Effects of training in short-term psychodynamic psychotherapy: changes in graduate clinician technique

Experience-Based Competency Training in Child and Adolescent Psychotherapy

Abstract. Background: Compared to adult psychotherapy training, there is little knowledge about the use of standardized actor-patients (SPs) for the development of professional competencies for younger patient populations. Objective: We assessed the effectiveness of two university-based training programs for diagnostic as well as intervention skills in child and adolescent psychotherapy. Methods: Psychology students took part in two courses on the development of diagnostic competencies ( N = 59) and on intervention skills ( N = 51). We applied active and experience-based learning strategies, including exercises on self-awareness, mindfulness, peer role-play, and the use of SPs. Competence gain as well as a general evaluation of the seminars were assessed by self-report. Results: For both seminars, self-reported competence increased significantly with a large effect. The retrospective evaluation of learning success and acceptance ratings of the didactic formats were high. Conclusions: Experience-based trainings that include SPs are a feasible option for child and adolescent psychotherapy. The findings are discussed from a conceptual as well as a practical perspective.

Patient crying during psychotherapy intake sessions: Relationship to patient characteristics and early treatment process

The aim of the present study is to further the understanding of who cries at the beginning of psychotherapy and patients' experience of crying in that process. Intake sessions for 53 patients beginning psychotherapy at a university-based clinic were coded for discrete crying segments. Data about patient characteristics were also collected at intake. Results indicate that crying during intake sessions was related to lower global functioning and higher severity of childhood sexual abuse. Furthermore, patients who cried at intake were over four times more likely to also cry at feedback, and those who cried at feedback were almost 12 times more likely to have cried at intake. Finally, crying in the intake session did not appear to be related to patient- or therapist-rated working alliance. Overall, the present study provides valuable information about characteristics of patients who cry at the outset of the therapy process and patients' experience of crying over time in therapy. Findings suggest the need for further research on patient characteristics and aspects of the therapy process that may predict patient crying over the course of treatment, as well as how these early crying experiences may be related to eventual patient outcomes.

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.

Prädiktoren des Lernerfolges eines erfahrungsbasierten Trainingsseminars zu psychodynamischen Interventionen

<b><i>Hintergrund:</i></b> Psychodynamische Psychotherapien spielen eine wichtige Rolle im deutschen Gesundheitssystem. Der Nachweis ihrer Lehrbarkeit bekommt vor dem Hintergrund des neuen Psychotherapiestudiums eine neue Bedeutung. Dies bezieht sich insbesondere auf erfahrungsbasierte di­daktische Modelle und auf das spezifische Üben von Interventionen. Hier ist bisher unklar, welche Aspekte kompetenz­orientierter psychodynamischer Lehre mit dem subjektiven Lernerfolg zusammenhängen. <b><i>Methode:</i></b> In einer Stichprobe mit 47 Kandidatinnen und Kandidaten eines Ausbildungsinstitutes wurden psychodynamische Interventionen mit ­Videofeedback, Peer-Rollenspielen und Simulationspatientinnen und -patienten unterrichtet. Der subjektive Kompetenzgewinn von Prä zu Post wurde in Bezug auf die Interventionen Klarifizieren, Konfrontieren und Deuten mithilfe von <i>t</i>-Tests abgebildet. Zudem wurden in einer multiplen linearen Regression verschiedene Prädiktoren für den subjektiven Lernerfolg getestet. <b><i>Ergebnisse:</i></b> Die subjektive Kompetenz nahm für die Interventionen Klarifizieren und Konfrontieren mit großen Effekten, für Deuten mit einem kleinen bis ­mittleren Effekt zu. Der Lernerfolg war korreliert mit einem antizipierten Transfer in den therapeutischen Alltag, einem positiven Erleben der Arbeit mit den Simulationspatientinnen und -patienten sowie mit hilfreich erlebtem Feedback durch die Dozentinnen und Dozenten. <b><i>Schlussfolgerungen:</i></b> Psychodynamische Interventionen sind mit erfahrungsbasierten und kompetenzorientierten Unterrichtsformaten lehrbar. Dabei ist wichtig, dass praxisorientierte Formate eine Lernumgebung schaffen, in der die Arbeit mit Simulationspatientinnen und -patienten und das Feedback als konstruktiv und hilfreich erlebt werden. Zukünftige Untersu­chungen sollten den Transfer in den Alltag sowie longitudinale Curricula in den Fokus nehmen.

