Anne Grete Hersoug

Quality of Early Working Alliance in Psychotherapy: Diagnoses, Relationship and Intrapsychic Variables as Predictors

Background: The aim of the study was the prediction of the quality of early working alliance, using possible predictors among patient pretreatment variables: diagnoses, current and past relationships and intrapsychic ones. Data arefrom the ongoing, naturalistic Norwegian Multisite Project on Process and Outcome of Psychotherapy (NMSPOP). Methods: The sample, n = 270, is recruited from 15 outpatient clinics; 61.1% of the patients have personality disorders. Alliance was assessed with the Working Alliance Inventory (WAI), and predictors include independent clinicians’ evaluations of diagnostic/interpersonal/intrapsychic characteristics and the patients’ self-reports on similar and additional variables. Results: Four of 6 hypotheses were supported: Quality of working alliance is difficult to predict, early alliance is better predicted than later, diagnostic variables do not predict quality of working alliance, but quality of both current and past relationships is associated with working alliance. In a hierarchical multiple-regression analysis, 7% variance of working alliance in the 3rd session was explained from current relationship variables, whereas alliance in the 12th session was not predicted by the same model. Intrapsychic variables predicted the therapists’ ratings of alliance, but not the patients’ ratings. Conclusion: The results are in line with previous research, and also with the theoretical model for working alliance.

Effects of transference work in the context of therapeutic alliance and quality of object relations.

OBJECTIVE Transference interpretation is considered as a core active ingredient in dynamic psychotherapy. In common clinical theory, it is maintained that more mature relationships, as well as a strong therapeutic alliance, may be prerequisites for successful transference work. In this study, the interaction between quality of object relations, transference interpretation, and alliance is estimated. METHOD One hundred outpatients seeking psychotherapy for depression, anxiety, and personality disorders were randomly assigned to 1 year of weekly sessions of dynamic psychotherapy with transference interpretation or to the same type and duration of treatment, but without the use of transference interpretation. Quality of Object Relations (QOR)-lifelong pattern was evaluated before treatment (P. Høglend, 1994). The Working Alliance Inventory (A. O. Horvath & L. S. Greenberg, 1989; T. J. Tracey & A. M. Kokotovic, 1989) was rated in Session 7. The primary outcome variable was the Psychodynamic Functioning Scales (P. Høglend et al., 2000), measured at pretreatment, posttreatment, and 1 year after treatment termination. RESULTS A significant Treatment Group × Quality of Object Relations × Alliance interaction was present, indicating that alliance had a significantly different impact on effects of transference interpretation, depending on the level of QOR. The impact of transference interpretation on psychodynamic functioning was more positive within the context of a weak therapeutic alliance for patients with low quality of object relations. For patients with more mature object relations and high alliance, the authors observed a negative effect of transference work. CONCLUSION The specific effects of transference work was influenced by the interaction of object relations and alliance, but in the direct opposite direction of what is generally maintained in mainstream clinical theory.

Pretreatment patient characteristics related to the level and development of working alliance in long-term psychotherapy

Abstract This study explored pretreatment patient characteristics associated with the level and growth of working alliance in therapies lasting up to 120 therapy sessions. The quality of working alliance was rated by both patients (N=201) and therapists (N=61) at Sessions 3, 12, and 20 and then at every 20th successive session. Patients reported that experience with good maternal care up to adolescence and better current interpersonal relationships were associated with positive ratings of working alliance throughout therapy. Higher global functioning was associated with growth of alliance over time. Higher levels of interpersonal problems of the cold/detached kind were associated with poorer early working alliance. On the other hand, this type of interpersonal problems was also associated with improvement of working alliance over time. Therapists’ ratings of alliance were associated with patients’ intrapsychic functioning. Implications for treatment and research are discussed.

Long-term effects of transference interpretation in dynamic psychotherapy of personality disorders.

BACKGROUND Only a few treatment studies of personality disorders (PD) patients are on longer-term psychotherapy, general outcome measures are used, and follow-up periods are usually short. More studies of long-term therapies, using outcome measures of core psychopathology, are needed. METHOD This study is a dismantling randomized controlled clinical trial, specifically designed to study long-term effects of transference interpretation. Forty-six patients with mainly cluster C personality disorders were randomly assigned to 1 year of dynamic psychotherapy with or without transference interpretations. The outcome measures were remission from PD, improvement in interpersonal functioning, and use of mental health resources in the 3-year period after treatment termination. RESULTS After therapy with transference interpretation PD-patients improved significantly more in core psychopathology and interpersonal functioning, the drop-out rate was reduced to zero, and use of health services was reduced to 50%, compared to therapy without this ingredient. Three years after treatment termination, 73% no longer met diagnostic criteria for any PD in the transference group, compared to 44% in the comparison group. CONCLUSIONS PD-patients with co-morbid disorders improved in both treatment arms in this study. However, transference interpretation improved outcome substantially more. Long-term psychotherapy that includes transference interpretation is an effective treatment for cluster C personality disorders and milder cluster B personality disorders.

