Outcome Of Psychodynamic Psychotherapy Research Articles

Changes in meaning in life, working alliance, and outcome in psychodynamic psychotherapy: What leads to what?

We examined how meaning in life was associated with working alliance (WA) and outcomes, all from the client perspective. Random intercept lagged cross-panel analyses were used to analyze data from intake and after every eight sessions for the first 24 sessions of open-ended individual psychodynamic psychotherapy from 94 clients nested within 12 therapists. We found that, for all four time periods, working alliance in one 8-week time period predicted both Meaning in Life Measure-Experience (MILM-E) and Meaning in Life Measure-Reflectivity (MILM-R) in the subsequent time period, and MILM-R in one 8-week time period predicted client outcome in the subsequent time period. These findings suggest that having a strong working alliance is associated with clients developing more meaning in life, and reflectivity about meaning in life is associated with clients improving in psychotherapy. Implications for practice and research are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Therapist initial attachment style, changes in attachment style during training, and client outcome in psychodynamic psychotherapy.

This study extended the cross-sectional therapist attachment literature by examining longitudinal changes of therapist attachment avoidance and anxiety in relation to client treatment outcome. Data consisted of 942 Outcome Questionnaire-45 assessments (Lambert et al., 1996, 2004) of 213 clients working with 30 therapists from a university clinic that provided psychodynamically/interpersonally oriented individual therapy, and yearly therapist self-report of attachment styles using the Experience in Close Relationships Scale (Brennan et al., 1998) over 2-4 years of training at a university clinic. Using multilevel growth modeling, we found that initial attachment anxiety or avoidance alone were not associated with treatment outcomes. Instead, therapists with small increases in attachment avoidance, from a low avoidance baseline, were more effective in helping clients reduce psychological distress than their peers. Findings suggest that small increases in attachment avoidance may be a beneficial development for trainees, as it may reflect a process of learning emotional boundary regulation (Skovholt & Rønnestad, 2003) and taking on the observer aspect of the participant-observer role (Sullivan, 1953). Current findings challenged the assumption that higher therapist attachment avoidance and anxiety is always associated with worse client outcome and suggested the importance of continuous self-reflection to understand how one's own attachment change impacts their clinical practice. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Testing a mediation model of psychotherapy process and outcome in psychodynamic psychotherapy: Previous client distress, psychodynamic techniques, dyadic working alliance, and current client distress

To test a sequential model of psychotherapy process and outcome, we included previous client distress, therapist psychodynamic techniques, dyadic working alliance, and current client distress. For 114 sets of eight-session segments in 40 cases of psychodynamic psychotherapy, clients completed the Outcome Questionnaire-45 and Inventory of Interpersonal Problems-32 after the first and final session, judges reliably coded one middle sessions on the Psychodynamic subscale of the Multitheoretical List of Therapeutic Interventions, and clients and therapists completed the Working Alliance Inventory after every session. Results indicated that higher use of psychodynamic techniques was associated with higher levels of the working alliance, which in turn was associated decreased client distress; and working alliance was higher later in psychotherapy. There was a significant indirect effect of psychodynamic techniques on decreases in distress mediated by the working alliance. Implications for theory, practice, and research are provided. Clinical or methodological significance of this article: Conducted a longitudinal, latent variable examination of the relationships of psychodynamic techniques and working alliance on client distress. Psychodynamic techniques have an indirect effect on decreases in client distress through the dyadic working alliance.

Do therapists' subjective variables impact on psychodynamic psychotherapy outcomes? A systematic literature review.

