Workshop 1 Title: Using Code-a-text to Analyse Psychotherapy Texts Authors



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Participants: Stephen Beck, Rachel LeFebvre, Martin Drapeau
Moderator: Christopher Perry
Address for Correspondence:
The Erikson Institute of the Austen Riggs Center

(& Harvard Medical School)

25 Main St.

Stockbridge, Massachusetts 01262-0962 (U.S.A.)

[& Institute of Community & Family Psychiatry, McGill University,

Montreal Quebec, Canada)


ABSTRACT
While case formulations are useful for guiding the therapist in focusing treatment, quantitative assessments are necessary for most research purposes. This panel examines three instruments designed for dynamic formulation that also yield quantitative ratings. These include a measure of defenses, the Defense Mechanism Rating Scales (DMRS), and two measures of dynamic patterns: the Core Conflictual Relationship Theme (CCRT) and the Wish and Fear List. As quantitative measures, they can address fundamental questions about psychopathology and treatment response.
In 1992, the Austen Riggs Center, a residential psychodynamically oriented facility for treatment-resistant patients, began a naturalistic follow-along study of adults entering treatment. This panel examines the first 25 to 35 subjects who have completed three to four years of follow-along after beginning treatment there. Treatments varied from one to 24 months, although most subjects continued some form of treatment after discharge. After entry, all subjects received repeated assessments every 6 to 12 months, including dynamic interviews, Relationship Anecdote Paradigm (RAP) interviews, and separate interviews to assess symptoms and functioning.
The presenters will compare the dynamic measures in three contexts. The first will compare the three assessments both to one another and to other measures of psychopathology. The second will examine change in each measure over the course of treatment. The third will compare dynamic change on the three methods with change in other measures of symptoms and functioning. This naturalistic data should help us understand the dynamic and descriptive changes that treatment-resistant adults make, and how the different measures capture this.

Paper in Panel - Panel Session 10
Title: Defenses, The CCRT, and Wishes & Fears: A Baseline Comparison to Psychopathology and Functioning Among Treatment-Resistant Adults in the Austen Riggs Follow-Along Study
Authors: Stephen Beck, J. Christopher Perry, Rachel LeFebvre, Martin Drapeau, Ann Greif, Eric Plakun, Barbara Zheutlin, and Lueen Lapitsky
Address for Correspondence:
The Erikson Institute of the Austen Riggs Center

25 Main St.

Stockbridge, Massachusetts 01262-0962 (U.S.A.)

[& Institute of Community & Family Psychiatry, McGill University, Montreal Quebec, Canada)


ABSTRACT
Dynamic therapies focus on dynamic mechanisms as an avenue to producing improvement in symptoms and functioning. Understanding how dynamic measures compare with one another is an important methodological need, while elucidating their relationship to psychopathology is a fundamental need. This presentation will examine both of these on a sample of individuals with treatment-resistant disorders referred to an intensive dynamically-oriented residential treatment facility.

Participating subjects were given independent diagnostic interviews (Guided Clinical Interview), dynamic interviews, and Relationship Anecdote Paradigm (RAP) interviews upon entry into the study. The latter two interviews were then scored for Defenses (DMRS), the CCRT, and Wishes & Fears. Each measure has several unique quantitative scores which we compared. The DMRS measures 28 individual defenses, 7 hierarchically arranged defense levels, and Overall Defensive Functioning (ODF), a weighted average of all the defenses identified. The CCRT, scored quantitatively, can assess Wishes, Response of the Other (RO) and Response of Self (RS) in each of 8 clusters, as well as the proportion of negative RO and RS components. The Wish and Fear list assesses 40 Wishes and 40 Fears hierarchically arranged by Erikson's 8 developmental stages. This allows quantitative assessment of individual motives, of the proportion in any stage, or an overall mean stage for Wishes or Fears. It also reports the percentage of Wishes that are Disappointed or of Fears that are Unrealized.

The inter-correlations of the above dynamic measures will be presented. Correlations will also be presented between these and descriptive measures, including number of lifetime Axis I disorders, Axis II disorders, GAF (current and usual), SCL-90-R, and any specific disorders of high prevalence in the sample (e.g. Borderline PD). Regression analyses will help determine whether the individual dynamic methods each predict unique variance in the psychopathology and functioning or whether they are redundant.
Paper in Panel - Panel Session 10
Title: Changes in Defenses, CCRT and Wishes and Fears After 3 to 4 years Among Treatment-Resistant Adults in the Austen Riggs Follow-Along Study
Authors: Rachel LeFebvre, J. Christopher Perry, Stephen Beck, Martin Drapeau, Valerie Lepine, Marta Valenzuela, Judy Kolmeir, Suzanne Marcote
Address for Correspondence:
The Erikson Institute of the Austen Riggs Center

25 Main St.

Stockbridge, Massachusetts 01262-0962 (U.S.A.)

