[Quality measurement in psychodynamic psychotherapy: Diagnosis-specific courses, the influence of different informants, and their view of moderators of change]. / Qualitätssicherung in der psychodynamischen Psychotherapie: Diagnosespezifische Verläufe, der Einfluss unterschiedlicher Respondenten und ihre Sicht auf Moderatoren der Veränderung.

Quality measurement in psychodynamic psychotherapy: Diagnosis-specific courses, the influence of different informants, and their view of moderators of change Abstract. This study uses a naturalistic design to assess the course and effectiveness of long-term psychodynamic therapies from the perspective of adolescent patients and their mothers. It looks at the context of different moderators of change, including the characteristics of the patient, the therapist, and the therapy. Assessments of the internalizing, externalizing, and overall symptom burden using the Youth Self Report (YSR) and the Child Behavior Checklist (CBCL) were collected on 161 patients and their mothers at three timepoints - the beginning, middle, and end of therapy. The assessments of both informants showed a decrease in symptoms over the course of therapy with similar effect sizes (η2 = .25 for the patients, η2 = .31 for their mothers). The adolescents differentiated more between the diagnosis groups, reported higher symptom intensities at the beginning, and saw fewer changes in the second half of the therapy than their mothers. Psychodynamic long-term therapy was particularly effective for internalizing disorders according to both parents and patients. Both informants differed, however, in their evaluation of short-term therapy. An examination of the moderators of change in the mothers' evaluation (difference value of the total symptom burden between the beginning and end) showed that the therapist and therapy characteristics predicted change, whereas for adolescents, the patient characteristics have the greatest influence.

Capturing the Unconscious-The "Psychoanalytic Core Competency Q-Sort". An Innovative Tool Investigating Psychodynamic Therapeutic Skills.

The Psychoanalytic Core Competency Q-Sort (PCC Q-Sort) is a newly developed empirical research tool that allows for the description and illustration of the ways psychodynamically-oriented psychotherapists work. It provides a simple, straightforward rating procedure utilizing a well-established q-sort method. The present pilot study describes the psychoanalytic core competency items and discusses the development procedure of the instrument as well as statistical analysis of ratings from psychoanalytic sessions, including inter-rater reliability as well as preliminary findings on possible construct validity. Additionally, a factor analysis was performed. Values were assessed by applying the PCC Q-Sort to 30 audio recordings of psychoanalytic sessions. The results of the present study indicate that the PCC Q-Sort is a reliable process research instrument that allows for a detailed investigation of psychotherapy processes in psychodynamic psychotherapies and change processes.

Psychotherapy with Suicidal Patients: The Integrative Psychodynamic Approach of the Boston Suicide Study Group.

Psychotherapy with suicidal patients is inherently challenging. Psychodynamic psychotherapy focuses attention on the patient's internal experience through the creation of a therapeutic space for an open-ended exploration of thoughts, fears, and fantasies as they emerge through interactive dialogue with an empathic therapist. The Boston Suicide Study Group (M.S., M.J.G., E.R., B.H.), has developed an integrative psychodynamic approach to psychotherapy with suicidal patients based on the authors' extensive clinical work with suicidal patients (over 100 years combined). It is fundamentally psychodynamic in nature, with an emphasis on the therapeutic alliance, unconscious and implicit relational processes, and the power of the therapeutic relationship to facilitate change in a long-term exploratory treatment. It is also integrative, however, drawing extensively on ideas and techniques described in Dialectical Behavioral Therapy (DBT), Mentalization Based Treatment (MBT), Cognitive-Behavioral Therapy (CBT), as well on developmental and social psychology research. This is not meant to be a comprehensive review of psychodynamic treatment of suicidal patients, but rather a description of an integrative approach that synthesizes clinical experience and relevant theoretical contributions from the literature that support the authors' reasoning. There are ten key aspects of this integrative psychodynamic treatment: 1. Approach to the patient in crisis; 2, instilling hope; 3. a focus on the patient's internal affective experience; 4. attention to conscious and unconscious beliefs and fantasies; 5. improving affect tolerance; 6. development of narrative identity and modification of "relational scripts"; 7. facilitation of the emergence of the patient's genuine capacities; 8. improving a sense of continuity and coherence; 9 attention to the therapeutic alliance; 10. attention to countertransference. The elements of treatment are overlapping and not meant to be sequential, but each is discussed separately as an essential aspect of the psychotherapeutic work. This integrative psychodynamic approach is a useful method for suicide prevention as it helps to instill hope, provides relational contact and engages the suicidal patient in a process that leads to positive internal change. The benefits of the psychotherapy go beyond crisis intervention, and include the potential for improved affect tolerance, more fulfilling relational experiences, emergence of previously warded off experience of genuine capacities, and a positive change in narrative identity.

