Examining Psychotherapeutic Processes with Depressed Adolescents: A Comparative Study of Two Psychodynamic Therapies.

To understand processes associated with better or poorer psychotherapy outcomes is vital. This study examined and contrasted interaction patterns between one therapist and two depressed 17-year-old girls, Johanna (good outcome) and Sonja (poor outcome), in short-term psychoanalytic therapies selected from an RCT. Outcome data were collected regarding level of inter- and intra-personal functioning and symptoms of depression. Process data were obtained using the Adolescent Psychotherapy Q-Set on all available sessions. Analyses yielded five relational patterns or "interaction structures" in the two therapy processes; Three explained most of the variance in sessions with Johanna (i.e., 'positive working alliance', 'therapist's active use of psychodynamic techniques', and 'a receptive patient') and two explained more of the variance in sessions with Sonja (i.e., 'therapist using a more problem-solving and symptom-oriented approach' and 'patient displaying limited capacity for mentalization'). The processes in the two cases presented differences related to mentalization, psychological mindedness, and attachment style of the patients. The therapist used different therapeutic approaches, favouring more psychodynamic interventions in the good outcome case and a more problem-solving and symptom-oriented approach with the poor outcome case. In the latter case, the relationship seemed to be more of a struggle.

Personality Disorders as a Possible Moderator of the Effects of Relational Interventions in Short-Term Psychoanalytic Psychotherapy with Depressed Adolescents.

A significant proportion of adolescents suffering from major depressive disorder (MDD) are likely to have a co-morbid personality disorder (PD). Short-term psychoanalytic psychotherapy (STPP) was found to be one treatment of choice for adolescents suffering from MDD. BACKGROUND: The first experimental study of transference work-in teenagers (FEST-IT) demonstrated the efficaciousness of transference work in STPP with adolescents suffering from MDD. The usefulness of STPP may be enhanced by exploring possible moderators. METHODS: Depressed adolescents (N = 69), aged 16-18 years, were diagnosed with the structured interview for DSM-IV PDs and randomized to 28 weeks of STPP with or without transference work. A mixed linear model was applied. The moderator effect was investigated by a three-way interaction including "time", "treatment group" and "number of PD criteria". RESULTS: A small but significant moderator effect was found for cluster B personality pathology. Patients with a higher number of cluster B PD criteria at baseline did better up to one-year post-treatment where therapists encouraged patients to explore the patient-therapist relationship in the here and now. CONCLUSION: When treated with psychoanalytic psychotherapy for MDD, adolescents with cluster B PD symptoms seem to profit more from transference work than adolescents without such pathology.

Therapists' Emotional Responses in Individual Therapy with Depressed Adolescents: An Evaluation of the Data Structure of the Feeling-Word Checklist-28.

Countertransference (CT) responses during therapy sessions can be understood as the therapist's emotional reactions towards the patient. Within adolescents' psychotherapy, little is known about the effects of the therapists' feelings on treatment outcome. The Feeling-Word Checklist-28 (FWC-28) is a self-report questionnaire designed to evaluate the therapist's in-session feelings during therapy with younger patients. The aim of the study was to evaluate the psychometric properties of the clinician-rated FWC-28 and explore the associations between the CT-subscales and therapeutic alliance. Data were collected from a randomized controlled trial in which 11 therapists specialized in child and adolescent psychotherapy treated 16- to 18-year-old patients (n = 62) with major depressive disorder in outpatient clinics. The patients received psychodynamic psychotherapy treatment over 28 sessions. Therapists rated their emotional responses towards their patients on FWC-28 after sessions 3, 12, 20, and 28. Principal component analysis (PCA) with oblique rotation was performed to find clinically meaningful subscales of the FWC-28. PCA revealed four clinically meaningful components termed as follows: inadequate, confident, motherly, and disengaged. The psychometric properties of the FWC and the reliability of the CT subscales measured with Cronbach's alpha were acceptable. The therapist-reported alliance showed significant and clinically meaningful correlations with all CT-subscales. Our findings indicate that the checklist is adequate for clinical practice and countertransference research in adolescents' psychotherapy.

Parental Bonding and Relationships with Friends and Siblings in Adolescents with Depression.

According to attachment theory, the quality of the early child-parent bond determines the child's interpersonal relationships later in life. Utilising data from The First Experimental Study of Transference Work-In Teenagers (FEST-IT), the current paper investigated the connection between the self-reported quality of bonding with mother and father and the self-reported importance of relationships with friends and siblings in adolescents with depression. The scales employed were the Parental Bonding Instrument (PBI) and the Adolescent Relationship scale (ARS). A Pearson's correlation tested the relationship between the reported levels of maternal and paternal care and control, and the reported importance of friendship and relationship with siblings. Results revealed a statistically significant negative correlation between high levels of maternal control and importance of friendship, and a statistically significant positive correlation between high levels of paternal care and importance of relationships with siblings. The results are in line with Bowlby's theory of attachment.