[& Institute of Community & Family Psychiatry, McGill University, Montreal Quebec, Canada)


ABSTRACT
Psychodynamic treatments aim at improving the individual's psychodynamic functioning. It is therefore important to assess the amount and course of change over treatment using psychodynamic measures. Futhermore, campring changes on one measure with another may elucidate those aspects of dynamic change that are more or less resistant to change. Finally, if the measures have a built in developmental framework, or some cut-off points for healthy functioning, it may be possible to estimate at any point in treatment how far the subject has progressed toward healthy dynamic functioning, or how much farther he or she has to improve. Those are the aims of this presentation.
Participating subjects from the Austen Riggs Follow-along Study were re-interviewed every 6-12 months after entry for up to four years. This presentation will focus on ratings made from dynamic interviews and Relationship Anecdote Paradigm (RAP) interviews. Each RAP interview was scored for the CCRT (quantitative methods), while both the RAP and dynamic interviews were scored for defenses (DMRS) and motives (Wish & Fear List). All ratings were done independently and blindly to one another. We examined change on each of the quantitative scores for each method. For defenses we examined improvement in Overall Defensive Functioning (ODF), as well as decreases in the lowest defense levels (action, major image-distorting, disavowal and minor image-distorting), and increase in the high adaptive (mature) level defenses. For the CCRT we examined the proportion of Wishes in each of the 8 clusters as well as decreases in the proportion of negative RO and RS components. For motives, we examined improvement in the mean Eriksonian stages of Wishes and Fears, as well as decreases in the lowest stages (I and II), and changes in the proportion of Disappointed Wishes and Unrealized Fears. These measures were then correlated and compared as to overall effect size.

Paper in Panel - Panel Session 10
Title: How Do Changes in Dynamic and Descriptive Measures Compare After 3 - 4 Years Among Treatment-Resistant Adults in the Austen Riggs Follow-Along Study?
Authors: Martin Drapeau, J. Christopher Perry, Rachel Lefebvre, Stephen Beck, Barbara Zheutlin, and Leueen Lapitsky
Address for Correspondence:
The Erikson Institute of the Austen Riggs Center

(& Harvard Medical School)

25 Main St.

Stockbridge, Massachusetts 01262-0962 (U.S.A.)

& Institute of Community & Family Psychiatry, McGill University,

Montreal Quebec, Canada)


ABSTRACT
Improvement in psychodynamic functioning should be associated with improvement in other measures of descriptive psychopathology and functioning. Examining the pattern and magnitude of the changes may reveal whether dynamic and descriptive measures change in unrelated or related ways. This presentation examines improvement in a sub-sample of 25-35 adults from the Austen Riggs Follow-along Study who were followed for up to four years. We will correlate the changes (within-condition effect sizes) for the quantitative measures of defenses, the CCRT, and Wishes & Fears along with descriptive measures including GAF, SCL-90-R, and proportion of time ill with Axis I disorders.
The developmental framework for ordering motives has the heuristic possibility of guiding the clinician to focus on issues at the appropriate developmental stage and helping track dynamic progress. Therapy appears to help individuals move to developmentally higher fears prior to improving the developmental level of Wishes that concern them.
Panel Session 11 - Overall Summary
Title: The Development and Implementation of a Continuous Quality Management Program into Clinical Practice
Participants: David Smart, Arthur E. Finch, Michael J. Lambert, David A. Vermeersch
Moderator: Michael J. Lambert
Discussant: Hans Kordy
Address for Correspondence:
Michael J. Lambert

Department of Psychology,

Brigham Young University

284 TLRB


Provo, Utah 84602, USA
ABSTRACT
The proposed panel summarizes four years of research aimed at monitoring and improving the clinical services in a university counseling center. The first presentation focuses on the development, logistics, and politics of implementing a quality control program into clinical practice, introducing the salient issues that must be addressed by administrators when monitoring service and how these issues were handled in our program. The second presentation summarizes the first three years of research and the use of these results to develop decision rules for quality management to improve clinical services. The third presentation describes the results from a controlled experiment utilizing the previously developed decision rules with an experimental group providing feedback to therapists about the progress of their clients. The outcome of the clients in the experimental group was compared with the outcome of clients in a control group whose therapists were not provided with feedback. Finally, the fourth presentation gives an overview of the reactions of clinicians involved in the quality management program. Particularly, this presentation focuses on how therapists utilize the information that was received through quality management feedback, and how this impacted clinical practice and client outcome. Hans Kordy, an internationally recognized expert on Quality Management, will be offering critical commentary on the proposed panel.


Paper in Panel - Panel Session 11
Title: Strategies for Implementing and Administrating a Quality Management Program in Clinical Practice
Authors: David Smart and Stevan L. Neilsen
Address for Correspondence:
Michael J. Lambert

Department of Psychology,

Brigham Young University

284 TLRB


Provo, Utah 84602, USA
ABSTRACT
This presentation aims at outlining essential features that need to be addressed in designing and implementing a quality control program into clinical practice. From an administrative perspective, there are many issues and competing needs that have to be weighed and balanced to successfully impact treatment delivery without affecting the morale of the clinic. The needs of therapists, staff, and clients, as well as possible third party payers, must be balanced along with issues of cost, time, and material resources. There are several key elements that will be covered in this presentation, including: (1) defining outcome and selecting measurement tools;

(2) addressing therapists’ fear of being monitored; (3) evaluating the quality of service and looking for areas for improvement; (4) maintaining therapist confidentiality; (5) identifying what equipment and staff are required; (6) weighing costs and benefits; (7) gaining and maintaining staff support; (8) providing feedback to therapists; and (9) providing opportunities for scholarly contributions. As each of these issues is addressed, the solution utilized in our program will be discussed, as well as the successes and failures we have experienced in implementing these strategies.