How do adolescents with depression experience improvement in psychodynamic psychotherapy? A qualitative study.

BACKGROUND: There is emerging evidence for the effectiveness of psychodynamic psychotherapy for depressive disorders. However, we know less of how this relation-focused therapy mode is experienced and what the patients themselves identify as helpful. Hence, the purpose of this study is to explore adolescents' experiences of factors promoting improvement in psychodynamic therapy. METHODS: Eight female patients participating in a Norwegian study on psychodynamic therapy, the First Experimental Study of Transference Work - In Teenagers (FEST-IT), were included. The participants were offered a total number of 28 sessions. Semi-structured qualitative interviews about experiences with therapy were then conducted and analysed with systematic text condensation and hermeneutic interpretation. RESULTS: The analysis revealed four main themes. 'Exploring oneself' comprises autonomy and acknowledgment, openness, insight and acceptance of oneself. 'Therapist relation and characteristics' includes confidence and trust in and support from the therapist as well as having a trustworthy and experienced therapist. 'Focusing on everyday life' includes learning and practical orientation. 'Time factors' refers to duration and frequency. CONCLUSIONS: Together with a supportive and listening therapist, the adolescents improve by exploring themselves within the frames of a time-limited treatment period. Improvement seems to be experienced through better relations to oneself and to others and by finding one's place in the family, or at school. Adolescents value problem solving and help with concrete challenges. Hence, therapy should be tailored to the needs of adolescents with depression and incorporate the challenges they face in their everyday life. TRIAL REGISTRATION: ClinicalTrials.gov . Id: NCT01531101. Date of registry: 8 February 2012, retrospectively registered.

Therapeutic Assessment in Personality Disorders: Toward the Restoration of Epistemic Trust.

Research evidence suggests Therapeutic Assessment positively affects clients with problems in living, including clients with personality disorders, who are typically quite resistant to change. Importantly, this change takes place quickly, in relatively few sessions. This article draws on a relatively new evolutionary-based theory of epistemic trust (ET) and epistemic hypervigilance (EH) as a lens to plausibly explain the efficacy of TA, and especially its influence on PD clients' alliance and motivation for subsequent psychotherapy (Fonagy, Luyten, & Alison, 2015). ET is the willingness to take in relevant interpersonally transmited information and it is essential to the immediate success of psychotherapy and its long-term impact. The collaborative, intersubjective framework of TA and many of its specific techniques might be understood as highly relevant to restoring ET in clients, especially those with PD. We close by discussing implications for psychological assessment, psychotherapy, and research.

Psychotherapy With Suicidal Patients Part 1: Expert Consensus Recommendations.

This column reviews and discusses recommendations made by individual experts and by expert panels for treating suicidal patients in psychotherapy. Therapies for suicidal patients that were considered for the extraction of shared elements include cognitive behavioral, psychodynamic, and integrated psychotherapies. There is a large amount of convergence among expert consensus recommendations for treating suicidal patients.

Intraindividual variability in symptoms consistently predicts sudden gains: An examination of three independent datasets.

OBJECTIVE: Sudden gains are robust predictors of outcome in psychotherapy. However, previous attempts at predicting sudden gains have yielded inconclusive findings. The aim of the present study was to examine a novel, transdiagnostic, transtherapeutic predictor of sudden gains that would replicate in different settings and populations. Specifically, we examined intraindividual variability in symptoms. METHOD: We examined data from a randomized controlled trial (RCT) of prolonged exposure therapy for posttraumatic stress disorder (PTSD) in children and adolescents (n = 63), an RCT of cognitive and behavioral therapies for obsessive-compulsive disorder (OCD) in adults (n = 91), and psychodynamic therapy delivered under routine clinical conditions in a naturalistic setting for diverse disorders (n = 106). In all 3 data sets, we examined whether a measure of variability in symptoms occurring during the first sessions could predict sudden gains. RESULTS: Variability in symptoms was found to be independent of total change during treatment. Variability in symptoms significantly predicted sudden gains in all 3 data sets and correctly classified 81.0%, 69.2%, and 76.9% of individuals to sudden gain or nonsudden gain status, respectively. CONCLUSIONS: The present study represents the first examination of variability in symptoms as a predictor of sudden gains. Findings indicated that sudden gains are significantly predicted by intraindividual variability in symptoms, in diverse settings, contexts, and populations. Advantages of this predictor, as well as clinical and research implications are discussed. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Advocacy for Psychodynamic Psychotherapy: Challenges and Benefits.