Despite growing attention to the general therapist effects in a wide range of clinical settings, little is known about the individual, cross-situational, and therapy-nonspecific variables that impact on the differential effectiveness of clinicians. The current study is a systematic review of the evidence relating to the influence of therapist's subjective characteristics on outcomes of psychodynamic psychotherapies. A multistage and systematic search of articles published between 1987 and 2017 identified 30 relevant studies, which were organized into 6 areas according to the specific therapist's variable considered. Therapists' interpersonal functioning and skills showed the strongest evidence of a direct effect on treatment outcomes. Furthermore, there were preliminary evidence that therapists' attachment styles, their interpersonal history with caregivers, and their self-concept might affect outcomes through interaction effects with other constructs, such as technical interventions, patient's pathology, and therapeutic alliance. The high variability between studies on therapists' overall reflective or introspective abilities and personality characteristics suggested the need for more systematic research in these areas, whereas therapists' values and attitudes showed small effects on therapeutic outcome. The present review clarifies how a deep examination of the contribution of therapists' subjective characteristics can help elucidate the complex association between relational and technical factors related to the outcome of psychodynamic treatments.

Effects of Scheduled Waiting for Psychotherapy in Patients With Major Depression.

The role of nonspecific factors in the outcome of psychotherapy is poorly understood. To study the effects of pretreatment expectancy of scheduled psychotherapy, we examined the effects of an agreed waiting time on the outcome of psychodynamic psychotherapy. Thirty-three treatment-naive outpatients with major depressive disorder were randomly selected to start psychotherapy either directly (DG; n = 17) or after waiting for 6 months (WG; n = 16). In WG, 18% to 60% of the total decline in symptoms took place during the waiting time. After 1 year of active psychotherapy, the anxiety score declined significantly only in WG, and the total length of treatment needed was shorter in WG. No other outcome differences between WG and DG were found. We conclude that scheduled waiting associates with a significant decline in depressive symptoms. Scheduled waiting should be regarded as a preparatory treatment and not as an inert nontreatment control.

Therapeutic alliance and treatment outcome in psychodynamic psychotherapy of depressed breast cancer patients: the same old story or different from other populations?

A good therapeutic alliance is associated with better treatment outcomes in diverse types of psychotherapy and patient populations, but little is known about therapeutic alliance in psychotherapies with cancer patients. This study examines the association of therapeutic alliance and treatment outcome in short term psychodynamic psychotherapy (STPP) for breast cancer patients. Within a randomized controlled trial, 47 completers of STPP could be included in the analyses. The therapeutic alliance was assessed by patients and therapists at treatment termination with the Helping Alliance Questionnaire. Outcome was defined as no diagnosis of depression assessed with Structured Clinical Interview for DSM-IV (SCID-I) and a reduction of the HADS-depression score by at least two points at treatment termination. Patients' alliance ratings were significantly associated with outcome (r=0.46, p=0.015), while, in contrast to findings in non-cancer populations, therapists' ratings were unrelated. There was no association between patients' and therapists' ratings of therapeutic alliance. Especially success and working related aspects of patients' alliance scores were associated with outcome. Patients' and therapists' alliance scores were unrelated to any of their baseline characteristics, therapist characteristic or treatment variables. We conclude that therapists should regularly assess the quality of patients' perceived therapeutic alliance in the course of psychotherapy with breast cancer patients to improve psychotherapy outcome. The breast cancer patients' perspective should be actively inquired and considered throughout treatment by therapists. Possible discrepancies between both judgements can be addressed in treatment.

Relationships among alexithymia, therapeutic alliance, and psychotherapy outcome in major depressive disorder

Previous studies have found that alexithymia predicts process and outcome of psychodynamic psychotherapy across a range of psychiatric disorders. There is preliminary evidence that alexithymia may exert its effects on outcome through the therapist. Other studies have found that alexithymia does not influence outcome of cognitive-behavioral therapy (CBT). The aim of the current study was to investigate the capacity of alexithymia to predict therapist- and patient-rated therapeutic alliance and response to CBT and interpersonal psychotherapy (IPT) for major depressive disorder. A total of 75 adults with major depressive disorder were randomized to receive weekly sessions of manualized individual CBT or IPT for a period of 16 weeks. Pre-treatment alexithymia exhibited a positive direct effect on depression change, and a negative indirect effect on depression change via patient-rated alliance at week 13. There was no mediating role of therapist-rated alliance. Although these findings are preliminary, they suggest that pre-treatment alexithymia has meaningful links to psychotherapy process and outcome, and that nuanced analyses incorporating intervening variables are necessary to elucidate the nature of these links.