Psychological Impact of Coronavirus Disease 2019 Among Italians During the First Week of Lockdown

Pandemics and government-mandated quarantining measures have a substantial impact on mental health. This study investigated the psychological impact of the coronavirus disease 2019 (COVID-19) crisis on Italian residents during the first week of government-imposed lockdown and the role of defense mechanisms as protective factors against distress. In this cross-sectional study, 5,683 Italians responded to an online survey assessing socio-demographics, overall psychological distress, post-traumatic symptoms, and defense mechanisms using validated measures as the Symptom Checklist-90 (SCL-90), the Impact of Event Scale-Revised (IES-R), and the Defense Mechanisms Rating Scale-Self-Report-30 (DMRS-SR-30). Data were collected from March 13 to March 18, within the first week of lockdown in Italy. Results showed that younger age and female gender were associated with increased psychological distress. Having positive cases nearby, more days on lockdown, and having to relocate were also associated with greater distress. Higher overall defensive functioning (ODF) was associated with lower levels of depression (r = -.44, 95% CI -0.48, -0.40), anxiety (r = -.38, 95% CI -0.42, -0.35), and post-traumatic stress symptoms (PTSS) (r = -.34, 95% CI -0.38, -0.30). Conversely, less adaptive defensive functioning was related to greater affective distress across all domains. Each increased unit of ODF decreased the chances of developing post-traumatic stress symptoms (PTSS) by 71% (odds ratio = 0.29, p < 0.001, 95% CI.026,.032). The psychological impact of COVID-19 among Italians during the early weeks of government lockdown has been significant. The pandemic continues to have extraordinary mental health impact as it moves across the globe. Given the salience of defensive functioning in psychological distress, consideration of interventions that foster the use of more adaptive defenses may be an important component of building resilience amidst a pandemic.

Does the supervisor's teaching style influence the supervisee's learning prescribed techniques?

OBJECTIVES

This study examined the directive and non-directive supervisors' instructional styles, supervisees' interactive communications within supervision sessions as well as the relative success of supervisees' learning to apply specific techniques within psychotherapy.

METHOD

The developers of Time-Limited Dynamic Psychotherapy (TLDP) provided the supervised training for 16 therapists as part of the "Vanderbilt II" psychotherapy project. Supervision sessions were rated for supervisors' adherence to TLDP content. Both supervisors and supervisee were rated for classroom interactive behaviors of "initiation" speech (e.g., introducing ideas) and "responsive" speech (e.g., amplifying the other speaker's topic). The third therapy session was targeted for discussion within supervision. Therapy sessions immediately before and after supervision were rated on TLDP adherence.

RESULTS

One of the supervisors (Supervisor A) was found to use an instructional style of relatively more initiation-based speech, whereas the other (Supervisor B) used more response-based speech. Technical adherence for supervisees of Supervisor A was significantly higher than those assigned to Supervisor B. Supervisees' initiation-based speech during supervision predicted less use of TLDP techniques in the therapy session after supervision. Supervisors' interactive style was not associated with therapy adherence.

CONCLUSIONS

Relatively more directive and structured supervision may influence the acquisition and use of manual-prescribed therapy techniques.

Object representation quality, therapeutic alliance, and psychotherapy process

This is the first study to demonstrate the existence of a relationship between patient pretreatment object relations functioning as measured by the Mutuality of Autonomy (MOA) Scale and patient-rated therapeutic alliance. Specifically, MOA scores were related to a patient-rated alliance Bond score (lower, more adaptive object-relations representations were associated with a stronger alliance). In addition, higher MOA scores indicating more malevolent object relations were related to a greater use of psychodynamic techniques. Specific psychodynamic techniques focused on the patient's relationships with the therapist as well as cyclical patterns in actions, feelings, and experiences. Implications for clinical practice and future research are discussed.

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.

Client Attachment Status and Changes in Therapeutic Alliance Early in Treatment

Several studies have examined associations between client attachment status and therapeutic alliance. Most, however, measure alliance at a single time point only. This study is among the first to examine how client attachment relates to changes in the therapeutic alliance early in treatment. Forty-six outpatients from a university-based community clinic participated. Attachment status was assessed with the Relationship Questionnaire (Bartholomew & Horowitz, 1991) prior to beginning treatment. Participants rated therapeutic alliance after an evaluation feedback session and again early in psychotherapy. Fearful insecurity was associated with declines in therapeutic alliance, while attachment security was associated with increasing client-therapist bonds. Although unrelated to global alliance, preoccupied insecurity was associated with greater confident collaboration at both time points and declines in idealized relationship from the evaluation to the early therapy time point. Results are discussed in light of prior theoretical formulations and previous research. Limitations of the study are reviewed, implications for clinical practice are noted, and suggestions for future research are made.

