Changes in Object Relations over the Course of Psychodynamic Psychotherapy

The Impact of Different Thematic Apperception Test Administration Methods on Narrative Length and Story Richness as Measured by the Social Cognition and Object Relations Scale-Global Rating Method (SCORS-G)

The Thematic Apperception Test (TAT) is the second most commonly used performance-based task in clinical practice. However, traditional TAT administration is time-consuming and raises accessibility issues. This study examines the effect of administration modifications (i.e., examiner handwriting versus typing, examiner recording versus participant recording, and re-prompting versus no re-prompting) on narrative length and richness as measured by the Social Cognition and Object Relations Scale-Global Rating Method (SCORS-G). A four-card TAT protocol was administered to 150 college students under one of five conditions. The resulting narratives were scored by two trained raters using the SCORS-G. MANOVA procedures showed (a) no significant differences between examiner handwriting versus typing; (b) the shortest, blandest narratives were produced when the examiner recorded the narratives without re-prompting; and (c) the longest, richest narratives were produced when the participant typed the narratives with re-prompts on the computer screen. Clinical and research implications and future directions will be discussed.

The effect of individual short- and long-term psychotherapy on perceived social support: analysis of secondary outcomes of a randomized clinical trial

PURPOSE

Social support is important for maintaining and restoring psychological well-being but the effects of individual psychotherapies on perceived social support are not well known. In this analysis of secondary outcomes from a randomized clinical study, we compared the effects of long-term psychotherapy and two short-term psychotherapies on social support during a 5-year follow-up.

MATERIALS AND METHODS

Altogether 326 adult outpatients suffering from depressive and/or anxiety disorders were randomly assigned to long-term psychodynamic psychotherapy (LPP, n = 126), short-term psychodynamic psychotherapy (SPP, n = 101) and solution-focused therapy (SFT, n = 97). Outcome was measured by the global index and six subscores of the self-reported Brief Inventory of Social Support and Integration scale (BISSI) at baseline and at 1, 2, 3, 4 and 5 years after the beginning of the therapy.

RESULTS

Social support improved in all therapy groups and the improvement was relatively stable, lasting several years after the end of therapy. Little difference in improvement was observed either between therapy orientations or durations.

CONCLUSIONS

While no major differences were observed between treatment groups, the slight differences call for further research to verify these findings and to better understand how different therapies may improve perceived social support.

Patient personality characteristics and therapeutic integration: treating borderline personality and emotionally dysregulated-dysphoric personality features

This study examines the relationship between patient personality characteristics and therapeutic integration. Within a sample of patients (N=93) receiving outpatient psychodynamically- oriented psychotherapy, we assessed patient Borderline and Emotionally Dysregulated personality features through the Shedler-Westen Assessment Procedure (SWAP-200), and therapeutic technique using the Comparative Psychotherapy Process Scale (CPPS) during an early treatment session. We examined personality dimensionally, psychotherapy interventions across different theoretical orientations, as well as psychotherapy integration. These analyses revealed an overlap between the Borderline Clinical Prototype and the Emotionally Dysregulated-Dysphoric Q-factor, with the former associated with higher use of integration and the latter associated with higher use of either psychodynamicinterpersonal or cognitive-behavioural interventions. Secondary analyses also indicated the greater presence of interventions oriented towards emotional exploration and to the didactic instruction of effective symptom coping techniques across both of these personality subtypes early in treatment. The key differences between these personality types, as well as the theoretical, empirical, and clinical implications of these findings are discussed.

Longitudinal stability of Social Cognition and Object Relations Scale-Global Rating Method dimensional ratings, score ranges and narrative 'blandness' in a clinical sample

While understanding how internalized representations of others (i.e., object relations) change over the course of treatment is essential for treatment planning and evaluation of progress, few studies have examined the nature of these changes through repeated psychological assessments. In this study, we applied the SCORS-G to Thematic Apperception Test narratives for 61 adult patients with complex psychiatric problems undergoing residential treatment over an 18-month period. Over the course of treatment, patient representations of self and others became more complex, indicating improvements in mentalization. Further, an analysis of default ratings (i.e., an aspect of story 'blandness') suggested that certain shifts in SCORS-G dimensional scores over time were accounted for by greater degree of scorable content across time points, rather than changes specific to the dimensions themselves. Findings from novel exploratory analyses aimed at evaluating the test-retest reliability of both default rating proportion and several emerging alternative scoring approaches (including changes in minimum, maximum and range of scores on individual dimensions) are reported. While the magnitude of change across mean dimensional scores was found to be lower compared to those previously found in outpatient populations, our results suggest that the SCORS-G remains capable of detecting changes in mentalization capacities in individuals contending with longstanding, severe psychiatric impairment and personality-based psychopathology. Implications for treatment, assessment and future research are discussed.

