Psychotherapy Process Q-Set Research Articles

Development of a psychotherapy process prototype for the Real Relationship

Objective The Real Relationship (RR) describes the aspect of the psychotherapy relationship that is based on a genuine connection and a realistic view between patient and therapist. In the current study, we aimed to develop a Psychotherapy Process Q-set (PQS) prototype of the RR to facilitate post-hoc assessment of the RR in psychotherapy session recordings. We also aimed to measure the association between the RR-PQS and current PQS measures of theoretical treatment principles and the working alliance. Method We developed an RR-PQS prototype based on ratings of an ideal RR session by eight RR experts. We assessed the associations between the RR-PQS and existing cognitive behavioral and psychodynamic process prototypes, and seven PQS items known to predict the working alliance. Results RR experts agreed on the ideal RR session ratings to a high degree (ICC = 0.89). The RR-PQS was moderately related to both cognitive behavioral (r = 0.66, p < 0.01), and psychodynamic prototypes (r = 0.56, p < 0.01). PQS items predictive of the working alliance were characteristic of the RR-PQS. Conclusion The RR-PQS prototype appears to behave in theoretically predicted ways and may be a valid measure of the RR.

Developing a prototype for relationship therapy psychoanalysis: an empirical study with the Psychotherapy Process Q-set.

Psychotherapy Process Q-set (PQS) prototype characteristic of psychoanalytic relationship therapy does not yet exist. Experts in psychoanalysis of relationship therapy [from the Italian Society of Psychoanalysis of the Relationship (SIPRe)] used the 100-Item PQS questionnaire to rate an ideal SIPRe therapy. Agreement between rates was high (Cronbach's alpha=0.84). The prototype for SIPRe therapy showed a significant correlation to the psychoanalytic prototype (r=0.68, p<0.000) and to the short expressive-supportive therapy (r=0.69, p<0.000) prototype. Correlations with Cognitive Behavioural Therapy (r=0.28, p<0.005) and Interpersonal Therapy (r=0.22, p<0.031), prototypes were significant, but weaker. The correlation between the two SIPRe samples (junior and expert therapists) was highly significant (Spearman's rho=0.936; p<000).

Object relations assessment predicts outpatients' attrition, early working alliance and psychotherapy process

This study investigated the predictive utility of assessing clients' object relations functioning to prognosticate therapy dropout, quality of the early working alliance and psychotherapy process events reported by clients after their first five sessions. Clients accepting a recruitment invitation were administered the thematic apperception test (TAT) shortly after intake, and those still in treatment three to four sessions later rated the working alliance and psychotherapy process events. Participants were 47 clients beginning psychotherapy with advanced doctoral practicum students at a university-based community-serving training clinic. The Social Cognition and Object Relations Scales (SCORS), an object relations scoring system for TAT stories, was used to assess object relations functioning. The California Psychotherapy Alliance Scales-Patient form measured four dimensions of the alliance. The Therapy Orientation Process Scales, created from the Psychotherapy Process Q-set, measured clients' perceptions of therapy process events as involving relatively more psychodynamic or cognitive behavioural techniques. The SCORS significantly predicted remaining in therapy, client ratings of stronger working alliance and typical therapy process as more psychodynamic than cognitive behavioural. SCORS complexity of representations and capacity for emotional investment in relationships scales were the strongest predictors, especially of the patient commitment facet of the alliance. The findings suggest that (1) beginning psychotherapy with object relations assessment can be useful for treatment planning and (2) the relationship between clients' object relations functioning, working alliance and greater sensitivity to psychodynamic than to cognitive behavioural interventions depends on the aspect of object relations that is being assessed.

