Convergence in patient and therapist alliance ratings early in treatment with Personality Assessment Inventory clinical scales and subscales

We examined discrepancies in 81 patient-therapist dyads' alliance ratings early in treatment (3rd or 4th session) in relation to Personality Assessment Inventory clinical scales, subscales and global psychopathology. Results indicated that PAI global psychopathology (mean clinical elevation) and the scales of Aggression [AGG], Somatization [SOM], and Anxiety-Related Disorders [ARD] were significantly, negatively associated with an absolute difference of patient and therapist alliance ratings at Session 3. Higher initial scores on these clinical scales at treatment onset are associated with less difference (i.e., more convergence) in patient/ therapist ratings of alliance at Session 3. Correlations between PAI clinical subscales and absolute differences of patient and therapist alliance ratings at Session 3 also demonstrated statistically significant inverse relationships for several PAI subscales of Aggression- Attitude [AGG-A], Aggression-Physical [AGG-P], Somatic- Health Concerns [SOM-H], Anxiety-Related Disorders-Traumatic Stress [ARD-T], Anxiety-Related Disorders- Obsessive Compulsive [ARD-O], Borderline Features-Affective Instability [BOR-A], Borderline- Self-Harm [BOR-S], Anxiety-Physiological [ANX-P], Depression-Physiological [DEP-P] and Antisocial-Stimulus Seeking [ANT-S]. Again, higher scores on these subscales at treatment onset are associated with less difference (i.e., more convergence) in patient/therapist ratings. We also examined group differences between patients rating alliance higher (Group 1) and therapists rating alliance higher (Group 2) and found that Group 1 had significantly lower scores on Mania-Activity Level [MAN-A]. Clinical implications of results are discussed.

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.

Personality assessment inventory items in relation to patient- and therapist-rated alliance

Based on the results of prior research, we examined relationships between Personality Assessment Inventory (PAI) items on clinical scales of antisocial features (ANT) and anxiety-related disorders (ARD) with patient- and therapist-rated alliance early in treatment (third or fourth session). We also explored the relationship between the PAI treatment rejection scale (RXR) and early session therapist-rated alliance, despite null findings in previous work. We used PAI protocols from a clinical outpatient sample (N = 80). Data were analysed using backwards linear regressions. Results indicated that a group of ANT items from different ANT subscales predicted patient-rated therapeutic alliance, F(8,59) = 5.182, p = .000, R² of .413, f²  = 0.70. Additionally, a group of ARD items from different ARD subscales significantly predicted therapist-rated alliance, F(6,62) = 3.007, p = .012, R² of .225, f²  = 0.29. No significant relationships were found for RXR items and therapist-rated alliance, consistent with prior findings. Clinical implications 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.

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.

Personality Assessment Inventory Clinical Scales in Relation to Patient and Therapist Rated Alliance Early in Treatment

We examined relationships between the Personality Assessment Inventory (PAI) clinical scales (e.g., Somatic Complaints [SOM]) and subscales (e.g., Conversion [SOM-C]) with patient- and therapist-rated alliance early in treatment (third or fourth session). We also replicated and extended findings from a previous study examining PAI treatment scales (Treatment Rejection, Treatment Process Index) and early session therapist-rated alliance. We used PAI protocols from a clinical outpatient sample (N = 84). Data were analyzed using stepwise linear regressions. Results suggest that patients who report lower early session alliance also report more antisocial features (β = -.219, p = .050, f² = 0.05) specifically more antisocial behaviors (β = -.315, p = .004, f² = 0.11). Additionally, therapists report higher early session alliance with patients who report more anxiety-related disorders (β = .274, p = .012, f² = 0.08), specifically traumatic stress (β = .325, p = .003, f² = 0.12). No significant relationships were found between patient- or therapist-rated alliance and Treatment Rejection and Treatment Process Index, consistent with prior findings. Clinical implications are discussed.