Do Patient Characteristics Predict Outcome of Psychodynamic Psychotherapy for Social Anxiety Disorder?

ObjectivesLittle is known about patient characteristics as predictors for outcome in manualized short term psychodynamic psychotherapy (PDT). No study has addressed which patient variables predict outcome of PDT for social anxiety disorder.Research Design and MethodsIn the largest multicenter trial on psychotherapy of social anxiety (SA) to date comparing cognitive therapy, PDT and wait list condition N = 230 patients were assigned to receive PDT, of which N = 166 completed treatment. Treatment outcome was assessed based on diverse parameters such as endstate functioning, remission, response, and drop-out. The relationship between patient characteristics (demographic variables, mental co-morbidity, personality, interpersonal problems) and outcome was analysed using logistic and linear regressions.ResultsPre-treatment SA predicted up to 39 percent of variance of outcome. Only few additional baseline characteristics predicted better treatment outcome (namely, lower comorbidity and interpersonal problems) with a limited proportion of incremental variance (5.5 to 10 percent), while, e.g., shame, self-esteem or harm avoidance did not.ConclusionsWe argue that the central importance of pre-treatment symptom severity for predicting outcomes should advocate alternative treatment strategies (e.g. longer treatments, combination of psychotherapy and medication) in those who are most disturbed. Given the relatively small amount of variance explained by the other patient characteristics, process variables and patient-therapist interaction should additionally be taken into account in future research.Trial RegistrationControlled-trials.com/ISRCTN53517394

Relationship between interpretation, alliance, and outcome in psychodynamic psychotherapy: control of therapist effects and assessment of moderator variable impact.

The current study examines the relationship between therapist interpretations in the early stages of psychodynamic psychotherapy and subsequent outcomes for 76 outpatients. Pre-treatment characteristics of global symptomatology, personality pathology, insight, and level of object relations were examined as possible significant patient characteristics. Independent clinicians reliably rated therapist use of interpretations over two early treatment sessions (third and ninth). Patient-rated alliance was also examined as a possible psychotherapy process predictor of change. Therapy outcomes were measured based on patients' changes in global symptomatology and estimates of improvement across a broad range of functioning at the end of treatment. An examination of the study independent variables revealed significant relationships between pre-treatment personality disorder symptomatology with patient object relations (OR), patient OR with pre-treatment insight, and pre-treatment insight with use of therapist interpretation. Pre-treatment symptomatology and early treatment interpretations predicted reliable change in global symptomatology. Patients' estimates of improvement across a broad band of functioning were most significantly impacted by quality of alliance. Analysis of these outcome relationships controlled for therapist effects. Statistical implications of therapist effects are discussed in regard to this area of research and future directions for investigation are explored.

PSYCHODYNAMIC PSYCHOTHERAPY VERSUS COGNITIVE BEHAVIOR THERAPY FOR SOCIAL ANXIETY DISORDER: AN EFFICACY AND PARTIAL EFFECTIVENESS TRIAL

Comparing the overall and differential effects of psychodynamic psychotherapy (PDT) versus cognitive behavior therapy (CBT) for social anxiety disorder (SAD). Patients with a primary SAD (N = 47) were randomly assigned to PDT (N = 22) or CBT (N = 27). Both PDT and CBT consisted of up to 36 sessions (average PDT 31.4 and CBT 19.8 sessions). Assessments took place at waitlist: pretest, after 12 and 24 weeks for those who received longer treatment: posttest, 3-month and 1-year follow-up. Changes in the main outcome measure self-reported social anxiety composite, as well as in other psychopathology, social skills, negative social beliefs, public self-consciousness, defense mechanisms, personal goals, independent rater's judgments of SAD and general improvement, and approach behavior during an objective test, were analyzed using multilevel analysis. No improvement occurred during waitlist. Treatments were highly efficacious, with large within-subject effect sizes for social anxiety, but no differences between PDT and CBT on general and treatment-specific measures occurred. Remission rates were over 50% and similar for PDT and CBT. Personality disorders did not influence the effects of PDT or CBT. PDT and CBT are both effective approaches for SAD. Further research is needed on the cost-effectiveness of PDT versus CBT, on different lengths PDT, and on patient preferences and their relationship to outcome of PDT versus CBT.

