Defensive Functioning Moderates the Effects of Nondirective Meditation.

We have recently found that nondirective meditation facilitates stress reduction. This supplementary study investigated whether defensive functioning would moderate these beneficial effects. We explored the occurrence of defense mechanisms and the impact of defensive functioning on the outcome of companies' stress management programs regarding worries nervousness, mental distress, sleep problems, and muscle pain. The sample was a population of active, working professionals recruited from Norwegian companies (n = 105). The intervention group obtained significant benefits on all outcome measures, but there were no effects in the control group. We analyzed defensive functioning with the self-report questionnaire, Life Style Index, at four time points. The healthy adults who participated had a low level of defense scores at the outset. There was a significant reduction in the level of defenses in both groups over the study period, 6 months. Defensive functioning significantly moderated the change of the outcome measures from baseline to follow-up in the intervention group, but not in the control group.

The first experimental study of transference work-in teenagers (FEST-IT): a multicentre, observer- and patient-blind, randomised controlled component study.

BACKGROUND: Little is known about the influence on outcome of exploration of the patient-therapist relationship (that is, transference work) in psychoanalytic psychotherapy. We hypothesized that depressed adolescents would have better long-term effects from psychoanalytic psychotherapy with than without transference work. METHODS: Depressed adolescent (16 to 18 years) were recruited in health authority funded out-patient clinics in Oslo and Vestfold County, Norway. They were randomized to 28 weeks of treatment with psychoanalytic psychotherapy with or without transference work. Change was assessed using linear-mixed models. The primary outcome measure was the Psychodynamic Functioning Scale (pre- post-, and 1-year post-treatment). Level of depression was measured at the same time points and during therapy (week 12, and 20). RESULTS: 69 adolescents were treated with (N = 39) or without (N = 31) transference work. The mean number of sessions was 18.6 (SD = 8,6) in the transference work group and 18.0 (SD = 10.9) in the non-transference work group. Both groups showed large and significant improvement on Psychodynamic Functioning Scale during the whole study period. The difference between the two groups was not significant during the treatment period (95% CI -.79 to 1.2, p = .674, F = .18), or from post-treatment to one-year follow-up (95% CI -.13 to .96; p = .134; F = 2.3). For the secondary outcome measures the transference work group had significantly better outcomes from 12 weeks in treatment to one-year follow-up (Beck Depression Inventory, 95% CI - 1.7 to -.14, p = .022; Montgomery and Åsberg Depression Rating Scale, 95% CI - 1.6 to -.23, p = .009). CONCLUSION: The findings suggest that exploration of the adolescents' relations to the therapist amplify the effects of short-term psychoanalytic psychotherapy on their depressive symptoms for adolescents with a Major Depressive Disorder. TRIAL REGISTRATION: ClinicalTrials.gov . Id: NCT01531101 . Registered 8 February 2012.

Psychodynamic case formulations without technical language: a reliability study.

BACKGROUND: To bridge the gap between symptoms and treatment, constructing case formulations is essential for clinicians. Limited scientific value has been attributed to case formulations because of problems with quality, reliability, and validity. For understanding, communication, and treatment planning beyond each specific clinician-patient dyad, a case formulation must convey valid information concerning the patient, as well as being a reliable source of information regardless of the clinician's theoretical orientation. The first aim of the present study is to explore the completeness of unstructured psychodynamic formulations, according to four components outlined in the Case Formulation Content Coding Method (CFCCM). The second aim is to estimate the reliability of independent formulations and their components, using similarity ratings of matched versus mismatched cases. METHODS: This study explores psychodynamic case formulations as made by two or more experienced clinicians after listening to an evaluation interview. The clinicians structured the formulations freely, with the sole constraint that technical, theory-laden terminology should be avoided. The formulations were decomposed into components after all formulations had been written. RESULTS: The results indicated that most formulations were adequately comprehensive, and that overall reliability of the formulations was high (> 0.70) for both experienced and inexperienced clinician raters, although the lower bound reliability estimate of the formulation component deemed most difficult to rate - inferred mechanisms - was marginal, 0.61. CONCLUSIONS: These results were achieved on case formulations made by experienced clinicians using simple experience-near language and minimizing technical concepts, which indicate a communicative quality in the formulations that make them clinically sound. TRIAL REGISTRATION: linicalTrials.gov Identifier: NCT00423462 . https://doi.org/10.1007/s00432-018-2781-7 ., January 18, 2007.

Long-term effects of analysis of the patient-therapist relationship in the context of patients' personality pathology and therapists' parental feelings.