How narrative source impacts convergence of ratings from the Social Cognition and Object Relations Scale-Global Rating Method with psychotherapy process measures

This study examines the construct validity of the Social Cognition and Object Relations Scale-Global Rating Method (SCORS-G; Westen, 1995; see also Stein & Mulford, 2018) by exploring the degree of convergence across different narrative sources (i.e., early memories [EM] and psychotherapy narratives [PT]) in relation to patient- and therapist-rated psychotherapy process measures. Using a university-based outpatient sample (n = 81), we found limited convergence for SCORS-G ratings across narrative type. First, paired t tests showed that the means for six of the eight SCORS-G dimensions differed significantly between the EM and PT narratives with the majority having a large magnitude of effect. Moreover, despite 29 significant correlations between a SCORS-G dimension and either an alliance or session quality variable, only two of the eight SCORS-G dimensions significantly correlated with the same process variable across narrative type (e.g., patient-rated session depth with SCORS-G Self Esteem [SE] and Identity and Coherence of Self [ICS]). Importantly, the high degree of theoretical coherence in the associations that emerged between the SCORS-G dimensions and the process variables suggest that the lack of convergence was not due to limited validity of the SCORS-G. Instead, the results underscore the importance of multi-method assessment techniques by highlighting that the manner in which a narrative is elicited will impact the object relational content patients provide. Future research and clinical implications related to the SCORS-G, alliance and psychotherapy process are discussed.

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.

Emotion regulation in adolescents: Influences of internal representations of relationships - An ERP study

Emotion regulation (ER) strategies can decrease the intensity or modify the experience of emotions. Deficits in emotion regulation are implicated in a wide range of psychopathologies. It is argued that interpersonal, socio-cognitive, and developmental variables play an important role in ER. This is the first study to explore the contribution of individual differences in internal representations of relationships (IRR) to neural correlates of ER in a sample of adolescents. Event related potentials of 53 adolescents (12 to 17 years old) were collected while performing an ER task. IRR was assessed with the social cognition and object relations scale (SCORS-G; Westen, 1995) coding of narratives from interviews. Results show that individual differences in IRR significantly predicted the modulation of emotional responses by expressive suppression in adolescents, accounting for 48% of the variance of changes in occipital late positive potentials (LPP). Thus, it appears that IRR are implicated in an individual's ability to regulate emotions. The clinical implications of the findings are discussed.

What interpersonal problems are related to different therapeutic techniques early in treatment?

The current study seeks to explore the relationship between patient-reported interpersonal problems and therapist interventions in early psychodynamic psychotherapy for 71 outpatients. Pretreatment ratings on the Inventory of Interpersonal Problems Circumplex Scales (IIP-C) total and subscale scores were examined in relation to early treatment process. Independent clinicians reliably rated therapist use of psychodynamic-interpersonal (PI) and cognitive-behavioural (CB) interventions using the Comparative Psychotherapy Process Scale (CPPS) over two early treatment sessions (third and ninth). Intraclass correlation (ICC) values were in the excellent range for CPPS-PI and CPPS-CB scale scores (CPPS-PI = 0.86; CPPS-CB = 0.78). A significant positive correlation was found between interpersonal problems and global PI therapist technique. A significant positive correlation was also found between interpersonal problems and specific PI interventions, most significantly experience and expression of feelings in session. In specific interpersonal problem subscales, most significant was that Cold/Distant and Socially Inhibited octants positively related to global PI and to specific PI techniques, including exploration of uncomfortable feelings. Multiple regression analyses revealed most significantly that CPPS Intervention 7 (discussion of patient-therapist relationship; positive) and CPPS Intervention 11 (therapist explanation of rationale behind treatment; negative) explained 15.6% of variance in interpersonal problem score. These findings demonstrate that the use of psychodynamic techniques tend to occur alongside patient-reported interpersonal problems early in psychotherapy treatment. Clinical implications are discussed for this area of research, and future directions are explored.

Psychodynamic technique early in treatment related to outcome for depressed patients

We examined the relationship between psychodynamic techniques early in treatment with reliable change in depressive symptomatology. Forty-six patients admitted for individual psychodynamic psychotherapy who received a diagnosis representative of a depressive spectrum disorder were assessed pretreatment and posttreatment through self-report of depressive symptoms. Videotapes from two early treatment sessions (3rd and 9th) were independently rated on the Comparative Psychotherapy Process Scale for use of psychodynamic-interpersonal and cognitive-behavioural techniques, with excellent interrater reliability (intraclass correlation coefficient > .75). We found a significant relationship between overall use of psychodynamic technique across early treatment (r = .31, p = .036), as well as specific psychodynamic techniques delivered across early treatment, with change in patient-reported depressive symptoms. Our findings suggest that focusing on affective experiencing and expression, as well as providing interpretations are particularly helpful early in psychodynamic treatment for depression. Clinical implications and future directions are discussed.