations. The outcome measures were remission from PD, improvement in interpersonal functioning, and use of mental health resources in the 3-year period after treatment termination. RESULTS: After therapy with transference interpretation PD-patients improved significantly more in core psychopathology and interpersonal functioning, the drop-out rate was reduced to zero, and use of health services was reduced to 50%, compared to therapy without this ingredient. Three years after treatment termination, 73% no longer met diagnostic criteria for any PD in the transference group, compared to 44% in the comparison group. CONCLUSIONS: PD-patients with co-morbid disorders improved in both treatment arms in this study. However, transference interpretation improved outcome substantially more. Long-term psychotherapy that includes transference interpretation is an effective treatment for cluster C personality disorders and milder cluster B personality disorders.

Long-term effects of brief dynamic psychotherapy.

The author addresses the use of transference interpretations in brief dynamic psychotherapy, length of treatment needed for limited characterological changes, and selection criteria for this treatment modality. Prior research has suggested that (a) frequent use of transference interpretations should be avoided in brief dynamic psychotherapy, (b) patients with personality disorders or a history of low-quality interpersonal relationships need more than 30-35 sessions to achieve stable dynamic changes, and (c) quality of interpersonal relationships is the best pretreatment predictor of long-term changes. This study examines specific effects of the moderate use of transference interpretations. Possible mediators of long-term effects (i.e., insight or identification with the therapist) are also tested. The author's experiences regarding the interface between research and clinical practice are discussed.

Quality of working alliance in psychotherapy: therapist variables and patient/therapist similarity as predictors.

Therapist characteristics were explored as possible predictors of working alliance, rated early and later in therapy both by therapists (n=59) and patients (n=270) in an ongoing multisite project on process and outcome of psychotherapy. Patients and therapists had divergent perspectives on the working alliance. Therapists' experience, training, skill, and progress as therapists did not have any significant impact on alliance as rated by patients. Training and skill were positively related to alliance as rated by therapists. Interpersonal relationships on the cold-warm dimension had a moderate impact for both patients' and therapists' alliance ratings. Some implications for therapist training are discussed.

Assessment of change in dynamic psychotherapy.

Five scales have been developed to assess changes that are consistent with the therapeutic rationales and procedures of dynamic psychotherapy. Seven raters evaluated 50 patients before and 36 patients again after brief dynamic psychotherapy. A factor analysis indicated that the scales represent a dimension that is discriminable from general symptoms. A summary measure, Dynamic Capacity, was rated with acceptable reliability by a single rater. However, average scores of three raters were needed for good reliability of change ratings. The scales seem to be sufficiently fine-grained to capture statistically and clinically significant changes during brief dynamic psychotherapy.

Psychotherapy research: new findings and implications for training and practice.

The last decade has seen progress in psychotherapy research, despite the methodological complexity in this field. However, empirical research has influenced training and clinical practice to only a limited extent. This article is a brief evaluation of trends and some findings in modern psychotherapy research that may influence professional psychotherapy training and practice.

Measurement of transference interpretations.

The authors present a cost-efficient process rating scale for detailed measurement of how much transference interpretations and related therapist interventions are used in brief dynamic psychotherapy. Theoretical and methodological considerations on how to operationalize and quantify such therapeutic interventions are discussed. The scale had highly satisfactory interrater reliability for three raters, who rated 60 whole sessions from an ongoing randomized study of two manualized forms of brief dynamic psychotherapy. In one treatment group, moderate emphasis on transference analysis was intended. In the other, minor or no use of the studied component was intended. The two treatment groups differed significantly in the use of transference interpretations and related interventions. There was no significant difference in therapists' general therapeutic skill or use of supportive interventions. The treatment differentiation was consistent with the manuals.

Convergent and discriminant validity of overall defensive functioning.

We examined the validity of the construct of overall defensive functioning and its discrimination from standard diagnostic assessments. Within a multisite field trial, patients received intake diagnostic interviews by clinicians who made standard axis I through V diagnoses, then rated defense mechanisms using the Defense Mechanism Rating Scales (DMRS). Patients filled out self-report measures of distress and defenses, the SCL-90-R, and Defense Style Questionnaire (DSQ). Overall defensive functioning (ODF) scales were derived from both the DMRS and the DSQ. Overlap between clinical and self-report ratings of defenses was modest. By two different methods of factor analysis, followed by confirmatory factor analysis, clinical ratings of ODF were clearly discriminable from axis I, axis II personality disorders, current and usual global functioning, and subjective distress. ODF measured by the DSQ was not clearly discriminated from subjective distress ratings, consistent with the hypothesis that subjective distress may distort conscious derivatives of actual defensive processes. The DSQ alone probably should not be considered as a substitute for observer-rated assessment of defensive functioning, although further study of the issue is warranted.

Field trial of a diagnostic axis for defense mechanisms for DSM-IV.