Therapist Evaluation of Client Adaptive Interpersonal Vulnerability: Relationship to Attachment Style

The clinician-rated Adaptive Interpersonal Vulnerability Scale (AIVS) was developed from items of the Shedler-Westen Assessment Procedure (SWAP; Westen & Shelder, 2007; Westen, Waller, Shedler, & Blagov, 2014). Convergent validity of the AIVS was examined with self-report attachment style measures: Relationship Questionnaire (RQ; Bartholomew & Horowitz, 1991) and Experiences in Close Relationships Questionnaire-Revised (ECR-R; Fraley, Waller, & Brennan, 2000). Fifty-nine patients completed the RQ and ECR-R before beginning psychotherapy. Clinicians rated patients on the SWAP after six sessions. The AIVS was negatively related to the RQ Fearful/Avoidance scale, the ECR-R attachment anxiety scale, and the ECR-R attachment avoidance scale and positively related to the RQ Secure Attachment scale, although not significant. Findings provide initial supposrt for the AIVS as a therapist-rated measure associated with lower client-reported levels of the fearful/avoidant attachment prototype, attachment anxiety, and attachment avoidance. Implications and suggestions for future research on the AIVS and clinical work 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.

In pursuit of truth: A critical examination of meta-analyses of cognitive behavior therapy

OBJECTIVE

Three recent meta-analyses have made the claim, albeit with some caveats, that cognitive-behavioral treatments (CBT) are superior to other psychotherapies, in general or for specific disorders (e.g., social phobia).

METHOD

The purpose of the present article was to examine four issues in meta-analysis that mitigate claims of CBT superiority: (a) effect size, power, and statistical significance, (b) focusing on disorder-specific symptom measures and ignoring other important indicators of psychological functioning, (c) problems inherent in classifying treatments provided in primary studies into classes of treatments, and (d) the inclusion of problematic trials, which biases the results, and the exclusion of trials that fail to find differences among treatments.

RESULTS

When these issues are examined, the effects demonstrating the superiority of CBT are small, nonsignificant for the most part, limited to targeted symptoms, or are due to flawed primary studies.

CONCLUSION

Meta-analytic evidence for the superiority of CBT in the three meta-analysis are nonexistent or weak.

Adherence, flexibility, and outcome in psychodynamic treatment of depression

This study examined the relationship between adherence flexibility early in treatment and outcome within psychodynamic psychotherapy of depression. For this purpose, we used multilevel modeling (MLM) to examine the relationship between adherence to global psychodynamic-interpersonal (PI) technique early in treatment with outcome, the impact of flexibly incorporating some limited cognitive-behavioral (CB) interventions, as well the role of therapist effects. Our sample included 46 outpatients who were consecutively enrolled in individual psychodynamic psychotherapy, received a Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association [APA], 1994) Axis I diagnosis of a depressive spectrum disorder, and were assessed pre- and posttreatment through self-report of depressive symptoms. Psychotherapy sessions were videotaped and 3rd and 9th sessions were independently rated on the Comparative Psychotherapy Process Scale (CPPS) for use of PI and CB techniques, with excellent interrater reliability (intraclass correlation coefficient [ICC] > .75). Mean technique ratings across the two early treatment sessions (3rd and 9th) were calculated. Our findings suggest that flexibly incorporating a limited amount of CB strategies early in psychodynamic therapy for depression can add some benefit to the unique positive relationship between PI adherence and outcome. Implications for clinical work and future research directions are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

"Gold Standards," Plurality and Monocultures: The Need for Diversity in Psychotherapy

For psychotherapy of mental disorders, presently several approaches are available, such as interpersonal, humanistic, systemic, psychodynamic or cognitive behavior therapy (CBT). Pointing to the available evidence, proponents of CBT claim that CBT is the gold standard. Some authors even argue for an integrated CBT-based form of psychotherapy as the only form of psychotherapy. CBT undoubtedly has its strengths and CBT researchers have to be credited for developing and testing treatments for many mental disorders. A critical review, however, shows that the available evidence for the theoretical foundations of CBT, assumed mechanisms of change, quality of studies, and efficacy is not as robust as some researchers claim. Most important, there is no consistent evidence that CBT is more efficacious than other evidence-based approaches. These findings do not justify regarding CBT as the gold standard psychotherapy. They even provide less justification for the idea that the future of psychotherapy lies in one integrated CBT-based form of psychotherapy as the only type of psychotherapy. For the different psychotherapeutic approaches a growing body of evidence is available. These approaches have their strengths because of differences in their respective focus on interpersonal relationships, affects, cognitions, systemic perspectives, experiential, or unconscious processes. Different approaches may be suitable to different patients and therapists. As generally assumed, progress in research results from openness to new ideas and learning from diverse perspectives. Thus, different forms of evidence-based psychotherapy are required. Plurality is the future of psychotherapy, not a uniform "one fits all" approach.