OBJECTIVE: Analysis of the patient-therapist relationship (relationship work) is considered a core active ingredient in dynamic psychotherapy. However, there are contradictory findings as for whom and under what circumstances these interventions are beneficial. This study investigates long-term effects of relationship work in the context of patients' level of personality pathology and therapists' self-reported parental feelings. METHOD: One hundred outpatients seeking psychotherapy for depression, anxiety, and personality disorders were randomly assigned to weekly dynamic psychotherapy, either with or without relationship work, for 1 year. Personality pathology was evaluated before treatment as the sum of fulfilled personality disorder criteria items on the Structured Clinical Interview for DSM-III-R Personality Disorders. Therapist feelings were assessed using the Feeling Word Checklist-58. The outcome variables were the Psychodynamic Functioning Scales and Inventory of Interpersonal Problems, measured at pretreatment, midtreatment, posttreatment, 1 year, and 3 years after treatment termination. RESULTS: A significant interaction of treatment group (relationship work vs. no relationship work) by personality pathology by parental therapist feelings was present, indicating that parental feelings were differentially associated with long-term effects of relationship work, depending on the level of personality pathology. In the context of low parental feelings, relationship work was positive for all patients. However, when parental feelings were stronger, the specific effects of such interventions were even more positive for patients with high levels of personality pathology, but negative for patients with low levels of personality pathology. CONCLUSION: The interaction of parental therapist feelings and patients' personality pathology was strongly associated with the long-term specific effects of analysis of the patient-therapist relationship.

The effects of the therapist's disengaged feelings on the in-session process in psychodynamic psychotherapy.

The primary aim of this article was to explore the effects of the therapist's disengaged feelings (i.e., bored, tired of, sleepy, indifferent, aloof) in psychodynamic therapy. The Transference Work Scale was used in combination with the Defense Mechanism Rating Scales and Structural Analyses of Social Behavior to explore the in-session process in 2 therapies with female patients with interpersonal problems. Analyses showed differences in in-session processes (i.e., defense mechanisms; transference work; degree of affiliation and interdependence in the dialogue) and treatment outcome between therapies characterized by a low versus a higher degree of disengaged feelings. Compared to the case with the engaged therapist, the disengaged therapist showed poorer interaction and less response to transference and defense interpretation. When aware of their disengaged feelings, therapists are advised to encourage their patients to discuss the patient-therapist interaction.

The combined predictive effect of patient characteristics and alliance on long-term dynamic and interpersonal functioning after dynamic psychotherapy.

On the basis of the well-established association between early alliance and outcome, this exploratory study investigated the associations between the therapeutic alliance and long-term outcome, 3 years after treatment termination. In addition to the early alliance, pre-treatment patient characteristics and expectancies that were significantly related to early alliance were included in the statistical analyses. The data are from the First Experimental Study of Transference, a dismantling randomized clinical trial with long-term follow-up. One hundred out-patients who sought psychotherapy due to depression, anxiety and personality disorders were treated. Alliance was measured with Working Alliance Inventory after session 7. Change was determined using linear mixed model analyses. The alliance alone had a significant impact on long-term outcome of the predetermined primary outcome variables of the study: Psychodynamic Functioning Scales and Inventory of Interpersonal Problems. Contrary to common clinical wisdom, when the pre-treatment patient variables were included, more personality disorder pathology was the strongest predictor of favourable outcome, over and above the effect of the alliance, which was no longer significant. Clinical implications are discussed.

Therapist interventions using the Psychodynamic Interventions Rating Scale (PIRS) in dynamic therapy, psychoanalysis and CBT.

One requirement for psychotherapy research is an accurate assessment of therapeutic interventions across studies. This study compared frequency and depth of therapist interventions from a dynamic perspective across four studies, conducted in four countries, including three treatment arms of psychodynamic psychotherapy, and one each of psychoanalysis and CBT. All studies used the Psychodynamic Intervention Rating Scales (PIRS) to identify 10 interventions from transcribed whole sessions early and later in treatment. The PIRS adequately categorized all interventions, except in CBT (only 91-93% categorized). As hypothesized, interpretations were present in all dynamic therapies and relatively absent in CBT. Proportions of interpretations increased over time. Defense interpretations were more common than transference interpretations, which were most prevalent in psychoanalysis. Depth of interpretations also increased over time. These data can serve as norms for measuring where on the supportive-interpretive continuum a dynamic treatment lies, as well as identify potentially mutative interventions for further process and outcome study.

Treatment of adolescents with depression: the effect of transference interventions in a randomized controlled study of dynamic psychotherapy.