The combined predictive effect of patient characteristics and alliance on long‐term dynamic and interpersonal functioning after dynamic psychotherapy

On the basis of the well-established association between early alliance and outcome, this exploratory study investigated the associations between the therapeutic alliance and long-term outcome, 3 years after treatment termination. In addition to the early alliance, pre-treatment patient characteristics and expectancies that were significantly related to early alliance were included in the statistical analyses. The data are from the First Experimental Study of Transference, a dismantling randomized clinical trial with long-term follow-up. One hundred out-patients who sought psychotherapy due to depression, anxiety and personality disorders were treated. Alliance was measured with Working Alliance Inventory after session 7. Change was determined using linear mixed model analyses. The alliance alone had a significant impact on long-term outcome of the predetermined primary outcome variables of the study: Psychodynamic Functioning Scales and Inventory of Interpersonal Problems. Contrary to common clinical wisdom, when the pre-treatment patient variables were included, more personality disorder pathology was the strongest predictor of favourable outcome, over and above the effect of the alliance, which was no longer significant. Clinical implications are discussed.

Therapist interventions using the Psychodynamic Interventions Rating Scale (PIRS) in dynamic therapy, psychoanalysis and CBT

Abstract One requirement for psychotherapy research is an accurate assessment of therapeutic interventions across studies. This study compared frequency and depth of therapist interventions from a dynamic perspective across four studies, conducted in four countries, including three treatment arms of psychodynamic psychotherapy, and one each of psychoanalysis and CBT. All studies used the Psychodynamic Intervention Rating Scales (PIRS) to identify 10 interventions from transcribed whole sessions early and later in treatment. The PIRS adequately categorized all interventions, except in CBT (only 91–93% categorized). As hypothesized, interpretations were present in all dynamic therapies and relatively absent in CBT. Proportions of interpretations increased over time. Defense interpretations were more common than transference interpretations, which were most prevalent in psychoanalysis. Depth of interpretations also increased over time. These data can serve as norms for measuring where on the supportive-interpretive continuum a dynamic treatment lies, as well as identify potentially mutative interventions for further process and outcome study.

Treatment of adolescents with depression: the effect of transference interventions in a randomized controlled study of dynamic psychotherapy

BackgroundDepression in adolescents seems to be a growing problem that causes mental suffering and prevents young people from joining the workforce. There is also a high risk of relapse during adult life. There is emerging evidence for the effect of psychodynamic psychotherapy in adolescents. In-session relational intervention (that is, transference intervention) is a key component of psychodynamic psychotherapy. However, whether depressed adolescents profit most from psychodynamic psychotherapy with or without transference interventions has not been stated.ObjectThe effect of transference interventions in depressed adolescents and the moderator moderating effect of quality of object relations, personality disorder and gender will be explored.Methods and study designThe First Experimental Study of Transference Work–In Teenagers (FEST–IT) will be a randomized clinical trial with a dismantling design. The study is aimed to explore the effects of transference work in psychodynamic psychotherapy for adolescents with depression. One hundred patients ages 16 to 18 years old will be randomized to one of two treatment groups, in both of which general psychodynamic techniques will be used. The patients will be treated over 28 weeks with either a moderate level of transference intervention or no transference intervention. Follow-up will be at 1 year after treatment termination. The outcome measures will be the Psychodynamic Functioning Scales (PFS), Inventory of Interpersonal Problems–Circumplex Version (IIP-C), Global Assessment of Functioning (GAF), and the total mean score of Symptom Checklist–90 (Global Severity Index; GSI), Beck Depression Inventory (BDI), and Montgomery Åsberg Rating Scale (MADRS). The quality of adolescents’ relationships will be a central focus of the study, and the Adolescent Relationship Scales (ARS) and Differentiation–Relatedness Scale (DRS) will also be used. Change will be assessed using linear-mixed models. Gender personality disorder (PD) and quality of object relations (QOR) will be the preselected putative moderators.DiscussionThe object of this clinical trial is to explore the effect of transference interventions in psychodynamic psychotherapy in adolescents with a major depressive disorder. Using a randomized and dismantling design, we hope that the study will add more specific knowledge to the evidence base.Trial registrationClinicalTrials.gov Identifier: NCT01531101First Experimental Study of Transference work Work–In Teenagers (FEST-IT)

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 therapists 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.

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.

When Is Transference Work Useful in Psychodynamic Psychotherapy? Main Results of the First Experimental Study of Transference Work (FEST)

Abstract This article presents the main results of the First Experimental Study of Transference (FEST). The background of the study, as well as the aims, main hypotheses, and methods are described. The participants were 100 patients who were randomized to psychodynamic psychotherapy of one years duration, with transference work or without transference work. The analyses of the effects of psychodynamic psychotherapy with transference work versus psychodynamic psychotherapy without transference work are presented. The two treatments were equally effective, but analyses of moderators revealed differential effects. Patients with low quality of object relations (QOR) and/or presence of personality disorder showed specific positive effects of transference work. Female patients responded better than men. Further analyses included mechanisms of change and three-way interactions among factors, with an impact on outcome. We also found that (1) insight was a mediator of change, and (2) that the specific effects of transference work were influenced by interaction of object relations and alliance, but in the direct opposite direction of what is generally maintained in mainstream clinical theory. For patients with more mature object relations and high alliance, a negative effect of transference work was observed.