Do Sleep Disturbances Improve Following Psychoanalytic Psychotherapy for Adolescent Depression?

Sleep disturbance is often a prominent symptom in adolescents diagnosed with major depressive disorder (MDD). Recent evidence indicates that short-term psychoanalytic psychotherapy (STPP) for depression may have an effect in reducing co-occurring sleep disturbance in youth. It is unknown if transference work (exploration of the patient-therapist relationship) has an additional effect in reducing sleep disturbance. Adolescents aged 16-18 years (n = 69, 84% female) who met diagnostic criteria for MDD based on the Mini International Neuropsychiatric Interview (M.I.N.I) were randomized to either STPP with transference work or without. Sleep problems were assessed at baseline, therapy session 20 (20 weeks), post-treatment (28 weeks), and one-year follow-up (80 weeks) with the Symptom Checklist-90-R. At baseline, 69% of the adolescents exhibited moderately to extreme sleep difficulties. Sleep disturbance was significantly correlated to depression depth at session 20 and at follow-up. Symptoms of insomnia significantly decreased from baseline to the end of treatment. Treatment gains were maintained until follow-up. No differences in recovery of sleep disturbance were found between the two treatment groups. The findings suggest that sleep disturbance improves following STPP for depression, with or without transference work. Future research should assess those with residual symptoms by different sleep measures.

Patient factors predict therapists' emotional countertransference differently depending on whether therapists use transference work in psychodynamic therapy.

AbstractObjective: Recently, studies have reported systematic relationships between the therapists' emotional response/countertransference (CT) during therapy and a variety of patient characteristics, speaking to the communicative potential of CT. Within an RCT assessing the role of transference work (TW) in psychodynamic therapy, we investigated whether therapist CT was related to patients' pre-treatment interpersonal problems, degree of personality pathology and motivation for psychodynamic therapy. Secondly, we explored if these relationships depended on whether the therapists used TW or not in sessions. Method: One hundred outpatients were treated with psychodynamic psychotherapy (with or without TW) for one year. Their therapists' emotional reactions after sessions (CT) were assessed with the Feeling Word Checklist-58 (FWC-58). Results: Four subscales of the FWC-58; Inadequate, Confident, Disengaged and Parental feelings were differentially predicted by patient characteristics. Some of the associations depended on treatment condition such that degree of PD pathology was associated with therapists feeling more inadequate in the non-TW-group. Patients' motivation for treatment was associated with less disturbing CT feelings, such as Inadequate and Disengaged CT (the latter especially in the TW group), and feeling more Confident CT. Conclusion: Patient factors predict therapists' emotional countertransference differently depending on whether therapists use transference work in psychodynamic therapy.Trial registration: ClinicalTrials.gov identifier: NCT00423462.

Psychotherapy Dropout: Using the Adolescent Psychotherapy Q-Set to Explore the Early In-Session Process of Short-Term Psychodynamic Psychotherapy.

Research suggests that short-term psychodynamic psychotherapy (STPP) is an effective treatment for depression in adolescence, yet treatment dropout is a major concern and what leads to dropout is poorly understood. Whilst studies have begun to explore the role of patient and therapist variables, there is a dearth of research on the actual therapy process and investigation of the interaction between patient and therapist. This study aims to address this paucity through the utilisation of the Adolescent Psychotherapy Q-set (APQ) to examine the early treatment period. The sample includes 69 adolescents aged 16-18 years with major depressive disorder receiving STPP as part of the First Experimental Study of Transference Work-in Teenagers (FEST-IT) trial. Of these, 21 were identified as dropouts and were compared to completers on pre-treatment patient characteristics, symptomatology, functioning, and working alliance. APQ ratings available for an early session from 16 of these drop out cases were analysed to explore the patient-therapist interaction structure. Results from the Q-factor analysis revealed three distinct interaction structures that explained 54.3% of the total variance. The first described a process of mutual trust and collaboration, the second was characterised by patient resistance and emotional detachment, the third by a mismatch and incongruence between therapist and adolescent. Comparison between the three revealed interesting differences which taken together provide further evidence that the reasons why adolescents drop out of therapy vary and are multidimensional in nature.

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.

Assessment of dynamic change in psychotherapy with asdolescents.