Psychodynamic Factor as Predictor of Outcome in the Treatment of a Psychosomatic Spectrum Patient

To investigate through the prototype methodology as well as the interaction structures methodology which are the factors involved in the psychotherapeutic progress in the treatment of a patient with chronic diseases and somatic symptoms. 62 of the total 120 videotaped sessions were analysed by independent judges using the Psychotherapy Process Q-Set. The interaction structures as well as the extent to which each session conformed to the ideal psychodynamic, cognitive behavioural therapy (CBT) and reflective function prototypes were evaluated through multiple regression analysis, in order to test which factors were able to predict therapeutic progress. The psychotherapeutic process was characterized by moderate adherence to both psychodynamic and CBT prototypes and by greater adherence to the reflective function prototype. The therapeutic progress was better predicted by the adherence to the psychodynamic prototype. Both the psychodynamic technique and the reflective function were prominent factors in this case. Mentalization has been considered a “common factor” among different psychotherapeutic approaches, and our results highlight the importance of considering it along with specific technical aspects. Examining elements of the therapeutic process focusing on the complex interaction among these different aspects can provide helpful new insights into the process factors associated with a favourable outcome.

An Italian validation of the Comparative Psychotherapy Process Scale: Reliability and validity.

The Comparative Psychotherapy Process Scale (CPPS) is an instrument designed to measure therapist interventions in a psychotherapy session. The scale includes 20 items divided into two subscales: the PI (psychodynamic-interpersonal) scale, which describes psychodynamic-interpersonal techniques; and the CB (cognitive-behavioural) scale, which includes cognitive-behavioural interventions. The aim of the study was to examine the psychometric properties of the CPPS, comparing the PI and CB subscales with the psychodynamic, cognitive and STTP prototypes, as described by the Psychotherapy Process Q-set(PQS). The sample comprised 94 sessions (N = 94) of psychodynamic and cognitive-behavioural orientation. Two groups of independent raters with excellent interrater reliability (ICC = .78) evaluated the sessions. The results suggest that the CPPS is a valid and reliable instrument that provides a clinically sensitive and psychometrically robust evaluation of a therapist's techniques. The clinical and research implications of the results are discussed.

Interaction structures in the psychodynamic psychotherapy of a patient with chronic diseases and somatic symptoms.

This study aimed to identify and analyze the interaction structures (ISs) (patterns of reciprocal interaction between the patient-therapist dyad) that characterize the process of a successful long-term psychodynamic psychotherapy (28 months) of a patient with chronic diseases (lupus and fibromyalgia) and somatic symptoms. The 113 sessions were videotaped and analyzed alternately (n = 60) by independent judges using the Psychotherapy Process Q-Set. Inter-rater reliability ranged from 0.60 to 0.90, with a mean of r = 0.71 (Pearson's correlation). Through a principal component exploratory factor analysis, four ISs were identified. The patterns of interaction between patient and therapist showed clinical validity (i.e., they were easily interpretable in the context of the case under study). The ISs were non-linear and more or less prominent across different treatment sessions and stages. Some ISs were similar to those in other studies, and others were probably unique to the present process. In addition, some ISs were independent, whereas others were interrelated over time. Process studies, such as the present one, seek to address questions about the characteristics of the interaction between patient and therapist as well as to identify particular patterns of interaction that are most prominent with a specific patient at a specific condition or time. Therefore, these studies can provide some support in establishing knowledge for clinical practice, assisting in the training of therapists, as well as in the elaboration of general guidelines for the technical management of patients with specific characteristics.

ASSESSMENT OF A PSYCOTHERAPY PROTOCOL FOR WOMEN WITH A HISTORY OF INTIMATE PARTNER VIOLENCE: STUDY OF CLINICAL CASES

Violence against women is a complex phenomenon that negatively impacts mental health (WHO, 2016). This study aimed to assess the process of a psychotherapy protocol for women with a history of intimate partner violence. A clinical case study design was used and the sample consisted of three participants. The process was analyzed using the Working Alliance Inventory (WAI-O) and Psychotherapy Process Q-Set (PQS), which assess therapeutic alliance and the most and least characteristic items of psychotherapy, respectively. The findings demonstrated good therapeutic alliance and good connection between the sessions, indicating that the protocol is correlated with the expected prototype for cognitive-behavioral therapy. Additionally, symptoms declined in all the women treated. The results provide initial evidence of the effectiveness of the intervention.