KEY PRACTITIONER MESSAGE

Assessing client attachment status can provide clinicians with information that helps them identify clients at risk for difficulties establishing a therapeutic alliance. Clients high in attachment security are more likely to develop strong bonds with therapists during the early portion of treatment. Clients high in fearful insecurity are at risk for developing weaker alliances early in treatment. Such clients appear more likely to experience declines in client-therapist bond, goal-task agreement and overall alliance early in the treatment process. Clients high in preoccupied insecurity may enter therapy with great confidence in the therapist and willing to engage in therapy but report more conflicts with therapists in the early phase of treatment.

Training in time-limited dynamic psychotherapy: A systematic comparison of pre- and post-training cases treated by one therapist

OBJECTIVE

This qualitative study systematically compared cases treated by the same therapist in order to understand the group comparison findings of a larger study on training of experienced therapists (the "Vanderbilt II" psychotherapy project).

METHOD

The therapist, Dr C., was selected based on the therapist's overall treatment successes. His two patients were selected based on their outcomes and the relative training cohort from which they were drawn: a case with successful outcome from the pre-training cohort and a case of negligible improvement from the post-training cohort.

RESULTS

Dr C. demonstrated a variety of interpersonal skills throughout his pre-training case, though there was also poor interpersonal process throughout. However, in the second case he had considerable difficulty in adapting his typical therapeutic approach to the requirements of the time-limited dynamic psychotherapy (TLDP) manual, even while appearing to work hard to find ways to use the manual.

CONCLUSIONS

Dr C.'s spontaneity, and his unique set of interpersonal skills may enhanced his initial rapport and alliance building with clients and yet may not have interfaced well with TLDP. His unique interpersonal skills also may have contributed to problems of interpersonal process. Future research may benefit from examining the interaction of between therapist interpersonal skills and the implementation of the treatment manual.

Psychodynamic techniques related to outcome for anxiety disorder patients at different points in treatment

Although psychodynamic therapy has a well-articulated model of therapeutic change for anxiety, few empirical studies have examined specific treatment interventions related to symptom improvement. We examined the degree of adherence to a psychodynamic model of therapy (Blagys and Hilsenroth [Clin Psychol 7:167-188, 2000) related to changes in anxiety symptoms across early treatment process. Secondary analyses also examined the use of specific psychodynamic techniques across early treatment process in relation to symptom change. The current study sought to extend the findings of , who found a relationship between the use of psychodynamic techniques in the third session (independent clinical ratings) and reduction in anxiety symptoms at posttreatment (r = 0.46, p = 0.04). Using the same sample of anxiety disorder patients (N = 20), we found a significant relationship between psychodynamic technique and posttreatment change in anxiety symptoms at the ninth session (r = 0.49, p = 0.03) and the mean levels of psychodynamic technique across both third and ninth sessions (r = 0.53, p = 0.02). In addition, specific psychodynamic techniques demonstrated significant relationships or moderate to large effects with posttreatment changes in anxiety symptoms at the third and ninth sessions as well as mean ratings across early treatment (third and ninth sessions). These findings indicate that therapist focus on cyclical intrapersonal patterns in patient actions, feelings, or experience as well as suggestions of alternative ways to understand these experiences or events not previously recognized by the patient (i.e., interpretation) in the early treatment process were particularly helpful in reducing posttreatment anxiety symptoms. Clinical implications and areas for future research will be discussed.

Patient Crying in Psychotherapy: Who Cries and Why?

AIM

The aim of the present study is to further the understanding of who cries in therapy and the relation of technique with crying behaviour in therapy.

METHOD

Psychological assessment feedback sessions, prior to the initiation of formal therapy for 52 patients beginning psychotherapy at a university-based clinic were coded for discrete crying segments. Data about patient characteristics and the process of the session were collected at the time of the session. Therapist's interventions were recorded verbatim and independently rated.

RESULTS

The number of times a patient cried during their session correlated negatively with global assessment of functioning scores and positively with measures of borderline personality disorder pathology as well as a measure of severity of childhood sexual abuse. Patients' crying behaviour demonstrated significant negative correlations with the overall experience of the session (bad/good), smoothness and positivity. Group differences between criers and non-criers reflected these trends as well. No significant correlations or group differences were found with regard to patient-rated or therapist-rated alliance as it relates to crying behaviour. Analysis indicates that therapist intervention prior to patient crying most often encouraged the exploration and expression of difficult affect, new perspectives on key issues or the patient's fantasies and wishes.

