Changes in clients' relational patterns with parents and therapist during psychodynamic psychotherapy: Their association and relation to treatment outcome.

OBJECTIVE: The study aimed to explore how changes in clients' relational patterns during psychodynamic psychotherapy relate to treatment outcomes and therapy effectiveness. METHOD: Seventy clients receiving psychodynamic psychotherapy in a university counseling center were interviewed three times and filled out the OQ-45 questionnaire five times during therapy. We used the Core Conflictual Relationship Theme (CCRT) to study clients' relational patterns. Mixed models were used to assess the interaction between clients' CCRT intensity toward their parents and toward their therapists, treatment effectiveness, and treatment outcome. RESULTS: First, we found that clients' relational patterns with their parents correlated with relational patterns with their therapists across several time points in therapy. Then, we found significant interactions, indicating that treatment effectiveness moderates the relationship between clients' CCRT intensity and treatment outcomes. CONCLUSIONS: The findings suggest that the transference phenomenon is related to therapy outcomes differently in effective and less-effective therapies, depending on the transference intensity. Further research is needed to expand knowledge about the intensity of transference and its possible impact on treatment choice and management.

Trajectories of change among highly challenging patients in intensive long-term psychoanalytic psychotherapy.

OBJECTIVES: This study aimed to identify and describe trajectories of change in distress among highly challenging patients who had received long and intensive psychoanalytic psychotherapy. METHODS: The longitudinal version of the K-means algorithm was applied to the outcome measures data of 74 patients treated in four public mental health centers. The patients were measured five times at 6-month intervals for three outcome measures. RESULTS: For the OQ45 and Symptom Checklist-90, one trajectory was marked by a lower initial distress level. In this trajectory, the improvement occurred in the first half of the measurements, with a plateau thereafter. A second trajectory was characterized by higher initial severity and an improvement, mainly in the second part of the measurements. For the Beck Depression Inventory, one trajectory was marked by lower initial distress. In this group, the improvement occurred throughout the entire period. The remaining patients were characterized by higher initial distress and a decreased level of distress in the last part of treatment. They began to improve only during the third year of therapy. CONCLUSION: The response to treatment is not uniform in long-term treatment for highly challenging patients. A significant number of patients require a longer period of therapy to ignite improvement.

Empirical examination of long-term and intensive psychodynamic psychotherapy for severely disturbed patients.

OBJECTIVES: This study examines the effectiveness and efficiency of intensive psychodynamic psychotherapy for severely impaired patients. METHOD: 104 patients in four public mental health centers underwent intensive psychodynamic psychotherapy. The number and duration of psychiatric hospitalizations were monitored for these patients from one year before therapy to eight years after. Several outcome variables were measured every six months, six times in total over two and a half years, using a longitudinal design. A multi-level analytic approach was applied to account for repeated measurements and missing data. RESULTS: Significant improvement was found in all three symptomatic outcome measures (SCL-90, OQ-45, BDI) throughout treatment. The numbers of psychiatric hospitalizations and psychiatric hospitalization days decreased significantly from the level they were in the year before the start of psychodynamic treatment to three years after the start of treatment. These results were maintained for at least up to eight years. After capitalization, the overall cumulative 127.47-day decrease in hospitalization days equals savings of 115,850 NIS. The average cost of treatment after capitalization was 26,770 NIS. The insurer's estimated direct savings is 89,080 NIS (24,054 $). CONCLUSION: These findings support the hypothesis that psychodynamic psychotherapy is clinically effective and economically efficient for severely impaired patients.

Countertransference awareness and treatment outcome.

Countertransference (CT) is considered a central component in the therapy process. Research has shown that CT management does not reduce the number of CT manifestations in therapy, but it leads to better therapy outcomes. In this study, we examined therapists' awareness of their CT using a structured interview. Our hypotheses were (a) treatments in which therapists were more aware of their CT would have a better outcome and (b) different definitions of CT would be related to different therapy outcomes. Twenty-nine patients were treated by 19 therapists in 16 sessions of short-term psychodynamic therapy. We used the core conflictual relationship theme to measure CT, a special interview was developed to study CT awareness. Results show that awareness of CT defined as the relationship with the patient moderated 10 outcome measures and awareness of CT defined as the relationship with the patient that repeats therapist conflicts with significant others moderated three outcome measures We present examples from dyads in this study and discuss how awareness can help the therapist talk to and handle patient challenges. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

How therapists' emotion recognition relates to therapy process and outcome.