Clients’ TAT Interpersonal Decentering Predicts Psychotherapy Retention and Process

Abstract. This naturalistic pilot study examined interpersonal decentering, a form of social cognitive maturity and self–other mentalizing scored from the Thematic Apperception Test, as a client personality variable that might predict psychotherapy retention and clients’ perceptions of in-session process. Clients having difficulty with mature decentering might struggle to engage in therapy, need different interventions, and be at risk for therapy dropout. Thematic Apperception Test stories were gathered from new outpatient therapy clients soon after their intake session. Interpersonal decentering scores from the nine stories were used to predict outpatients’ therapy attrition or perceptions of psychotherapy process four to six sessions later. Clients’ perceptions of therapy events commonly associated differentially with psychodynamic and cognitive-behavioral therapies were measured using self-rated items from the Psychotherapy Process Q-set. Lower decentering scores predicted early attrition (before Session 6). Clients with more mature decentering scores reported more frequent psychodynamic relative to cognitive-behavioral therapy process events in these early sessions. Lower decentering maturity may limit clients’ processing of psychodynamic interventions. Interpersonal decentering may be a valuable, easy-to-score assessment tool for predicting attrition risk and making treatment planning recommendations for intervention strategies.

FATORES ENVOLVIDOS NA INTERRUPÇÃO DE UMA PSICOTERAPIA PSICANALÍTICA COM UMA PACIENTE BORDERLINE: UM ESTUDO DE CASO SISTEMÁTICO

Estudos de caso sistemáticos naturalísticos oferecem uma oportunidade para compreender os processos que promovem mudança terapêutica a partir da análise profunda das interações terapeuta-paciente. Da mesma forma, oferecem subsídios para a compreensão dos processos que não alcançaram os objetivos terapêuticos propostos. Este estudo buscou integrar fatores técnicos, variáveis de processo terapêutico e medidas de aliança terapêutica para compreender um processo terapêutico que culminou em interrupção prematura. Método: Estudo de caso sistemático naturalístico, realizado a partir da psicoterapia psicanalítica de uma paciente com Transtorno de Personalidade Borderline. Para tanto, foram utilizados os instrumentos: Instrumento para Avaliar Sessões Psicanalíticas (IASP), Therapeutic Cycles Model (TCM), Psychotherapy Process Q-Set (PQS) e Working Alliance Inventory – versão observacional (WAI-O). Resultados: Identificou-se que as variáveis estudadas não se apresentam de forma linear, revelando a complexidade de uma psicoterapia. Na análise dos resultados, verificou-se que a paciente se mostrava descomprometida com o processo terapêutico e havia indícios de rupturas da aliança terapêutica. Três sessões não foram aderidas à técnica psicanalítica. Implicações dos achados e limitações do estudo foram discutidas.

Simulation modeling analysis of sequential relations among therapeutic alliance, symptoms, and adherence to child-centered play therapy between a child with autism spectrum disorder and two therapists.

This study examined the sequential relations among three pertinent variables in child psychotherapy: therapeutic alliance (TA) (including ruptures and repairs), autism symptoms, and adherence to child-centered play therapy (CCPT) process. A 2-year CCPT of a 6-year-old Caucasian boy diagnosed with autism spectrum disorder was conducted weekly with two doctoral-student therapists, working consecutively for 1 year each, in a university-based community mental-health clinic. Sessions were video-recorded and coded using the Child Psychotherapy Process Q-Set (CPQ), a measure of the TA, and an autism symptom measure. Sequential relations among these variables were examined using simulation modeling analysis (SMA). In Therapist 1's treatment, unexpectedly, autism symptoms decreased three sessions after a rupture occurred in the therapeutic dyad. In Therapist 2's treatment, adherence to CCPT process increased 2 weeks after a repair occurred in the therapeutic dyad. The TA decreased 1 week after autism symptoms increased. Finally, adherence to CCPT process decreased 1 week after autism symptoms increased. The authors concluded that (1) sequential relations differ by therapist even though the child remains constant, (2) therapeutic ruptures can have an unexpected effect on autism symptoms, and (3) changes in autism symptoms can precede as well as follow changes in process variables.