Psychodynamic psychotherapy, also called psychodynamic therapy (PDT), is an effective mental health treatment that is currently under siege on several fronts. It is at risk of being effectively excluded from the future of American health care. Psychiatrists need to learn how to advocate for a future mental health care delivery system that assures their patients have access to PDT. This article examines the stigma against both psychiatrists and PDT, identifies some of the challenges to advocacy that psychiatrists face, and offers an approach to developing the necessary skills that psychiatrists need to advocate effectively for PDT.

Innovative Educational Initiatives to Train Psychodynamic Psychiatrists in Underserved Areas of the World.

Psychodynamic psychiatry remains a challenging subject to teach in underserved areas, where enthusiasm to learn is substantial. Besides logistical and psychiatric workforce shortcomings, sensible cultural adaptations to make psychodynamic psychiatry relevant outside of high-income countries require creative effort. Innovative pedagogical methods that include carefully crafted mentoring and incorporate videoconferencing in combination with site visits can be implemented through international collaborations. Emphasis on mentoring is essential to adequately train future psychodynamic psychotherapy supervisors. Examples of World Psychiatric Association initiatives in countries such as Indonesia, Iran, Malaysia, and Thailand are presented as possible models to emulate elsewhere.

The design of the MBT-G adherence and quality scale.

Few group psychotherapy studies focus on therapists' interventions, and instruments that can measure group psychotherapy treatment fidelity are scarce. The aim of the present study was to evaluate the reliability of the Mentalization-based Group Therapy Adherence and Quality Scale (MBT-G-AQS), which is a 19-item scale developed to measure adherence and quality in mentalization-based group therapy (MBT-G). Eight MBT groups and eight psychodynamic groups (a total of 16 videotaped therapy sessions) were rated independently by five raters. All groups were long-term, outpatient psychotherapy groups with 1.5 hours weekly sessions. Data were analysed by a Generalizability Study (G-study and D-study). The generalizability models included analyses of reliability for different numbers of raters. The global (overall) ratings for adherence and quality showed high to excellent reliability for all numbers of raters (the reliability by use of five raters was 0.97 for adherence and 0.96 for quality). The mean reliability for all 19 items for a single rater was 0.57 (item range 0.26-0.86) for adherence, and 0.62 (item range 0.26-0.83) for quality. The reliability for two raters obtained mean absolute G-coefficients on 0.71 (item range 0.41-0.92 for the different items) for adherence and 0.76 (item range 0.42-0.91) for quality. With all five raters the mean absolute G-coefficient for adherence was 0.86 (item range 0.63-0.97) and 0.88 for quality (item range 0.64-0.96). The study demonstrates high reliability of ratings of MBT-G-AQS. In models differentiating between different numbers of raters, reliability was particularly high when including several raters, but was also acceptable for two raters. For practical purposes, the MBT-G-AQS can be used for training, supervision and psychotherapy research.

[Evidence of the effect of psychodynamic psychotherapy].

Evidence of the effect of psychodynamic psychotherapy (PDT) has been called into question. Thus, an updated review of the effect of short-term and long-term PDT (STPP and LTPP) for anxiety, depression and personality disorders seems necessary. A systematic search of randomized controlled studies of PDT published from January 2000 to May 2016 was conducted, and we found 57 single studies and 13 meta-analyses fulfilling the criteria for inclusion. The studies show that PDT has therapeutic efficacy and effectiveness matching other forms of psychotherapy. LTPP shows better effect than STPP in the treatment of complex psychiatric disorders and long-term depression.

Mentalization-based therapy adherence and competence stimulates in-session mentalization in psychotherapy for borderline personality disorder with co-morbid substance dependence.

OBJECTIVE: To test whether adherence to mentalization-based treatment (MBT) principles predict better patient in-session mentalizing. METHODS: Two sessions for each of 15 patients with borderline personality disorder and comorbid substance abuse disorder were rated for MBT adherence and competence. Individual patient statements were rated for Reflective Functioning (RF), therapist statements were rated as demanding RF or not. Data were analysed using multilevel modelling. RESULTS: MBT adherence and competence predicted higher session RF (ß = .58-.75), even while controlling for pre-treatment RF. In addition, therapist interventions directed toward exploring mental states predicted higher RF of subsequent patient responses (ß = .11-.12). CONCLUSIONS: MBT adherence and competence were significantly related to patient in-session mentalizing, supporting the validity of MBT principles. Results point to the importance of supervision for therapists to become adherent to MBT principles. The small number of patients and sessions limits generalizability of results.

Relational interventions in psychotherapy: development of a therapy process rating scale.