BACKGROUND: Depression in adolescents seems to be a growing problem that causes mental suffering and prevents young people from joining the workforce. There is also a high risk of relapse during adult life. There is emerging evidence for the effect of psychodynamic psychotherapy in adolescents. In-session relational intervention (that is, transference intervention) is a key component of psychodynamic psychotherapy. However, whether depressed adolescents profit most from psychodynamic psychotherapy with or without transference interventions has not been stated. OBJECT: The effect of transference interventions in depressed adolescents and the moderator moderating effect of quality of object relations, personality disorder and gender will be explored. METHODS AND STUDY DESIGN: The First Experimental Study of Transference Work-In Teenagers (FEST-IT) will be a randomized clinical trial with a dismantling design. The study is aimed to explore the effects of transference work in psychodynamic psychotherapy for adolescents with depression. One hundred patients ages 16 to 18 years old will be randomized to one of two treatment groups, in both of which general psychodynamic techniques will be used. The patients will be treated over 28 weeks with either a moderate level of transference intervention or no transference intervention. Follow-up will be at 1 year after treatment termination. The outcome measures will be the Psychodynamic Functioning Scales (PFS), Inventory of Interpersonal Problems-Circumplex Version (IIP-C), Global Assessment of Functioning (GAF), and the total mean score of Symptom Checklist-90 (Global Severity Index; GSI), Beck Depression Inventory (BDI), and Montgomery Åsberg Rating Scale (MADRS). The quality of adolescents' relationships will be a central focus of the study, and the Adolescent Relationship Scales (ARS) and Differentiation-Relatedness Scale (DRS) will also be used. Change will be assessed using linear-mixed models. Gender personality disorder (PD) and quality of object relations (QOR) will be the preselected putative moderators. DISCUSSION: The object of this clinical trial is to explore the effect of transference interventions in psychodynamic psychotherapy in adolescents with a major depressive disorder. Using a randomized and dismantling design, we hope that the study will add more specific knowledge to the evidence base. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01531101First Experimental Study of Transference work Work-In Teenagers (FEST-IT).

Psychodynamic group psychotherapy: impact of group length and therapist professional characteristics on development of therapeutic alliance.

OBJECTIVES: Little research has been done on therapeutic alliance in group psychotherapy, especially the impact of treatment duration and therapist professional characteristics. METHODS: Therapeutic alliance was rated by patients on the Working Alliance Inventory-Short Form at three time points (sessions 3, 10 and 17) in a randomized controlled trial of short-term and long-term psychodynamic group psychotherapy. As predictors we selected therapist clinical experience and length of didactic training, which have demonstrated ambiguous results in previous research. Linear latent variable growth curve models (structural equation modeling) were developed for the three Working Alliance Inventory-Short Form subscales bond, task and goal. RESULTS: We found a significant variance in individual growth curves (intercepts and slopes) but no differential development due to group length. Longer therapist formal training had a negative impact on early values of subscale task in both treatments. There was an interaction between length of the therapists' clinical experience and group length on early bond, task and goal: therapists with longer clinical experience were rated lower on initial bond in the long-term group but less so in the short-term group. Longer clinical experience influenced initial task and goal positively in the short-term group but was unimportant for task or significantly negative for goal in the long-term group. CONCLUSION: There was no mean development of alliance, and group length did not differentially impact the alliance during 6 months. Early ratings of the three Working Alliance Inventory-Short Form subscales partly reflected different preparations of patients in the two group formats, partly therapist characteristics, but more research is needed to see how these aspects impact alliance development and outcome. Therapists should pay attention to all three aspects of the alliance, when they prepare patients for group therapy. KEY PRACTITIONER MESSAGE: In psychodynamic groups, length of therapy does not differentiate the overall level or the development of member-leader alliance. Within psychodynamic groups, each individual appear to have their unique perception of the member-leader alliance. Therapists with longer formal psychotherapy training may be less successful in establishing early agreement with patients on the tasks of psychodynamic group psychotherapy. Patients perceive a somewhat lower degree of early emotional bonding with the more clinically experienced therapists in long-term psychodynamics groups. Therapists with more clinical experience may contribute to a stronger degree of initial agreement with patients on the tasks and goals of short-term group psychotherapy.

Effects of transference work in the context of therapeutic alliance and quality of object relations.

