[The techniques of the psychodynamic therapist: verbal interventions from a theoretical and practice-oriented perspective ]

Associations between therapists' verbal techniques and patient-rated therapeutic alliance, insight, and problem solving

OBJECTIVE

To investigate associations between common factors (alliance, insight, problem solving) and therapists' techniques. We expected a positive association between (1) supportive techniques and the alliance, (2) interpretative techniques and insight, and (3) a stronger association between interpretative techniques and insight for patients with more severe baseline symptoms. Other associations were analyzed in an exploratory way.

METHOD

Sixty sessions from 15 adult female patients diagnosed with personality disorder were analyzed using the Psychodynamic Interventions List (verbal techniques, observer-rated transcripts), and the Session Questionnaire for General and Differential Individual Psychotherapy (common factors, patient-rated after each session). Multilevel modeling was applied.

RESULTS

A greater use of supportive techniques was related to a higher therapeutic alliance (b = .28, 95% CI: .01-.55, p = .042). Neither the positive association between interpretative techniques and insight nor the moderating effect of baseline symptom severity could be confirmed. Exploratory analyses revealed associations between problem-solving and different verbal techniques.

CONCLUSION

Therapists' use of supportive techniques seems to influence the therapeutic alliance positively in patients with personality disorders. The effect of interpretative techniques might depend on other factors like patient characteristics. In general, there seem to be differential and specific associations between different therapists' verbal techniques and common factors.

[Functions of language in psychotherapy: A qualitative study of psychotherapists' subjective theories of the "talking cure"]

Functions of language in psychotherapy: A qualitative study of psychotherapists' subjective theories of the "talking cure" Objectives: Psychotherapy is traditionally considered as a "talking cure". The specific functions of verbal activity, however, are disputed. The present study aims at identifying central therapeutic functions of verbal activity. Methods: In qualitative interviews n = 23 psychotherapists with psychodynamic (n = 12) or behavioral (n = 11) background were interviewed regarding their theories of the "talking cure." Based on Consensual Qualitative Research (CQR) a category system of therapeutic functions of verbal activity was constructed. Results: The participants described a wide range of relational, experiential, and behavioral functions of verbal activity in psychotherapy. Psychodynamic therapists emphasized relational and experiential functions of verbal activity, while behavioral therapists emphasized behavioral functions. Conclusions: The findings imply that verbal activity fulfills diverse functions in therapeutic contexts. This suggests a basic verbal materiality of many therapeutic techniques and common factors that needs to be specified in subsequent research.

Interpretation and Working through Contemptuous Facial Micro-Expressions Benefits the Patient-Therapist Relationship

INTRODUCTION

The significance of psychotherapeutic micro-processes, such as nonverbal facial expressions and relationship quality, is widely known, yet hitherto has not been investigated satisfactorily. In this exploratory study, we aim to examine the occurrence of micro-processes during psychotherapeutic treatment sessions, specifically facial micro-expressions, in order to shed light on their impact on psychotherapeutic interactions and patient-clinician relationships.

METHODS

In analyzing 22 video recordings of psychiatric interviews in a routine/acute psychiatric care unit of Vienna General Hospital, we were able to investigate clinicians' and patients' facial micro-expressions in conjunction with verbal interactions and types. To this end, we employed the Emotion Facial Action Coding System (EmFACS)-assessing the action units and microexpressions-and the Psychodynamic Intervention List (PIL). Also, the Working Alliance Inventory (WAI), assessed after each session by both patients and clinicians, provided information on the subjective quality of the clinician-patient relationship.

RESULTS

We found that interpretative/confrontative interventions are associated with displays of contempt from both therapists and patients. Interestingly, displays of contempt also correlated with higher WAI scores. We propose that these seemingly contradictory results may be a consequence of the complexity of affects and the interplay of primary and secondary emotions with intervention type.

CONCLUSION

Interpretation, confrontation, and working through contemptuous microexpressions are major elements to the adequate control major pathoplastic elements. Affect-cognitive interplay is an important mediator in the working alliance.

A bottom-up approach to assess verbal therapeutic techniques. Development of the Psychodynamic Interventions List (PIL)

OBJECTIVE

Knowing which specific verbal techniques "good" therapists use in their daily work is important for training and evaluation purposes. In order to systematize what is being practiced in the field, our aim was to empirically identify verbal techniques applied in psychodynamic sessions and to differentiate them according to their basic semantic features using a bottom-up, qualitative approach.

METHOD

Mixed-Method-Design: In a comprehensive qualitative study, types of techniques were identified at the level of utterances based on transcribed psychodynamic therapy sessions using Qualitative Content Analysis (4211 utterances). The definitions of the identified categories were successively refined and modified until saturation was achieved. In a subsequent quantitative study, inter-rater reliability was assessed both at the level of utterances (n = 8717) and at the session level (n = 38). The convergent validity of the categories was investigated by analyzing associations with the Interpretive and Supportive Technique Scale (ISTS).

RESULTS

The inductive approach resulted in a classification system with 37 categories (Psychodynamic Interventions List, PIL). According to their semantic content, the categories can be allocated to three dimensions: form (24 categories), thematic content (9) and temporal focus (4). Most categories showed good or excellent inter-rater reliability and expected associations with the ISTS were predominantly confirmed. The rare use of the residual category "Other" suggests that the identified categories might comprehensively describe the breadth of applied techniques.

CONCLUSIONS

The atheoretical orientation and the clear focus on overt linguistic features should enable the PIL to be used without intensive training or prior theoretical knowledge. The PIL can be used to investigate the links between verbal techniques derived from practice and micro-outcomes (at the session level) as well as the overall therapeutic outcomes. This approach might enable us to determine to what extent the outcome of therapy is due to unintended or non-theoretically relevant techniques.

Measuring Verbal Psychotherapeutic Techniques-A Systematic Review of Intervention Characteristics and Measures

Language is one of the most important “tools” of psychotherapists. The working mechanisms of verbal therapeutic techniques, however, are still marginally understood. In part, this is due to the lack of a generally acknowledged typology as well as a gold standard for the assessment of verbal techniques, which limits the possibility of conducting studies focusing this topic. The present study reviews measures used in clinical research which assess directly observable dimensions of verbal interventions in a reliable manner. All measures were evaluated with respect to their theoretical foundation, research goals, assessment modes, and various psychometric properties. A systematic search in databases (PubMed, PsycInfo, PsycArticles, PSYNDEX, Web of Science, Embase) followed by an additional “snowballing” search covering the years 1940–2013 yielded n = 179 publications eligible for review. Within these publications, 34 measures were identified showing great heterogeneity regarding the aspects under study. Only two measures reached the highest psychometric standards and can be recommended for clinical use without any reservation. Central problems include deficiencies in the systematization of techniques as well as their partly ambiguous and inconsistent definitions. To promote this field of research, it will be important to achieve a consensus concerning the terminology, conceptions and measures of verbal interventions.