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.

Is therapist evaluation of Social Anxiety/Avoidance traits associated with patient-reported attachment style?

The Social Anxiety/Avoidance Scale was recently added to the Shedler Westen Assessment Procedure (SWAP), and requires independent validation. This study used data drawn from a larger ongoing project in order to retrospectively examine its convergent validity with two self-report attachment measures: Relationship Questionnaire (RQ) and Experiences in Close Relationships Questionnaire-Revised (ECR-R). Fifty-two patients completed the RQ and the ECR-R before beginning psychotherapy treatment. Clinicians rated the patients on the SWAP after six sessions. The SWAP Social Anxiety/Avoidance Scale (SWAP-SAAS) was negatively related to the RQ secure attachment prototype scale and positively related to the ECR-R attachment anxiety scale. Our findings provide initial support for the use of the SWAP-SAAS as a therapist-rated measure associated with lower patient-reported levels of fit with a secure attachment prototype and with higher patient-reported levels of attachment anxiety. Implications and suggestions for future research on the SWAP-SAAS, as well as for clinical work with socially anxious and avoidant patients, are discussed.

An introduction to the special issue on psychotherapy termination

This introduction to the special issue on psychotherapy termination begins by noting the almost complete lack of research and clinical discussion on this topic in the literature. It is with a desire to effect some sort of change to this current state of affairs that Psychotherapy invited manuscripts for this special issue. Specifically, the editors sought contributions on both the clinical practice and research aspects of the psychotherapy termination process from a variety of different theoretical orientations, perspectives, and methodologies. This special issue will include two sections, clinical practice and research, each serving to help better define the nature and extent of this important, but often ignored aspect of psychotherapy. (PsycINFO Database Record

Perfectionism and Therapeutic Alliance: A Review of the Clinical Research

In this review, we synthesize findings regarding the relationship between perfectionism and therapeutic alliance, most of which come from analyses by Blatt and colleagues. Results suggest what follows. First, patients’ initial level of perfectionism negatively affects patients’ bond with therapists and perception of therapists’ Rogerian attributes (empathy, congruence, and regard) early in treatment and engagement in therapy later in treatment. Second, therapists’ contribution to alliance is not seemingly affected by patients’ initial perfectionism level. Third, individual patients of therapists who are perceived on average by their patients to be higher on Rogerian attributes experience greater decreases in perfectionism and symptoms. Fourth, more positive perceptions of therapists’ Rogerian attributes early in treatment lead to greater symptom decrease for patients with moderate perfectionism. Fifth, greater early patient engagement in therapy is related to greater decrease in perfectionism, but a strong relationship with the therapist may be necessary for an accompanied greater decrease in symptoms. The relationship between pre-treatment perfectionism and alliance is partially explained by higher levels of hostility and lower levels of positive affect. Sixth, the relationship between pre-treatment perfectionism and outcome is almost entirely explained by level of patient contribution to alliance and satisfaction with social network, highlighting the importance of focusing on social functioning for patients with high perfectionism (both in and outside of the session). Limitations include that most of the findings are from analyses of one large data set and a range of measurement issues. Future research should utilize different measures, perspectives, and populations and examine specific session process.