Empathy is an essential characteristic for therapists that explained 9% of the variance in treatment outcomes. Many measures of empathy are based on self-report questionnaires. Therefore, they reflect how a person perceives his empathic abilities, which can be biased from his true abilities. The ability to recognize emotions has been found to be related to empathy and serves as a measure for the use of empathic abilities. In this study, we examined therapists' empathic abilities, using a novel task for recognizing emotions, and looked at how they related to the therapy process and outcomes. The study included 33 patient-therapist dyads. Therapist empathy was assessed with an emotion detection task, the JeFEE. Clients filled questionnaires after each session regarding therapy progress and their symptoms. We found that emotion recognition moderated the change in (a) client secure attachment to therapist, (b) client avoidant attachment to therapist, (c) client working alliance, (d) client rate of tense or upset they felt during the session, (e) client lack of emotional clarity of emotions, (f) client non-acceptance of emotional responses, (g) client overall emotion regulation and (h) client main target complaint. Implication for therapy and therapists' selection and training are discussed.

The combined effect of psychodynamic psychotherapy and pharmacotherapy on healthcare cost.

OBJECTIVE: Previous studies have established a connection between therapy and healthcare cost: an increase in cost prior to therapy and a maintained decrease post therapy. There is, however, a lack of studies examining the combined effects of psychotherapy and pharmacotherapy on healthcare cost. METHOD: Healthcare cost was examined quarterly in 1,213 patients (28,776 observations) in a naturalistic longitudinal design. Psychotherapy only was compared to combined treatment and to an addition of psychotherapy to preexisting pharmacotherapy. The comparisons were conducted with a multilevel piecewise model (LMLM) computed for three phases: pre-, during-, and post-therapy. RESULTS: Significant interactions were found between the contrast comparing preexisting pharmacotherapy to the during-psychotherapy and no-pharmacotherapy groups and the three piecewise variables. The pre-therapy increase was larger for the preexisting-pharmacotherapy group than for the other groups. The during-therapy decrease was larger for the preexisting-pharmacotherapy group than for the other groups. In the post-therapy period, the increase was significant only for the prior-psychiatric-medication group. CONCLUSIONS: Preexisting psychotropic treatment along with an increase in healthcare expenditure may serve as an indication of the need for additional psychotherapy treatment.

Therapist effects in yearlong psychodynamic therapy: An exploratory study.

A large body of research indicates that therapists can have a strong impact on treatment outcome, but little is known about the relationship between therapist effects and treatment phase. Our objective was to examine the interactive effect of therapist effectiveness and treatment phase on the outcome of 1 year of dynamic therapy. Therapists' effectiveness scores were defined as the extent of change for each therapist on the OQ-45 scores across their clients at five time points. The sample included 24 therapists who conducted psychodynamic therapy with 65 clients in a naturalistic setting. A three-level hierarchical linear model was applied. In accordance with the hypotheses, a significant main effect was found for effectiveness (estimate = 1.69, p < .05), for the two-way interactions between effectiveness and time (estimate = 1.36, p < .01), and for effectiveness and initial severity of symptoms (estimate = -0.02, p < .05). Simple slope analysis was conducted showing that among the less effective therapists, no significant change in outcome was found as time progressed; among the more effective therapists, outcome improved as time progressed. In addition, therapists were more influential in the treatments of clients with low initial severity. Our findings lend some support to the notion that therapist effects become increasingly influential as therapy progresses. The findings highlight the need for further research into changes in the magnitude of therapists' effect in various phases of therapy. Furthermore, the severity level of the initial symptoms of the client should be taken into account.

Breastfeeding at Any Cost? Adverse Effects of Breastfeeding Pain on Mother-Infant Behavior.

