How can we Study the Efficacy of Psychoanalysis?

Development of a new observer-rated measure to assess the real relationship in psychotherapy sessions

OBJECTIVES

Real relationship (RR) refers to a genuine human relationship between client and therapist, that has been found to be positively related to treatment outcome, and to predict unique variance in outcome over and above the working alliance. However, thus far, the measurement of RR has been limited to self-report. We aimed to develop an observer-rated version of the RR measure (RR-O) to assess RR in therapy sessions.

METHODS

We adapted items from the self-report measures to an observer rated measure, which was reviewed by RR experts. The final 24-item RR-O was rated in 540 session transcripts from 27 psychoanalytic treatments that already had existing process and outcome scores.

RESULTS

The RR-O showed good internal consistency and good interrater reliability. In hierarchical EFA, items clustered into a general RR factor, and client realism, client genuineness, therapist genuineness, and therapist realism group factors. In addition, the RR-O was positively related to another RR measure and to the therapeutic alliance.

CONCLUSION

The RR-O shows initial reliability and validity as an observer-rated measure of the RR to be used in post-hoc psychotherapy research. Future research should clarify the relation between RR-O and treatment outcome.

Thinking about Psychoanalytic Curricula: an Epistemological Perspective

The author discusses the role that curriculum development can play in preparing psychoanalytic candidates to understand the challenges created by theoretical pluralism in our field and by the growth of knowledge in neighboring disciplines. Curriculum design can be used to encourage the development of epistemological perspectives that can serve as organizing frameworks to help candidates think critically about psychoanalytic knowledge. It is possible to teach these complex matters in a way that students find accessible and useful. The author presents exemplars taken from the curriculum at the Columbia University Center for Psychoanalytic Training and Research in New York.

Assessment of Change in Psychoanalysis: Another Way of Using the Change After Psychotherapy Scales

A systematic method is presented whereby material from a full course of psychoanalytic treatment is analyzed to assess changes and identify patterns of change. Through an analysis of session notes, changes were assessed using the CHange After Psychotherapy scales (CHAP; Sandell 1987a), which evaluate changes in five rating variables (symptoms, adaptive capacity, insight, basic conflicts, and extratherapeutic factors). Change incidents were identified in nearly every session. Early in the analysis, relatively more change incidents related to insight were found than were found for the other types of change. By contrast, in the third year and part of the fourth year, relatively more change incidents related to basic conflicts and adaptive capacity were found. While changes related to symptoms occurred throughout the course of treatment, such changes were never more frequent than other types of change. A content analysis of the change incidents allowed a determination of when in the treatment the patient's main conflicts (identified clinically) were overcome. A crossing of quantitative data with clinical and qualitative data allowed a better understanding of the patterns of change.

Evidence-based psychotherapeutics

Evidence-based medicine requires clinicians to base treatment of their patients on the findings of systematic clinical research. In recent years EBM has become linked with appropriate but also inappropriate efforts at cost containment. Organized psychiatry responded by developing evidence-based practice guidelines and launching a range of clinical research initiatives to determine the effectiveness and efficacy of current psychiatric practices. Psychoanalysis is particularly challenged because it has for most of the 20th century been based on conviction alone. Investigators have now identified the obstacles to research into psychoanalysis and dynamic psychotherapy and are developing techniques to overcome these and to study not only outcomes but also the internal processes of these treatment modalities. We may look forward to an evidence-based psychoanalysis in the 21st century.

Change in psychoanalysis: getting from A to B

The change that occurred during an analytic hour with a seven-year-old girl is explored by means of videotape observation and aspects of developmental theory drawn from the field of infant research. Detailed review of the videotape and transcript of twelve minutes of the analytic hour revealed significant change in the girl's attitude toward the loss represented by a cancelled session. The moment-to-moment process between two points, A and B--identified as representing the beginning and end of the change in the girl's ability to deal with loss in the analytic relationship--is studied and described in two forms: written transcript for the verbal material, and narrative description for the nonverbal material. The methodology is based on observed behaviors but also relies on the clinical experience of the analyst in the interpretation of affects and the recognition of intentions in both participants. The results suggest that, taken as a whole, many such small transitional episodes during the course of a treatment play an important role in the process of therapeutic change.

Modern ego psychology

This paper reviews the history of ego psychology, describing problems in the theory that have perhaps contributed to subsequent theory development and theoretical splintering. The present status of ego psychology is then described, with a focus on broadly accepted general principles. A proposal/prediction is then made regarding efforts to integrate the main schools and splinter groups. It is argued that the ego's method of synthesizing aspects of experience will help integrate divergent metapsychological viewpoints.