Interrupted therapeutic process of a patient with borderline personality disorder / Proceso terapéutico interrumpido con un paciente con trastorno de personalidad borderline

Aim: to describe and understand an interrupted psychotherapy of a patient with Borderline Personality Disorder. Method: systematic, naturalistic and exploratory case study of the therapeutic dyad. The Therapeutic Cycles Model (TCM) and the Psychotherapy Process Q-Set (PQS) were the instruments used. Results: according to TCM, the case can be divided into two stages: one with cycles of change and one without cycles of change. According to the PQS, the themes addressed by the dyad were relevant to psychotherapy and related to patient diagnosis. However, the patient seemed to be uncommitted to the therapeutic process and did not rely on the therapist to solve her problems. The therapist’s attitudes were adequate but technical interventions were not prominent. The combination of patient and therapist data assisted in understanding why the psychotherapy was abandoned.

Uncovering Interaction Structures in a Brief Psychodynamic Psychotherapy

Abstract Interaction structures refers to the repetitive ways of interaction between the patient-therapist dyad over the course of treatment. This construct is operationalized by the repeated application of the Psychotherapy Process Q-Set (PQS) to psychotherapy sessions. Studies in this line of research have so far focused only on long-term treatment. The present study examines whether interaction structures can be detected empirically in short-term psychotherapies. All sessions (N = 31) of a successful case of brief psychodynamic psychotherapy were coded with the Psychotherapy Process Q-Set (PQS). The application of Q type factor analysis procedures with varimax rotation revealed five interaction structures: resistance, alliance, facing depression, expectation of change, and introspection and hearing. The analysis of variation of these structures over the course of the treatment showed that these interactions are nonlinear, may be positively or negatively protruding in different sessions, or be predominant at some treatment phase.

The Munich Attachment and Effectiveness Study: Study Design and a Case Example

The "Munich Attachment and Effectiveness Study" is a prospective psychotherapy study examining process and outcome of psychoanalytic psychotherapies. The study design and results are exemplified in a single case. At 6 points in time audio-taped and transcribed therapy sessions are evaluated using process instruments (e. g. Psychotherapy Process Q-Set PQS) and interviews (e. g. Operationalized Psychodynamic Diagnostics OPD, Heidelberg Structural Change Scale HSCS, Adult Attachment Interview AAI). In the single case, findings from the psychotherapeutic process (e. g. "therapist is empathic" according to PQS) complement the achieved changes. 5 HSCS problem foci reached level of "restructuring", on the Reflective Functioning Scale a marked change of RF took place and the attachment classification changed over time. The instruments employed in this study corresponded well in assessing change processes in spite of differing theoretical background.

Developing a prototype for short-term psychodynamic (supportive-expressive) therapy: An empirical study with the psychotherapy process Q-set

Objective: A Psychotherapy Process Q-set (PQS) prototype characteristic of short-term psychodynamic therapy (STPP) does not yet exist. Method: Experts in supportive-expressive (SE) therapy used the 100-Item PQS questionnaire to rate an ideal short-term SE therapy. Results: Agreement between raters was high (Cronbach's alpha = 0.94). The prototype for SE therapy showed a significant correlation with the psychoanalytic prototype, but with 28% of variance explained, the majority of variance of the former was not explained by the latter or vice versa. Furthermore, the SE prototype showed significant correlations with the cognitive-behavioral prototype and the prototype of interpersonal therapy by Ablon and Jones (r = 0.69, 0.43). Conclusions: We recommend using the PQS prototype presented here for future process research on STPP.

Expert clinicians’ prototypes of an ideal child treatment in psychodynamic and cognitive-behavioral therapy: Is mentalization seen as a common process factor?