Following critiques that the DSM multiaxial system lacks psychodynamic information useful for treatment, an axis for defense mechanisms was developed for DSM-IV, including up to 7 individual defenses from a glossary of 27, and 3 predominant defense levels from a list of 7. We tested the feasibility, reliability, and discriminability of the proposed axis. Clinician and psychiatric resident volunteers were trained at two U.S. and one Norwegian sites. After conducting initial interviews on 107 patients, they rated the DSM-III-R and defense axes, as did a second blind rater. Median kappa reliabilities were .42 (individual defenses), and .47 (defense levels). A summary measure, Overall Defensive Functioning (ODF), had similar reliability to current GAF (IR .68 vs. .62), similar 1-month stability (.75 vs. .78), but greater 6-month stability (.51 vs. .17). Independent of Axis III, ODF had small to moderate associations with other Axes and symptoms. Our findings indicate that the defense axis is a feasible, acceptably reliable, and nonredundant addition to DSM-IV, which may prove useful for planning and conducting treatment.

Defensive functioning predicts improvement in major depressive episodes.

We investigated the predictive effect of psychological defenses on the course of major depression in a subsample of psychiatric patients from a larger study. We tested the hypothesis that a group of eight defenses, associated with depression in previous research, would predict, outcome of major depression. After an intake interview, 37 patients were rated on all DSM-III-R Axes, the SCL-90-R, and 28 defenses, using the Defense Mechanism Rating Scales. At 6-month follow-up interview, SCL-90-R and Global Assessment and Functioning (GAF) were redetermined on 34 (92%), 16 of whom had major depression at intake. Overall Defensive Functioning (ODF) significantly predicted GAF at 6-month follow-up over and above initial level of global functioning and presence of a personality disorder. The group of eight defenses were identified more often (p = .068) in depressed patients who improved less than predicted by their initial functional status. The high adaptive level defense, self-observation, was identified more often in those who improved more than predicted by their initial status. Our findings support the theory of a hierarchy of defenses, and the mediating effects of specific low and high adaptive level defenses on the course of a major depressive episode. Further research should examine passive aggression, acting out, help-rejecting complaining, splitting of self-images, splitting of others' images, projective identification, projection, and devaluation in relationship to the onset, course, and treatment response of depressive disorders.

Long-term effects of transference interpretations: comparing results from a quasi-experimental and a naturalistic long-term follow-up study of brief dynamic psychotherapy.

A follow-up study, using a quasi-experimental non-equivalent groups comparison design, the so-called regression discontinuity design, reported a negative long-term effect of a high frequency of transference interpretations given to patients in brief dynamic psychotherapy who had been deemed highly suitable for such treatment. The major threat to internal validity of the findings was the possibility that the patients who were evaluated as highly suitable for dynamic psychotherapy might be the ones with the naturally worst outcomes, independent of therapy technique (selection maturation). Data from a similar naturalistic study with no quasi-experimental manipulation of the treatment technique revealed, however, that highly suitable and relatively less suitable patients had similar outcomes. This makes selection maturation a less plausible confound of the (negative) treatment effect estimated in the quasiexperimental study. A high frequency of transference interpretations in brief dynamic psychotherapy seems to be causally related to less favourable long-term dynamic change.

Motivation for brief dynamic psychotherapy.

BACKGROUND: Preliminary research indicates that motivation may be a key predictor of success in brief dynamic psychotherapy, but different aspects of motivation have not been studied as predictors. METHODS: In this study 48 out-patients were clinically evaluated before therapy with regard to different aspects of motivation. Seven motivation items modified after Sifneos were rated by several experienced judges. Forty-three patients were treated and followed up 2 and 4 years after brief dynamic psychotherapy. The predictive validity of each of the motivation items was tested by their direct correlations with long-term outcome, and their collective predictive validity was tested by use of multiple regression analyses. RESULTS: The interrater reliability was problematic for single items, but when the average scores of 4 judges were used, adequate reliabilities on 4 items were achieved. Two items, Motivation for change and Realistic expectations, showed the best predictive validity of long-term outcome. CONCLUSIONS: An Active engagement aspect of motivation may predict both successful and unsuccessful cases. Our data indicate that patients should be instructed about the principles and procedures of dynamic psychotherapy and they should be told why it is important for them to actively test alternative problem-solving strategies during and after therapy.

The role of insight in exploratory psychodynamic psychotherapy.

Psychoanalytic theory holds that dynamic insight is used for self-observation and self-analysis during and after explorative therapy. Such self-analysis is held to lead to stable dynamic change. Within a sample of 43 moderately disturbed out-patients, pre-treatment level of insight was associated with treatment length, with not being an early or late drop-out, and with receiving additional psychotherapy during a four-year follow-up period. Pre-treatment level of insight turned out to be not directly correlated with outcome two and four years after therapy. However, level of insight was significantly correlated with outcome in interaction with treatment length. Gain of insight measured at two-year follow-up was the strongest predictor of overall dynamic change four years after therapy, compared with all the other outcome assessments made at two-year follow-up.