Therapeutic Interventions Related to Outcome in Psychodynamic Psychotherapy for Anxiety Disorder Patients

Therapeutic Interventions Related to Outcome in Psychodynamic Psychotherapy for Anxiety Disorder Patients

Therapeutic Interventions Related to Outcome in Psychodynamic Psychotherapy for Anxiety Disorder Patients

This is the first study with acceptable inter-rater reliability to examine specific therapeutic techniques related to change in anxiety disorder patients during short-term psychodynamic psychotherapy. The study first examined the effectiveness of short-term psychodynamic psychotherapy and results showed significant and positive pre-/post-treatment changes on both patient and independent clinical ratings for anxiety, global symptomatology, relational, social, and occupational functioning. Likewise, the majority of patients (76%) reported anxiety symptoms within a normal distribution at termination. Importantly, psychodynamic interventions rated early in treatment (third/fourth session) were positively related to changes in anxiety symptoms. Further, results showed that several individual psychodynamic techniques were meaningfully related to outcome including (1) focusing on wishes, fantasies, dreams, and early memories; (2) linking current feelings or perceptions to the past; (3) highlighting patients' typical relational patterns; and (4) helping patients to understand their experiences in new ways. Clinical applications are discussed.

A Closer Look at Good and Poor Outcome in Psychodynamic Psychotherapy: A Case Comparison Study

The process and outcome of three patients’ individual psychodynamic psychotherapies with the same therapist were investigated in this case comparison study. Multiple assessments with different instruments, including an independent assessor’s perspective both at termination and at follow-up were examined, to identify factors with an impact on good versus poor outcome. This case study illustrated that, assessing the outcome more than one, and with several measures, gave a more complete picture than one single measure at termination. Although this procedure represented the outcome in a better way, it also reflected the complexity of assessing psychotherapy results. Among the central factors for the outcome are: initial severity, quality of object relations, and vulnerability. Treatment implications of the findings are discussed (e.g., the importance of adjustment of therapy techniques, assessments and realistic expectations). Due to the complexity of the results, it is a challenge to understand fully and explain differences between patients and their individual ways of changing over the course of psychodynamic psychotherapy.

Predictive Value of Object Relations for Therapeutic Alliance and Outcome in Psychotherapy for Depression

The concept of object relations has been shown to be relevant for the process and outcome of psychodynamic psychotherapies. However, little is known about its relevance for the psychotherapeutic treatment of depression. In this study, we explored the predictive value of object relational functioning (ORF) for the therapeutic alliance and outcome of short-term psychodynamic supportive psychotherapy in patients with mild to moderately severe depression. The ORF of 81 patients was rated by using the Developmental Profile. The overall maturity of ORF measured at baseline was higher in patients who showed a better treatment response. In multiple regression analysis, the adaptive level of individuation appeared to be specifically predictive of outcome. Patients with a recurrent depression showed less mature levels of ORF, lower adaptive levels and a higher score on the symbiotic level. No association was found between ORF and therapeutic alliance during treatment. In contrast to the single measure of alliance early in therapy, the growth of the alliance was related to outcome. The study indicated the relevance of ORF for depression and established that it is distinctive from the actual therapeutic alliance.