BACKGROUND: In psychodynamic psychotherapy, one of the therapists' techniques is to intervene on and encourage exploration of the patients' relationships with other people. The impact of these interventions and the response from the patient are probably dependent on certain characteristics of the context in which the interventions are given and the interventions themselves. To identify and analyze in-session effects of therapists' techniques, process scales are used. The aim of the present study was to develop a simple, not resource consuming rating tool for in-session process to be used when therapists' interventions focus on the patients' relationships outside therapy. METHODS: The present study describes the development and use of a therapy process rating scale, the Relational Work Scale (RWS). The scale was constructed to identify, categorize and explore therapist interventions that focus on the patient's relationships to family, friends, and colleges Relational Interventions and explore the impact on the in-session process. RWS was developed with sub scales rating timing, content, and valence of the relational interventions, as well as response from the patient. For the inter-rater reliability analyzes, transcribed segments (10 min) from 20 different patients were scored with RWS by two independent raters. Two clinical vignettes of relational work are included in the paper as examples of how to rate transcripts from therapy sessions with RWS. RESULTS: The inter-rater agreement on the RWS items was good to excellent. CONCLUSION: Relational Work Scale might be a potentially useful tool to identify relational interventions as well as explore the interaction of timing, category, and valence of relational work in psychotherapies. The therapist's interventions on the patient's relationships with people outside therapy and the following patient-therapist interaction might be explored. TRIAL REGISTRATION: First Experimental Study of Transference-interpretations (FEST307/95) REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT00423462 .

Common Errors in Conducting Psychodynamic Psychotherapy: Illustrative Vignettes and Alternative Strategies.

In this paper 12 common errors that occur in the course of psychodynamic psychotherapy are reviewed. Rationales for why we consider these to be errors are described, and vignettes are used to illustrate the errors, lastly, recommendations for alternate approaches consistent with effective psychodynamic psychotherapy are presented. The errors reviewed include concerns regarding the maintenance of appropriate limits and boundaries; decisions regarding the focus and form of treatment; no-suicide contracts; fee arrangements; missed sessions; psychological testing of psychotherapy patients; selecting appropriate patients for psychotherapy; and the importance of personal psychotherapy for the therapist. The suggestions provided are consistent with what we believe are the goals of psychodynamic psychotherapy: autonomy, insight, and self-determination.

Relationship Between Patient SWAP-200 Personality Characteristics and Therapist-Rated Therapeutic Alliance Early in Treatment.

In the present study, we assess the extent to which patient personality features and prototypes are associated with early treatment therapist-rated alliance. The study sample consisted of 94 patients receiving psychodynamic psychotherapy at an outpatient clinic. Clinicians completed the Working Alliance Inventory (J Couns Psychol 36:223-233; Psychother Res 9:405-423) to assess their views of early alliance and the Shedler-Westen Assessment Procedure 200 (SWAP-200; Assessment 5:333-353, Am J Psychiatry 161:1350-1365, 1743-1754; Am J Psychiatry 156:258-272, 273-285) to assess patient personality. The SWAP-200 Narcissistic Clinical Prototype, Dysphoric Q-Factor, and Dysphoric/High-Functioning Neurotic Q-Subfactor significantly correlated with early therapist-rated alliance. Correlations that trended toward significance were also found. Also identified were specific SWAP-200 items that were found to relate to high early therapist-rated alliance scores. These results demonstrate some relationship, albeit small, between patient personality characteristics and therapists' views of the alliance that may serve to further a conceptual understanding of the alliance, specific personality syndromes, and the associated impact on the therapeutic interaction.

Expert clinicians' prototypes of an ideal child treatment in psychodynamic and cognitive-behavioral therapy: Is mentalization seen as a common process factor?

OBJECTIVE: To investigate (a) whether expert clinicians within psychodynamic therapy (PDT) and cognitive-behavioral therapy (CBT) agree on key features of child psychotherapy process using the Child Psychotherapy Process Q-Set (CPQ); (b) whether these two prototypes can be empirically distinguished; and (c) whether promoting mentalization (operationalized as reflective functioning [RF]) is a shared component of the way expert clinicians conceptualize these two treatment models. METHOD: Thirty-one raters with expertise in PDT, CBT, and RF provided ratings of the 100 CPQ items to describe an ideal prototype session that adheres to the principles of their treatment model. Two Q-factor analyses with varimax rotation were conducted. RESULTS: Expert clinicians reached a high level of agreement on their respective PDT and CBT prototypes. These prototypes loaded onto two independent factors. The RF process prototype loaded onto both factors. CONCLUSIONS: From the theoretical perspective of expert clinicians representing PDT and CBT, a focus on RF appears to be a common process factor in the way both treatment models are conceptualized. The CPQ can also be a useful instrument in teaching psychotherapy process from different theoretical perspectives and training future clinicians in their application. Future researchers can use these prototypes to explore process in actual sessions.