The circumscribed focus in intensive brief dynamic psychotherapy.

The clinical proposition that an ideal focus for intensive brief dynamic psychotherapy is an intra-psychic conflict rooted in oedipal pathology with circumscribed effects on personality functioning has been widely accepted a priori, without empirical validation. In this study 4 clinical raters assessed the 'degree of circumscribed conflict' and 'hypothesized psychosexual development level' from a dynamic evaluation interview. The variables were only marginally associated with DSM-III diagnoses. Within a subsample of 22 patients treated with intensive psychoanalytic technique, patients with whom a highly circumscribed conflict could be identified had the most favourable dynamic change 4 years after therapy.

Suitability for brief dynamic psychotherapy: psychodynamic variables as predictors of outcome.

The success rate in predicting symptom change 2 years after brief dynamic psychotherapy increased 20% by adding quality of interpersonal relations from a psychodynamic evaluation interview to DSM-III diagnoses, Axis V and Axis II. The success rate in predicting dynamic change 4 years after therapy increased nearly 40% by adding the same variable. Selection criteria such as circumscribed focus, motivation and involvement in the evaluation interview were shown to be redundant as predictors.

Transference interpretations and long-term change after dynamic psychotherapy of brief to moderate length.

In our study of 43 neurotic outpatients treated with brief dynamic psychotherapy, a significant inverse relationship was found between frequency of transference interpretations and long-term outcome for the subsample of 21 patients with a history of high quality of interpersonal relationships. At four-year follow-up, only one of four such patients achieved successful dynamic change when the interpretive focus had been on the transference relationship, whereas three of four patients achieved successful dynamic change when the interpretive focus had been on extratransference relationships. Contrary to what we expected, the subsample of 22 patients with a history of low quality of interpersonal relationships were more able to tolerate high numbers of transference interpretations from early on in treatment. Interpretive work on the transference is ancillary to work outside the transference. This, indeed, was Freud's theoretical position.

Brief dynamic psychotherapy : patient suitability, treatment length, and outcome.

Forty-three neurotic outpatients were treated according to common practice with dynamic psychotherapy of brief to moderate length. Suitability for brief dynamic psychotherapy, measured by quality of interpersonal relations, was independent of DSM-III diagnoses. Suitability was a significant direct predictor of symptomatic and dynamic change 2 and 4 years after therapy. Treatment length added no explained outcome variance over patient characteristics. However, patients with high suitability had a relatively more favorable dynamic outcome with a brief, focused treatment approach, whereas patients with low suitability had relatively more favorable outcome with a longer, less focused treatment of more than 1 year's duration. The significant interaction emerged at 4-year follow-up.

Interpretations of the patient-therapist relationship in brief dynamic psychotherapy : effects on long-term mode-specific changes.

The authors examined whether persistent analysis of the patient-therapist relationship in brief dynamic psychotherapy favorably affects long-term dynamic change in patients initially deemed suitable for such treatment. As in common practice, 22 highly suitable patients were given a high number of transference interpretations per session. A comparison group of 21 patients with lower suitability received the same treatment, but transference interpretations were withheld. Statistical adjustment for the deliberate nonequivalence in pretreatment suitability indicated a significant negative effect of high numbers of transference interpretations on long-term dynamic changes. Demographic variables, DSM-III diagnoses, additional treatment, life events in the follow-up years, or therapist effects did not explain or obscure the findings.

Long-term changes after brief dynamic psychotherapy: symptomatic versus dynamic assessments.

Dynamic change in psychotherapy, as measured by theory-related or mode-specific instruments, have been criticized for being too intercorrelated with symptomatic change measures. In this study, long-term changes after brief dynamic psychotherapy were studied in 45 moderately disturbed neurotic patients by a reliable outcome battery. The factor structure of all the change variables suggested that they tapped 2 distinct and stable sources of variance: dynamic and symptomatic change. The categories of overall dynamic change were different from categories of change on the Global Assessment Scale. A small systematic difference was found between the categories of overall dynamic change and the categories of target complaints change also, due to false solutions of dynamic conflicts.

Selection criteria for brief dynamic psychotherapy: reliability, factor structure and long-term predictive validity.

Forty outpatients were evaluated for psychotherapy with a modified version of Sifneos' selection criteria for brief dynamic psychotherapy. Reliabilities were acceptable for most items when the ratings of 4 clinical judges were averaged. A factor analysis of the reliable items produced four of the five dimensions of suitability proposed by Sifneos and others: circumscribed focus, motivation, flexible interaction, quality of interpersonal relations. A combination of these dimensions were more significant predictors of long-term dynamic change than background and DSM-III axis I-V variables. Problem solving capacity (use of self-understanding) before treatment could not be reliably rated and was accordingly not tested as a possible fifth dimension of suitability.