OBJECTIVE: Transference interpretation is considered as a core active ingredient in dynamic psychotherapy. In common clinical theory, it is maintained that more mature relationships, as well as a strong therapeutic alliance, may be prerequisites for successful transference work. In this study, the interaction between quality of object relations, transference interpretation, and alliance is estimated. METHOD: One hundred outpatients seeking psychotherapy for depression, anxiety, and personality disorders were randomly assigned to 1 year of weekly sessions of dynamic psychotherapy with transference interpretation or to the same type and duration of treatment, but without the use of transference interpretation. Quality of Object Relations (QOR)-lifelong pattern was evaluated before treatment (P. Høglend, 1994). The Working Alliance Inventory (A. O. Horvath & L. S. Greenberg, 1989; T. J. Tracey & A. M. Kokotovic, 1989) was rated in Session 7. The primary outcome variable was the Psychodynamic Functioning Scales (P. Høglend et al., 2000), measured at pretreatment, posttreatment, and 1 year after treatment termination. RESULTS: A significant Treatment Group × Quality of Object Relations × Alliance interaction was present, indicating that alliance had a significantly different impact on effects of transference interpretation, depending on the level of QOR. The impact of transference interpretation on psychodynamic functioning was more positive within the context of a weak therapeutic alliance for patients with low quality of object relations. For patients with more mature object relations and high alliance, the authors observed a negative effect of transference work. CONCLUSION: The specific effects of transference work was influenced by the interaction of object relations and alliance, but in the direct opposite direction of what is generally maintained in mainstream clinical theory.

Therapeutic alliance mediates the effect of patient expectancy in dynamic psychotherapy.

OBJECTIVES. Patient expectancy has been regarded as an important predictor of psychotherapy outcome, for more than half a century. In recent years, some evidence has emerged indicating that the therapeutic alliance may mediate the association between expectancy and outcome. DESIGN. In this dismantling, randomized clinical study, 100 out-patients who sought psychotherapy due to depression, anxiety, and personality disorders, were assigned to 1 year of dynamic psychotherapy with and without transference interpretation. METHODS. Patients' pre-treatment target expectancies and global expectancy were measured in this clinical trial. Tests of mediation were performed with two patient-rated and one therapist-rated measure of the therapeutic alliance, using regression analyses. Six putative moderators of the mediational paths were explored. RESULTS. Global Optimism was significantly associated with two clinician-rated outcome measures - the Psychodynamic Functioning Scales and Global Assessment of Functioning. Both patient ratings, but not the therapist rating of alliance mediated the association between global expectancy and clinician-rated outcome. None of the putative moderators had a significant effect. CONCLUSION. The results, together with previous findings, indicate that the expectancy-alliance-outcome mediational chain is a general phenomenon, not limited to subgroups of patients or modes of treatment.

Development of working alliance over the course of psychotherapy.

OBJECTIVES: The goal was to investigate patients' rating of working alliance in longer-term individual psychotherapy (N=201), in order to determine different patterns of development and predictors of positive versus negative development. DESIGN: The study explored patient factors that might be associated with positive versus negative development of the alliance, from early in treatment until the end. Subgroups of patients with different alliance development were compared, in order to identify predictors of these groups. METHODS: The data analyses identified patients who demonstrated significant change in the perceived quality of alliance using the reliable change index. Most patients were expected to have a stable alliance, and fewer were expected to have improving or deteriorating alliance. RESULTS: We found three patterns: stable alliance, improving alliance, and deteriorating alliance. Seventy per cent of the therapies had a stable alliance, which was maintained throughout the treatment, supporting the assumption that the quality of the early alliance is important for the therapy process. We observed different pre-treatment scores of Target Complaint and Expectation of Change in Target Complaint between the subgroups with different development of the working alliance. Higher Expectation of Change was associated with improving alliance, whereas the combination of higher Target Complaint scores and lower Expectation of Change was associated with deteriorating alliance. Also, lower score on Global Assessment Scale (<50) was associated with deteriorating alliance. Clinical case vignettes illustrate the developments of improving and deteriorating alliance. CONCLUSION: Several pre-treatment patient characteristics were associated with development of alliance in positive versus negative directions. Clinical implications are discussed.

Pretreatment patient characteristics related to the level and development of working alliance in long-term psychotherapy.

This study explored pretreatment patient characteristics associated with the level and growth of working alliance in therapies lasting up to 120 therapy sessions. The quality of working alliance was rated by both patients (N=201) and therapists (N=61) at Sessions 3, 12, and 20 and then at every 20th successive session. Patients reported that experience with good maternal care up to adolescence and better current interpersonal relationships were associated with positive ratings of working alliance throughout therapy. Higher global functioning was associated with growth of alliance over time. Higher levels of interpersonal problems of the cold/detached kind were associated with poorer early working alliance. On the other hand, this type of interpersonal problems was also associated with improvement of working alliance over time. Therapists' ratings of alliance were associated with patients' intrapsychic functioning. Implications for treatment and research are discussed.