Biases in research: risk factors for non-replicability in psychotherapy and pharmacotherapy research

Replicability of findings is an essential prerequisite of research. For both basic and clinical research, however, low replicability of findings has recently been reported. Replicability may be affected by research biases not sufficiently controlled for by the existing research standards. Several biases such as researcher allegiance or selective reporting are well-known for affecting results. For psychotherapy and pharmacotherapy research, specific additional biases may affect outcome (e.g. therapist allegiance, therapist effects or impairments in treatment implementation). For meta-analyses further specific biases are relevant. In psychotherapy and pharmacotherapy research these biases have not yet been systematically discussed in the context of replicability. Using a list of 13 biases as a starting point, we discuss each bias's impact on replicability. We illustrate each bias by selective findings of recent research, showing that (1) several biases are not yet sufficiently controlled for by the presently applied research standards, (2) these biases have a pernicious effect on replicability of findings. For the sake of research credibility, it is critical to avoid these biases in future research. To control for biases and to improve replicability, we propose to systematically implement several measures in psychotherapy and pharmacotherapy research, such as adversarial collaboration (inviting academic rivals to collaborate), reviewing study design prior to knowing the results, triple-blind data analysis (including subjects, investigators and data managers/statisticians), data analysis by other research teams (crowdsourcing), and, last not least, updating reporting standards such as CONSORT or the Template for Intervention Description and Replication (TIDieR).

Patient and Therapist Perspectives During the Psychotherapy Termination Process: The Role of Participation and Exploration

OBJECTIVE

This study was the first to examine psychotherapy termination from both therapists' and patients' perspectives by using standardized psychotherapy process measures. Our aim was to examine whether patient participation and therapist exploration during the termination phase of treatment are related to how good and productive the session was.

METHOD

The sample consisted of 30 outpatient adults who had completed the Vanderbilt Psychotherapy Process Scale-Short form (VPPS-S; Smith, Hilsenroth, Baity, & Knowles, 2003) and the Session Evaluation Questionnaire (SEQ; Stiles, 1980) during a termination-phase session. These ratings were examined from mutually agreed upon terminations with largely successful outcomes.

RESULTS

Higher ratings of patient participation, as rated by both the therapist and patient, were significantly related to patient ratings of how good and productive the session was. Mixed findings were shown for therapist exploration.

CONCLUSIONS

We provide clinical examples and suggestions for future research to illuminate process elements of psychotherapy termination.

Use of the MMPI-2 Personality Disorder Scales in the Assessment of DSM-IV Antisocial, Borderline, and Narcissistic Personality Disorders

This study explored the diagnostic utility of the MMPI-2 Personality Disorder (MMPI-2 PD) scales to correctly classify three Cluster B Personality Disorders (Antisocial, Borderline, and Narcissistic Personality Disorder). Classification was compared against the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) chart diagnoses checked for interrater agreement. MMPI-2 PD scale scores for 53 outpatients diagnosed with a Cluster B Personality Disorder were contrasted with an Other Personality Disorder group ( n = 20) and a nonclinical population ( n = 67). Scores for both the overlapping and nonoverlapping scales of the MMPI-2 PD scales were used in calculating diagnostic efficiency statistics. In support of past findings, results suggest the MMPI-2 PD scales should be used conservatively; they are best at screening for presence or absence of a personality disorder, identifying members of personality disorder clusters, and identifying negative occurrences of specific personality disorders or personality disorder clusters. Findings endorse the use of both versions of the Antisocial Personality Disorder scale and the overlapping version of the Borderline Personality Disorder scale. Use of the Narcissistic Personality Disorder scales is recommended for negative predictive power values only. A multimodal approach is recommended, whereby assessment measures may be used conjointly to improve diagnostic efficiency.

A Review of Interpersonal-Psychodynamic Group Psychotherapy Outcomes for Adult Survivors of Childhood Sexual Abuse

This article discusses the use of interpersonal-psychodynamic group treatments for survivors of childhood sexual abuse. Empirically based interpersonal-psychodynamic group outcome studies are reviewed according to efficacy and effectiveness models of treatment outcome research. To facilitate the evaluation and comparison of clinically significant change across studies, effect size indicators were calculated when descriptive data were reported. Findings suggest that interpersonal-psychodynamic group therapy is an effective treatment approach for many survivors of childhood sexual abuse. Implications for future research are considered.

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.

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.