Therapist Affect Focus and Patient Outcomes in Psychodynamic Psychotherapy: A Meta-Analysis

The authors systematically examined the relationship between therapist facilitation of patient emotional experience/expression and outcome in psychodynamic psychotherapy. Computer and manual searches were conducted for relevant publications, and 10 independent samples of short-term dynamic psychotherapy were included in a meta-analysis. Data analysis included calculation of an overall effect size of the relationship between therapist affect focus and outcome, statistical significance, and test for homogeneity. In addition, moderator analyses were conducted to examine the potential impact of type of outcome construct used and the methodological quality of individual studies. The overall average weighted effect size across all outcome types was statistically significant (r=0.30), and the homogeneity statistic was nonsignificant. Moderator analyses indicated a statistically significant relationship between therapist facilitation of patient emotional experience/expression and outcome when more than one outcome construct was included but not when either a single or an unclear outcome construct was used. There were no significant relationships between methodological quality and the size of the effects, although use of audio- or videotaping for supervision demonstrated a moderate effect. These data indicate that therapist facilitation of patient affective experience/expression is associated with patient improvement over the course of psychodynamic psychotherapy. Although the size of this relationship was not significantly related to methodological quality, results suggest the importance of close supervision of actual techniques through the use of audio- or videotapes. Additionally, results highlight the importance of defining outcome in a multidimensional way to properly assess theoretically relevant effects.

Therapist Affect Focus and Patient Outcomes in Psychodynamic Psychotherapy: A Meta-Analysis

Objective: The authors systematically examined the relationship between therapist facilitation of patient emotional experience/expression and outcome in psychodynamic psychotherapy. Method: Computer and manual searches were conducted for relevant publications, and 10 independent samples of short-term dynamic psychotherapy were included in a meta-analysis. Data analysis included calculation of an overall effect size of the relationship between therapist affect focus and outcome, statistical significance, and test for homogeneity. In addition, moderator analyses were conducted to examine the potential impact of type of outcome construct used and the methodological quality of individual studies. Results: The overall average weighted effect size across all outcome types was statistically significant (r=0.30), and the homogeneity statistic was nonsignificant. Moderator analyses indicated a statistically significant relationship between therapist facilitation of patient emotional experience/expression and outcome when more than one outcome construct was included but not when either a single or an unclear outcome construct was used. There were no significant relationships between methodological quality and the size of the effects, although use of audio- or videotaping for supervision demonstrated a moderate effect. Conclusions: These data indicate that therapist facilitation of patient affective experience/expression is associated with patient improvement over the course of psychodynamic psychotherapy. Although the size of this relationship was not significantly related to methodological quality, results suggest the importance of close supervision of actual techniques through the use of audio- or videotapes. Additionally, results highlight the importance of defining outcome in a multidimensional way to properly assess theoretically relevant effects.

"Therapist interpretation, patient-therapist interpersonal process, and outcome in psychodynamic psychotherapy for avoidant personality disorder": Correction to Schut et al. (2005).

Reports an error in "Therapist Interpretation, Patient-Therapist Interpersonal Process, and Outcome in Psychodynamic Psychotherapy for Avoidant Personality Disorder" by Alexander J. Schut, Louis G. Castonguay, Kelly M. Flanagan, Alissa S. Yamasaki, Jacques P. Barber, Jamie D. Bedics and Tracey L. Smith (Psychotherapy: Theory, Research, Practice, Training, 2005 Win, Vol 42(4), 494-511). The correct legend for Figure 1 on page 500 should read as follows: Figure 1. The SASB circumplex model, cluster version, interpersonal surfaces. Adapted from Benjamin (1993), Interpersonal diagnosis and treatment of personality disorders. New York: Guilford Press, copyright Guilford Press, and from: Benjamin (1987), Use of the SASB dimensional model to develop treatment plans for personality disorders, I: Narcissism. Journal of Personality Disorders, 1, 43-70, copyright Guilford Press. (The following abstract of the original article appeared in record 2006-03309-008.) The authors examined the link between interpretive techniques, the therapeutic relationship, and outcome in psychodynamic psychotherapy. Two independent teams of judges each coded one early session from patients diagnosed with avoidant personality disorder. Results revealed (a) an inverse association between concentration of interpretation and favorable patient outcome; (b) that small amounts of disaffiliative patient-therapist transactions before, during, and after interpretations were reliably or meaningfully associated with negative patient change; and (c) concentration of interpretation was positively associated with disaffiliative therapy process before and during interpretation and negatively associated with affiliative patient responses to interpretation. The results suggest that therapists who persisted with interpretations had more hostile interactions with patients and had patients who reacted with less warmth than therapists who used interpretations more judiciously. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Are psychodynamic and psychoanalytic therapies effective? A review of empirical data