Therapist characteristics influencing the quality of alliance in long-term psychotherapy.

This study explored therapist characteristics associated with the development of working alliance in long-term therapies, up to 120 sessions. The quality of working alliance was rated by both patients (n = 201) and therapists (n = 61) at sessions 3, 12, 20 and every 20th successive session. Therapists' self-reported scores on the 'cold/detached' dimension of Inventory of Interpersonal Problems-64 tapping therapists' interpersonal style, such as being distanced, disconnected or indifferent, had a negative impact on the working alliance as rated both by patients and therapists. More professional training was associated with poorer quality of working alliance, as rated by patients. A trend indicated that more experienced therapists rated the alliance lower at all sessions. Therapists' report of better maternal care up to their adolescence had a positive impact on patients' rating of alliance. Clinical implications are discussed.

Assessment of therapists' and patients' personality: relationship to therapeutic technique and outcome in brief dynamic psychotherapy.

My first focus of this study was to explore therapists' personal characteristics as predictors of the proportion of interpretation in brief dynamic psychotherapy (N=39; maximum 40 sessions). In this study, I used data from the Norwegian Multicenter Study on Process and Outcome of Psychotherapy (1995). The main finding was that therapists who had experienced good parental care gave less interpretation (28% variance was accounted for). Therapists who had more negative introjects used a higher proportion of interpretation (16% variance was accounted for). Patients' pretreatment characteristics were not predictive of therapists' use of interpretation. The second focus was to investigate the impact of therapists' personality and the proportion of interpretation on the development of patients' maladaptive defensive functioning over the course of therapy. Better parental care and less negative introjects in therapists were associated with a positive influence and accounted for 5% variance in the reduction of patients' maladaptive defense.

Is there an optimal adjustment of interpretation to the patients' level of defensive functioning?

In this process-outcome study, we explored whether the therapists' Adjustment Ratio of interpretation would be predictive of the development of working alliance in brief dynamic psychotherapy (N = 39, max 40 sessions). Therapist interventions were rated in an early session (7th) and in the mid-phase of therapy (16th session). We found that, what was assumed to be an optimal Adjustment Ratio in relation to patients' defensive functioning, was associated with lower quality of working alliance, whereas what was assumed to be a poor Adjustment Ratio was associated with a more favorable alliance. The general finding was that when relatively more supportive interventions were given to patients with higher ODF, the working alliance was improved. Implications of the findings are discussed.

Quality of early working alliance in psychotherapy: diagnoses, relationship and intrapsychic variables as predictors.

BACKGROUND: The aim of the study was the prediction of the quality of early working alliance, using possible predictors among patient pretreatment variables: diagnoses, current and past relationships and intrapsychic ones. Data are from the ongoing, naturalistic Norwegian Multisite Project on Process and Outcome of Psychotherapy (NMSPOP). METHODS: The sample, n = 270, is recruited from 15 outpatient clinics; 61.1% of the patients have personality disorders. Alliance was assessed with the Working Alliance Inventory (WAI), and predictors include independent clinicians' evaluations of diagnostic/interpersonal/intrapsychic characteristics and the patients' self-reports on similar and additional variables. RESULTS: Four of 6 hypotheses were supported: Quality of working alliance is difficult to predict, early alliance is better predicted than later, diagnostic variables do not predict quality of working alliance, but quality of both current and past relationships is associated with working alliance. In a hierarchical multiple-regression analysis, 7% variance of working alliance in the 3rd session was explained from current relationship variables, whereas alliance in the 12th session was not predicted by the same model. Intrapsychic variables predicted the therapists' ratings of alliance, but not the patients' ratings. CONCLUSION: The results are in line with previous research, and also with the theoretical model for working alliance.

Contribution of defensive functioning to the quality of working alliance and psychotherapy outcome.

We analyzed whether defense mechanisms changed and/or predicted outcome during brief dynamic psychotherapy (N = 43, max 40 sessions, Norwegian Multisite Study on Process and Outcome of Psychotherapy). Defenses were rated with the Defense Mechanism Rating Scales (DMRS, clinician-rated) and Defense Style Questionnaire (DSQ self-rated). Overall defensive functioning (ODF) as rated by DMRS changed significantly. We found that the initial ODF's neither predicted the quality of working alliance nor influenced the outcome. Symptoms improved most rapidly early in therapy, while defenses changed during the last half of therapy, consistent with the phase model of change.