BACKGROUND: Diagnostic interviews and questionnaires are commonly used in the assessment of adolescents referred to child and adolescent mental health services. Many of these rating scales are constructed for adults and focus on symptoms related to diagnosis. Psychodynamic Functioning Scales (PFS) focus on relational aspects and how the patients handle affects and solve problems, rather than manifest symptoms. As these aspects are considered important for mental health, the PFS were developed to assess change in adults, consistent with the relational and intrapsychic concepts of dynamic psychotherapy. The scales describe internal predispositions and psychological resources that can be mobilized to achieve adaptive functioning and life satisfaction. PFS consist of six subscales; the relational subscales Family, Friends and Romantic/Sexual relationships and the dynamic subscales Tolerance for Affects, Insight and Problem-solving Capacity. PFS has been used for the first time as a measure of change in adolescent psychotherapy. This study examines the reliability of PFS when used to assess adolescents' level of relational functioning, affective tolerance, insight, and problem-solving capacities. METHODS: Outpatient adolescents 16-18 years old with a major depressive disorder were included in the First Experimental Study of Transference work in Teenagers (FEST-IT). They were evaluated before and after time-limited psychodynamic psychotherapy with an audio-recorded semi-structured psychodynamic interview. Based on the audio-tapes, raters with different clinical background rated all the available interviews at pre-treatment (n = 66) and post-treatment (n = 30) using PFS. Interrater reliability, the reliability of change ratings and the discriminability from general symptoms were calculated in SPSS. RESULTS: The interrater reliability was on average good on the relational subscales and fair to good on the dynamic subscales. All pre-post changes were significant, and the analyses indicated discriminability from general symptoms. The interrater reliability on PFS (mean) and Global Assessment of Functioning were good to excellent. CONCLUSION: Based on the interrater reliability in our study, PFS could be recommended in psychotherapy with adolescents by experienced clinicians without extensive training. From the post-treatment evaluations available, the scales seem to capture statistically and clinically significant changes. However, the interrater reliability on dynamic subscales indicates that subscales of PFS might be considered revised or adjusted for adolescents.Trial registration First Experimental Study of Transference-Work-In Teenagers (2011/1424 FEST-IT). ClinicalTrials.gov Identifier: NCT01531101.

Does Therapists' Disengaged Feelings Influence the Effect of Transference Work? A Study on Countertransference.

Exploration of the patient-therapist relationship (transference 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 transference work in the context of patients' quality of object relations (QOR) and therapists' self-reported disengaged feelings. Therapists' disengaged feelings may negatively influence the therapeutic process, especially while working explicitly with the transference since discussing feelings that are present in the session is an essential aspect of transference work. One hundred outpatients seeking psychotherapy for depression, anxiety and personality disorders were randomly assigned to one year of dynamic psychotherapy with transference work or to the same type and duration of treatment, but without transference work. Patients' QOR-lifelong pattern was evaluated before treatment and therapists' feelings were assessed using the Feeling Word Checklist-58 after each session. Outcome was measured with self-reports and interviews at pre-treatment, mid-treatment, post-treatment, one year and three years after treatment termination. A significant interaction of treatment group (transference work versus no transference work) by QOR by disengaged therapist feelings was present, indicating that disengaged feelings, even small amounts, were associated with negative long-term effects of transference work, depending on QOR Scale scores. The strengths of the negative association increased significantly with lower levels of QOR. The negative association between even a small increase in disengaged therapist feelings and long-term effects of transference interpretation was substantial for patients with poor QOR, but small among patients with good QOR. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: Therapists' emotional reactions to their patients (countertransference) seem to have a significant impact on both the treatment process and outcome of psychotherapy. Therapists' heightened level of disengaged feelings over a treatment period shows an adverse impact on the effect of transference work for all patients, and especially so for patients with a history of poor, non-mutual and complicated relationships. For patients with a history of reciprocal, sound relationships the negative influence of therapists' disengaged countertransference is minimal. Higher therapist disengagement is strongly related to inferior therapists' skill for patients with a history of poor relationships and/or more personality disorder pathology. Training and supervision should provide direct feedback and focus on therapists' internal thought processes and emotional reactions. Therapists need to recognize and understand their feelings and attitudes in order to use the countertransference as a tool to understand the interpersonal process in therapy.

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 .

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.

Countertransference feelings in one year of individual therapy: an evaluation of the factor structure in the Feeling Word Checklist-58.

Although countertransference phenomena have been given much attention within psychotherapy theory, single-case studies and clinical anecdotes, empirical research is still conspicuous by its absence. To assess the therapists' emotional reactions, which are understood to be part of the countertransference (CT), we used the Feeling Word Checklist 58 (Røssberg, Hoffart, & Friis, 2003); a self-report questionnaire, comprising 58 feeling words. The aims of the present study were to examine the underlying factor structure and psychometric properties of these factors, and to validate the factors by exploring the relationships between countertransference feelings and the following variables: therapeutic alliance, patient personality pathology, suitability for psychodynamic therapy, interpersonal problems, level of general functioning, and symptoms. Six therapists, who treated 75 patients, with weekly, psychodynamic therapy, over 1 year, completed the checklist after each session. To establish the number of subscales in the checklist, a principal component analysis with promax rotation was conducted. The analysis revealed four clinically meaningful factors named Confident, Inadequate, Parental and Disengaged. The psychometric properties of all subscales proved to be acceptable. Alliance as reported by both patient and therapist showed differential correlations with the subscales. The patients' relational functioning showed stronger correlations with the CT feelings than the patients' symptoms and level of functioning. The four subscales found in the Feeling Word Checklist-58 seem to capture clinically meaningful aspects of the therapeutic dyad, and countertransference feelings are systematically related to different relational variables.