There is a need for empirical outcome research in psychodynamic and psychoanalytic therapy. However, both the approach of empirically supported therapies (EST) and the procedures of evidence‐based medicine (EBM) have severe limitations making randomised controlled trials (RCTs) an absolute standard. After a critical discussion of this approach, the author reviews the empirical evidence for the efficacy of psychodynamic psychotherapy in specific psychiatric disorders. The review aims to identify for which psychiatric disorders RCTs of specific models of psychodynamic psychotherapy are available and for which they are lacking, thus providing a basis for planning further research. In addition, results of process research of psychodynamic psychotherapy are presented. As the methodology of RCTs is not appropriate for psychoanalytic therapy, effectiveness studies of psychoanalytic therapy are reviewed as well. Studies of psychodynamic psychotherapy published between 1960 and 2004 were identifed by a computerised search using Medline, PsycINFO and Current Contents. In addition, textbooks and journal articles were used. Twenty‐two RCTs were identifed of which 64% had not been included in the 1998 report by Chambless and Hollon. According to the results, for the following psychiatric disorders at least one RCT providing evidence for the efficacy of psychodynamic psychotherapy was identifed: depressive disorders (4 RCTs), anxiety disorders (1 RCT), post‐traumatic stress disorder (1 RCT), somatoform disorder (4 RCTs), bulimia nervosa (3 RCTs), anorexia nervosa (2 RCTs), borderline personality disorder (2 RCTs), Cluster C personality disorder (1 RCT), and substance‐related disorders (4 RCTs). According to results of process research, outcome in psychodynamic psychotherapy is related to the competent delivery of therapeutic techniques and to the development of a therapeutic alliance. With regard to psychoanalytic therapy, controlled quasi‐experimental effectiveness studies provide evidence that psychoanalytic therapy is (1) more effective than no treatment or treatment as usual, and (2) more effective than shorter forms of psychodynamic therapy. Conclusions are drawn for future research.

Therapist interpretation, patient-therapist interpersonal process, and outcome in psychodynamic psychotherapy for avoidant personality disorder.

The authors examined the link between interpretive techniques, the therapeutic relationship, and outcome in psychodynamic psychotherapy. Two independent teams of judges each coded one early session from patients diagnosed with avoidant personality disorder. Results revealed (a) an inverse association between concentration of interpretation and favorable patient outcome; (b) that small amounts of disaffiliative patient‐ therapist transactions before, during, and after interpretations were reliably or meaningfully associated with negative patient change; and (c) concentration of interpretation was positively associated with disaffiliative therapy process before and during interpretation and negatively associated with affiliative patient responses to interpretation. The results suggest that therapists who persisted with interpretations had more hostile interactions with patients and had patients who reacted with less warmth than therapists who used interpretations more judiciously.

Impact of the Turning-Against-Self Defense Mechanism on the Process and Outcome of Inpatient Psychotherapy

The authors examined the relation between specific defense mechanisms and treatment process and outcome in psychodynamic psychotherapy. Three measures, Questionnaire for Conflict Coping Strategies, Questionnaire on the Experience of the Inpatient Therapeutic Process, and Symptom Checklist-90-R, were given to 65 inpatients of a psychosomatic clinic, predominantly with depressive or eating disorders. Turning against self was the most frequently used defense mechanism in the patient group. A high level of turning against self that could be reduced significantly during treatment was associated with good adaptation to treatment setting and positive treatment outcome defined by symptom distress reduction. Assessment of defense mechanisms and their interaction with therapeutic factors in the therapy setting can be useful to better understand the treatment process and the subsequent development of specific interventions to enhance treatment outcome.