Objective: To investigate (a) whether expert clinicians within psychodynamic therapy (PDT) and cognitive-behavioral therapy (CBT) agree on key features of child psychotherapy process using the Child Psychotherapy Process Q-Set (CPQ); (b) whether these two prototypes can be empirically distinguished; and (c) whether promoting mentalization (operationalized as reflective functioning [RF]) is a shared component of the way expert clinicians conceptualize these two treatment models. Method: Thirty-one raters with expertise in PDT, CBT, and RF provided ratings of the 100 CPQ items to describe an ideal prototype session that adheres to the principles of their treatment model. Two Q-factor analyses with varimax rotation were conducted. Results: Expert clinicians reached a high level of agreement on their respective PDT and CBT prototypes. These prototypes loaded onto two independent factors. The RF process prototype loaded onto both factors. Conclusions: From the theoretical perspective of expert clinicians representing PDT and CBT, a focus on RF appears to be a common process factor in the way both treatment models are conceptualized. The CPQ can also be a useful instrument in teaching psychotherapy process from different theoretical perspectives and training future clinicians in their application. Future researchers can use these prototypes to explore process in actual sessions.

Is It All about the Higher Dose? Why Psychoanalytic Therapy Is an Effective Treatment for Major Depression.

Empirical evidence for the effectiveness of long-term psychodynamic psychotherapy (LTPP) in patients with mood disorders is growing. However, it is unclear whether the effectiveness of LTPP is due to distinctive features of psychodynamic/psychoanalytic techniques or to a higher number of sessions. We tested these rival hypotheses in a quasi-experimental study comparing psychoanalytic therapy (i.e., high-dose LTPP) with psychodynamic therapy (i.e., low-dose LTPP) and cognitive-behavioural therapy (CBT) for depression. Analyses were based on a subsample of 77 subjects, with 27 receiving psychoanalytic therapy, 26 receiving psychodynamic therapy and 24 receiving CBT. Depressive symptoms, interpersonal problems and introject affiliation were assessed prior to treatment, after treatment and at the 1-, 2- and 3-year follow-ups. Psychoanalytic techniques were assessed from three audiotaped middle sessions per treatment using the Psychotherapy Process Q-Set. Subjects receiving psychoanalytic therapy reported having fewer interpersonal problems, treated themselves in a more affiliative way directly after treatment and tended to improve in depressive symptoms and interpersonal problems during follow-up as compared with patients receiving psychodynamic therapy and/or CBT. Multilevel mediation analyses suggested that post-treatment differences in interpersonal problems and introject affiliation were mediated by the higher number of sessions, and follow-up differences in depressive symptoms were mediated by the more pronounced application of psychoanalytic techniques. We also found some evidence for indirect treatment effects via psychoanalytic techniques on changes in introject affiliation during follow-up. These results provide support for the prediction that both a high dose and the application of psychoanalytic techniques facilitate therapeutic change in patients with major depression. Psychoanalytic therapy is an effective treatment for major depression, especially in the long run. The differential effectiveness of psychoanalytic therapy cannot be fully explained by its higher dose. Distinctive features of psychoanalytic technique (e.g., focusing on patients' dreams, fantasies, sexual experiences or childhood memories) may play an important role in establishing sustained therapeutic change.

Therapists' thoughts on therapy: Clinicians' perceptions of the therapy processes that distinguish schema, cognitive behavioural and psychodynamic approaches

Objective: Debates continue over shared factors in therapy processes between different theoretical orientations. By seeking the opinions of practicing clinicians, this study aimed to elucidate the similarities and differences between cognitive-behavioural (CBT), psychodynamic (PDT), and schema therapy (ST) approaches. Method: Forty-eight practitioners aligning with one of the three approaches were asked to identify crucial processes in their therapy using a modified online version of the Psychotherapy Process Q-set. Results: Distinct differences between each theoretical orientation with few shared common factors were found. A comparison with ratings from previous studies indicated that CBT therapists have not changed over the last 20 years, whereas PDT therapists have changed and the differences appeared consistent with modern PDT theory. Conclusions: The differences between the therapy approaches were consistent with theories underlying each model. PDT therapists valued a neutral relationship, CBT therapists emphasized a didactic interaction, and therapists form a ST orientation placed a greater emphasis on emotional involvement.