DISCUSSION

Our study addresses a significant gap in the clinical literature on crying. Crying behaviour seems to be related to certain clinical variables and has a negative impact on patient experience of the session in which they cry, although the alliance remained unaffected.

LIMITATIONS

Small sample, outpatients with mild/moderate psychopathology and graduate trainees provided therapy.

KEY PRACTITIONER MESSAGE

Patients with greater problems in emotional dysregulation, borderline personality disorder symptoms and greater severity of childhood sexual abuse are more likely to display greater affective intensity during the beginning of treatment. Results suggest that the alliance may remain strong despite patients experiencing a session in which they cried as difficult. Therapeutic interventions that focus on affect, new understanding of old patterns and patient fantasies with outpatient clinical populations appeared to be associated with crying in session.

The influence of supervision on manual adherence and therapeutic processes

OBJECTIVES

To identify the effectiveness of psychotherapy supervision on therapists' immediate (next session) and long-term (1 year) adherence to time-limited dynamic psychotherapy (TLDP).

METHOD

Sixteen therapists from the Vanderbilt II psychotherapy project were assigned new cases in pretraining, training, and booster/posttraining year-long cohorts. Technical adherence to the manual, as well as general therapeutic relational processes, were rated for clinical supervisory sessions in which the third therapy session was discussed. The therapy sessions immediately before and after the supervisory sessions were also rated for technical adherence and relational processes.

RESULTS

Postsupervision adherence increased from the presupervision session during the training cohort. In supervision, therapists' discussion of techniques and strategies from the manual in supervision was significantly related to technical adherence in the session prior to (but not after) supervision. However, supervisors' discussion of specific techniques predicted therapists' total technical adherence in the therapy session after (but not before) supervision. In terms of the type of techniques, supervisors' influenced postsupervision therapy adherence on TLDP's unique approach to formulation, the cyclical maladaptive pattern, but did not influence technical adherence on the therapeutic relationship.

CONCLUSIONS

In supervision, therapists tend to focus on how they adhered to techniques from the previous session, whereas supervisors' comments about specific techniques predicted how the therapist would adhere to techniques in the next therapy session. The findings provide support for the immediate effects of supervision in shaping therapist techniques as well as highlighting the challenges of altering common relational processes through technical training.

Short-term and long-term effects of training in emotionally focused couple therapy: professional and personal aspects

This study investigated the immediate and long-term personal and professional effects of a 4-day externship training in emotionally focused couple therapy (EFT). EFT externship training uses lecture, discussion, video vignettes, live demonstrations, and role-plays to convey an attachment-based approach to working with couples. The two samples included clinicians (N = 76) who completed surveys immediately before and after training, and a subset of these clinicians (N = 29) who completed measures an average of 8 months later. Results indicate that following training, participants increased in their EFT knowledge and competence, became more open to their feelings, were more self-compassionate, were less likely to use avoidant attachment behaviors, and improved their own personal relationships.

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.

The use of therapist self-disclosure: clinical psychology trainees' experiences

This qualitative study examined clinical psychology trainees' experiences of using, or not using, therapist self-disclosure and their experience of training and supervision on this issue. Fourteen trainees were interviewed and their accounts analyzed using interpretative phenomenological analysis, yielding nine themes organized into two domains. The first domain ("the decision in the moment") concerned participants' struggle with decision making about disclosure; the second ("the developing therapist") reflected their evolving ideas about disclosure over training and within the wider philosophical context of therapy. The dilemmas surrounding disclosure seemed to distill some central issues associated with participants' developing professional therapist identity. Working out one's position on self-disclosure is a challenge that trainee therapists may require support in mastering.

Personality Traits and the Working Alliance in Psychotherapy Trainees: An Organizing Role for the Five Factor Model?

Ackerman and Hilsenroth (2001, 2003) suggested that therapist personality may be meaningfully associated with the psychotherapy working alliance. We extended this line of research by examining the association between Five Factor Model (Costa & McCrae, 1997b) personality traits Neuroticism, Extraversion, Openness to Experience, Agreeableness, and Conscientiousness, and ratings of the working alliance made by clients and psychotherapy trainees. Higher trainee Neuroticism was associated with better client ratings of the alliance, but with worse trainee ratings of the alliance. Higher trainee Openness was associated with lower client ratings of the alliance, and higher trainee Agreeableness with lower trainee ratings of the alliance. Because levels of Neuroticism were low and levels of Openness high among therapist trainees, the results suggest that average rather than low Neuroticism, and average rather than high Openness facilitate better client perceptions of the alliance. Implications are discussed in terms of monitoring and training therapists who evidence these dispositions, in order to assist them in developing maximally effective alliances with clients.