Process and technique factors associated with patient ratings of session safety during psychodynamic psychotherapy

This study investigates the relationships between patient ratings of in-session safety with psychotherapeutic techniques and process. Ninety-four participants received Short-Term Dynamic Psychotherapy (STDP) at a university-based clinic. Patient experiences of therapeutic process were self-assessed early in treatment using the Session Evaluation Questionnaire (SEQ Stiles, 1980). Techniques implemented in session were identified using the Comparative Psychotherapy Process Scale (CPPS: Hilsenroth et al., 2005). Alliance was evaluated with the Combined Alliance Short Form-Patient Version (CASF-P; Hatcher and Barends, 1996). Safety significantly correlated with session depth, smoothness, and positivity. Safety was significantly related to the interaction of psychodynamic-interpersonal and cognitive-behavioral techniques, but to neither individual subscale Safety significantly correlated with CASF-P Total, Confident Collaboration, and Bond. Patient experiences of safety are consistent with exploration and depth of session content. Integration of some CB techniques within a psychodynamic model may facilitate a sense of safety. Safety is notably intertwined with the therapeutic relationship.

Introduction to the 50th anniversary special issue on psychotherapy outcome: a return to the beginning

Then and now, Psychotherapy is a home to those interested in expanding the research base of how and why psychotherapy is effective. In preparing to celebrate the 50th anniversary of our journal, we on the editorial board and Division 29 thought nothing could pay better homage to these issues than to reprint the seminal articles by Strupp and Eysenck on psychotherapy outcome from Volume 1. These reprinted articles will then be followed by papers from several of today's most prominent authors in psychotherapy process and outcome research who address the progress on these issues now, 50 years later, as well as provide important suggestions for how the field can move forward in future work. Again, this will be the first of several initiatives to celebrate this very special golden anniversary year!

Risk factors for medically serious suicide attempts: evidence for a psychodynamic formulation of suicidal crisis

This study explored a psychodynamic model for suicide risk by examining risk factors for medically serious suicide attempts, including assessments of affect flooding, negative self-schema / fragmentation, and impaired reality testing, closely approximating Maltsberger's psycho-dynamic formulation of suicide crisis. Baseline risk factors including age, gender, psychiatric symptoms, high-risk behaviors, and the Implicit Risk for Suicide Index (IRSI) were used to detect medically serious suicide attempts monitored for up to a year after the assessment. Twenty-five psychiatric inpatients who made life-threatening suicide attempts after assessment were compared to 25 inpatients and 25 psychotherapy outpatients who made no suicide attempts during follow-up. Statistical analysis revealed that a history of at least one suicide attempt and elevated IRSI scores accounted for 60 percent of the variance in detecting medically serious suicide attempts. Elevated IRSI accurately identified suicide attempt status above and beyond past suicide attempts and other empirically validated risk factors. Results are discussed in light of psychodynamic formulations of suicide risk.

Will patients accept randomization to psychoanalysis? A feasibility study

The feasibility of using a randomized design in a psychoanalytic outcome study was evaluated. Our hypothesis was that it would be feasible to randomize patients to psychoanalysis three or four times weekly on the couch for five years, supportive expressive therapy once or twice weekly for up to forty sessions, and cognitive behavior therapy once or twice weekly for up to forty sessions. Successful randomization was defined as a 30% recruitment rate among eligible patients. Recruitment began in September 2009 and closed in April 2010. A total of 132 subjects responded to study advertisements, 107 of whom (81%) were triaged out. The remaining 25 were scheduled for the first of two clinical interviews, and 21 of 25 (88%) completed the interview. Eleven of the 25 (44%) were determined to be eligible based on inclusion and exclusion criteria. Eight of the 11 accepted the idea of randomization and completed the diagnostic assessment phase. Calculated on the basis of 8 of 11 eligible patients accepting randomization, the 95% confidence interval was that 39% to 92% of eligible subjects would participate in a larger study of this design. Our findings support the feasibility of implementing an RCT comparing psychoanalysis as defined by the American Psychoanalytic Association (three or four times weekly on the couch for approximately five years) with shorter-term dynamic or cognitive behavioral therapy once or twice a week. Pre-treatment characteristics of these eight patients are presented, as are initial reliability data for the treatment adherence scales used in this trial.