Agency as a Mechanism of Change in Psychotherapy

Abstract

Study 1: Therapeutic Agency Inventory: Development and Psychometric Validation of a Patient Self-Report Objectives: Therapeutic agency is defined as a patient’s intentional influence over the process of psychotherapeutic change. However, there is a lack of conceptually sound self-report measure with adequate psychometric properties. The aim of this study was to develop and psychometrically evaluate the patient-rated Therapeutic Agency Inventory (TAI). Method: Based on the literature, we developed items related to therapeutic agency and investigated their psychometric properties in a naturalistic study with a sample of 334 psychotherapy participants. We assessed changes in TAI scores in a subsample of 58 patients over the course of inpatient psychotherapy and related TAI scores to therapeutic improvement. Results: The TAI consists of 15 items. We performed exploratory factor analyses, and the following three factors were extracted: in-session activity, therapy-related processing, and therapist-oriented passivity. Internal consistency was .84 for the total score and ranged between .73 and .80 for each of the factors. The TAI was significantly associated with other psychotherapy process factors, self-efficacy expectations, control beliefs, lower overall psychological distress, and lower depression scores. Changes in agency during psychotherapy predicted therapy outcome, even after controlling for baseline distress. Conclusions: The TAI is a reliable, valid, and change-sensitive self-report instrument that can be used to assess agency in psychotherapy. Study 2: Therapeutic Agency, In-Session Behavior, and Patient-Therapist Interaction Objectives: The aim of this study was to investigate associations between patients’ subjective agency, their observable in-session behavior, and the patient-therapist interaction during the early phase of psychotherapy. Method: The sample included 52 depressed patients in psychodynamic psychotherapy. After session 5, the patients’ agency and the quality of the therapeutic alliance were assessed. Based on session recordings, two independent observers rated the patients’ involvement, their interpersonal behavior, and the therapists’ directiveness. Results: Higher agency was associated with stronger therapeutic alliances. Patients who indicated higher agency in their therapy participated more actively in the session and showed less hostile impact messages. Patients’ agency was not related to therapists’ directiveness. Conclusions: Patients’ sense of agency in psychotherapy was associated with more active involvement and affiliative interaction. The findings support the idea that patients need to feel capable of acting within and having influence on their therapy in order to benefit from it. Study 3: Agency and Alliance as Mechanisms of Change in Psychotherapy Objective: This study examined the reciprocal effects between changes in therapeutic agency, working alliance, and symptoms during psychotherapy. We aimed to predict symptom improvement by previous changes in either agency or alliance. In addition, we examined whether alliance development was predicted by previous changes in agency. Method: A sample of 386 patients in psychodynamic outpatient psychotherapy answered the Therapeutic Agency Inventory, the Working Alliance Inventory-SR, and the Symptom Checklist-K11 after sessions 1, 5, 10, 15, and 20. Dynamic panel models were estimated using structural equation modelling. Associations were tested while controlling for autoregressive effects and differentiating within-person changes over time from between-person differences. Results: Increases in agency predicted subsequent symptom improvement. Similarly, increases in alliance predicted subsequent symptom improvement. For agency and alliance, we found reciprocal effects over time. Conclusions: Findings show evidence for agency and alliance as mechanisms of change in psychodynamic psychotherapy. The study supports the importance of both agency and alliance and further suggests that both mechanisms may need to be balanced in successful psychotherapies.