Breast milk is considered the ideal infant nutrition, and medical organizations encourage breastfeeding worldwide. Moreover, breastfeeding is often perceived as a natural and spontaneous socio-biological process and one of the fundamental roles of new mothers. While breastfeeding is beneficial, little scientific consideration has been given to its potential psychological challenges. Here, we investigate the phenomenon of breastfeeding pain in mothers and its association with maternal and infant behavioral regulation. During the postpartum weeks, the mother-infant dyad can be considered one allostatic unit directed at infant regulation and development. We hypothesize that pain comprises an allostatic challenge for mothers and will thus impair the capacity for dyadic regulation. To test this, we recruited 71 mothers with varying levels of breastfeeding pain and videotaped them with their infants (2-35 weeks old) during spontaneous face-to-face interactions. We quantified the individual differences in dyadic regulation by behaviorally coding the second-by-second affective expressions for each mother and infant throughout their interactions. We tested the extent to which breastfeeding pain alters affect regulation during mother-infant interactions. We discovered that mothers with severe breastfeeding pain express less affective expressions and less infant-directed gaze during interactive moments of engagement and play than mothers with no or moderate pain. Moreover, infants of mothers experiencing pain during breastfeeding express less affective expressions and more mother-directed gaze while interacting with their mothers than infants of mothers who are not in pain. This demonstrates that the allostatic challenge of maternal pain interferes with the behavioral regulation of both mothers and infants. Since the mother-infant dyad is a codependent allostatic unit, the allostatic challenges of one partner can impact the dyad and thus potentially impact child development, bonding, and mother and infant well-being. The challenges of breastfeeding should be considered in addition to the nutritional advances.

Evidence for cultural differences in affect during mother-infant interactions.

Maternal care is considered a universal and even cross-species set of typical behaviors, which are necessary to determine the social development of children. In humans, most research on mother-infant bonding is based on Western cultures and conducted in European and American countries. Thus, it is still unknown which aspects of mother-infant behaviors are universal and which vary with culture. Here we test whether typical mother-infant behaviors of affect-communication and affect-regulation are equally represented during spontaneous interaction in Palestinian-Arab and Jewish cultures. 30 Palestinian-Arab and 43 Jewish mother-infant dyads were recruited and videotaped. Using AffectRegulation Coding System (ARCS), we behaviorally analyzed the second-by-second display of valence and arousal in each participant and calculated the dynamic patterns of affect co-regulation. The results show that Palestinian-Arab infants express more positive valence than Jewish infants and that Palestinian-Arab mothers express higher arousal compared to Jewish mothers. Moreover, we found culturally-distinct strategies to regulate the infant: increased arousal in Palestinian-Arab dyads and increased mutual affective match in Jewish dyads. Such cross-cultural differences in affect indicate that basic features of emotion that are often considered universal are differentially represented in different cultures. Affect communication and regulation patterns can be transmitted across generations in early-life socialization with caregivers.

Reevaluating ruptures and repairs in alliance: Between- and within-session processes in cognitive-behavioral therapy and short-term psychodynamic psychotherapy.

OBJECTIVE: Ruptures and repairs in alliance and their association with treatment outcome have been studied widely. Many of these studies have used indirect methods, focused on decreases in alliance across sessions while measuring alliance at postsession. However, this approach does not establish whether observed decreases occur within (as insinuated by most theories) or between sessions. In the current study, we examined decreases of alliance measured both pre- and postsession in 3 clinical trials and explored the phenomenology and interpretation of these decreases. Additionally, we investigated the effects of rupture magnitude and the interpretation of repairs on treatment outcome, examining whether the "repairs benefit" or the "unrepaired ruptures damage" theories were supported by the data. METHOD: Presession and postsession therapeutic alliance and outcome measures were examined from patients who participated in 1 of 3 studies: cognitive-behavioral therapy (CBT) for social anxiety disorder (N = 29), CBT for panic disorder (N = 31), or short-term psychodynamic psychotherapy for depression (N = 44). Patterns of change in alliance are described. Ruptures and repairs are examined according to several criteria and are used to predict outcome using longitudinal multilevel modeling. RESULTS: In all samples, alliance systematically decreased between sessions and increased within them. Decreases in alliance as measured by traditional postsession to postsession were unreliable predictors of within-session decreases in alliance and of outcomes. CONCLUSIONS: Decreases in alliance across sessions are not valid measures of ruptures as defined by most theories. Instead, we suggest that they are indicative of an ebb-and-flow model for the development of alliance. (PsycInfo Database Record (c) 2020 APA, all rights reserved).