The Relation between Prototypical Processes and Psychological Distress in Psychodynamic Therapy of Five Inpatients with Borderline Personality Disorder

Five inpatients with borderline personality disorder (BPD) participated in 6 months of three times per week psychodynamic therapy (PDT). Patients completed a measure of psychological distress every week. A total of 127 sessions were audiotaped and coded using the psychotherapy process Q-set (PQS) and correlated with PQS prototypes of five treatment models-PDT, cognitive-behaviour therapy (CBT), interpersonal therapy, transference focused psychotherapy and dialectical behaviour therapy. Prototypical CBT process was most prevalent in three of the five PDT-labelled treatments. Prototypical PDT process significantly decreased over time in three of the five treatments. Prototypical process correlations with time were inversely proportional to prototypical process correlations with distress levels. In a multiple regression model that included all five prototypical process correlations across these three treatments, CBT and transference focused psychotherapy predicted distress reduction, whereas PDT predicted increases in distress. PQS items most negatively correlated with distress included the therapist's emphasis on feelings, empathic attunement and control over the interaction. Discussion of dreams or fantasies and therapist aloofness were most positively correlated with distress. An effective PDT treatment model for severely disturbed BPD inpatients requires technical flexibility to supplement CBT processes such as control over the interaction that can structure intense interpersonal dysregulation and stabilize distress. Practitioners and their patients sense which prototypical processes to increase or decrease over time to reduce patients' distress. An effective PDT treatment model for severely disturbed BPD patients needs to integrate and encourage the emergence of empathically attuned interactions in the context of a highly structured therapy experience. Practitioners need to be flexible enough to change intervention strategies when they seem to be increasing distress in severely disturbed BPD patients.

Interaction Structure and Transferential Patterns in Brief Psychotherapy: A Single-case Study

Nowadays it is sufficiently accepted that the therapeutic action of psychotherapy is expected to lie at the interface between two dimensions: identification and interpretation of the patient's dysfunctional relationship patterns arising in the relationship with the clinician. This can only happen, however, if there is a temporal space where the transference-countertransference reactions to be explored and understood can emerge (Jones, 2000). The limited number of sessions characterizing short-term psychotherapy does not seem to allow the unfolding of these dynamics, thus suggesting that the therapeutic action of this approach lies outside the patient-therapist relationship. The aim of this study is to investigate the possibility that, even within the few sessions that characterize short-term psychotherapy, the dynamics of transferencecountertransference typical of the patient's dysfunctional relationship patterns do in fact emerge. For this purpose, a study has been made of the patterns of patient-therapist interaction, measured by the Psychotherapy Process Q-set. The patterns identified are related to the change found in the Core Conflictual Relationship Theme, allowing reflection on the role played by alternating interaction patterns in the variation of the patient's intrapsychic conflicts in this psychotherapy model.

Trying to be useful: Three different interventions for one therapeutic stance.

This article is an attempt to analyze therapist's actions or strategies that contribute to an effective therapy session and are clinically useful to the therapeutic process. To link the clinical practice to the empirical research, three kinds of therapist interventions, based on the Psychotherapy Process Q-Set, are described. They include (1) an empathic attitude in dealing with the difficulties of the patient and his or her affective experience, (2) the identification and exploration of recurrent themes in the patient's experience or conduct, and (3) addressing a patient's defenses, to ward off awareness of threatening feelings. For each of these interventions, the author provides both clinical and research data that support their use, as well as verbatim clinical exchanges, which allow a better understanding of the mechanisms of therapeutic actions in real clinical practice.