Paper in Panel - Panel Session 11
Title: Developing Decision Rules for Monitoring Outcome and Informing Clinical Practice
Authors: Arthur E. Finch and Michael J. Lambert
Address for Correspondence:
Michael J. Lambert

Department of Psychology,

Brigham Young University

284 TLRB


Provo, Utah 84602, USA
ABSTRACT
This presentation comes as a response to the need for research to be integrated into feedback delivery systems for therapists regarding the progress of individual clients in psychotherapy. There is little question that patient outcomes need to be measured and evaluated to assure the quality of treatment that is provided. In order to inform therapists about client progress, two goals need to be met: (1) clients need to be grouped into meaningful categories that are predictive of outcome (prior to and early in treatment) and (2) normative recovery curves need to be established for these categories. Outcome data from three years of clinical work at a university counseling center from 1654 subjects who have completed repeated administrations of the Outcome Questionnaire (OQ) were analyzed using cluster analysis to form meaningful client groupings. These groups were then subjected to a Hierarchical Linear Modeling analysis to identify differential growth curves. The results were then used to create tables of expected recovery rates for the various client groupings. This provided the foundation for the development of parameters for an early warning system to identify clients who are not benefitting from psychotherapy as expected. The merits of this type of therapy monitoring for informing clinical practice will be discussed.

Paper in Panel - Panel Session 11
Title: The Implementation of a Quality Management System into Clinical Practice: A Controlled Experiment
Authors: Michael J. Lambert, David A. Vermeersch, and Nathan B. Hansen
Address for Correspondence:
Michael J. Lambert

Department of Psychology,

Brigham Young University

284 TLRB


Provo, Utah 84602, USA
ABSTRACT
This study examines the effects of providing clinicians with psychotherapy outcome data at specified times throughout the course of treatment. Six hundred individuals who received treatment at a college counseling center and who completed the Outcome Questionnaire (OQ) (a widely used instrument designed to track patient progress throughout the course of treatment) prior to each therapy session were included in the study. Expected levels of patient progress were determined by prior research which utilized the OQ to establish normative rates of change for counseling center patients. Prior to receiving services, patients were randomized to either the “feedback” (experimental) or the “non-feedback” (control) group. Therapists of patients in the experimental group were provided feedback regarding patient progress following sessions 3, 5, and 9, whereas therapists of patients in the control group received no feedback regarding patient progress. Therapists receiving feedback were given one of four messages based on the client’s initial OQ score and the OQ score change from intake. Each of the four messages were designed to: (1) inform therapists regarding a specific patient’s progress relative to expected change at that point in time; and (2) provide therapists with suggestions for altering their treatment plan. Results were analyzed through the use of Hierarchical Linear Modeling to see if the provision of feedback enhanced outcomes for patients who were expected to have a poor outcome. Implications of the current study and suggestions for further research designed to improve the quality of clinical services through the utilization of psychotherapy outcome data are discussed.

Paper in Panel - Panel Session 11
Title: Quality Management and Outcome Monitoring: The Therapist's Perspective
Authors: David A. Vermeersch and Nathan B. Hansen
Address for Correspondence:
Michael J. Lambert

Department of Psychology,

Brigham Young University

284 TLRB


Provo, Utah 84602, USA
ABSTRACT
This presentation focuses on the experience of therapists who participated in a continuous quality management study that included providing feedback to clinicians on client progress in treatment. A structured interview format was used to address the following questions: (1) Did therapists use the feedback information; (2) How did therapists use the feedback information; (3) Did this result in treatment plan change; (4) Did changing the treatment plan impact client change; (5) Was there agreement between feedback information and therapist perception of client status and needs; (6) What are the overall perceptions of having and using feedback; (7) Compare treating clients with and without feedback; and (8) What would therapists change about the feedback system? Also, a sample of individual cases will be selected for discussion where feedback was found to be particularly helpful or unhelpful. It is felt that obtaining feedback from the individual treatment providers in the quality management program is an important aspect of continuous quality management. The implications of therapist reactions are discussed in relation to modifying both the process and product of the patient progress feedback system.


Panel Session 12 - Overall Summary
Title: Self-Criticism: Understanding and Tracking the Self-Critical Process
Participants: Heidi Levitt, Nele Stinckens, William J. Whelton
Moderator: Leslie Greenberg
Address for Correspondence:
William J. Whelton

Department of Psychology, York University

4700 Keele St.

Toronto, Ontario, Canada M3J-1P3

wwhelton@yorku.ca
ABSTRACT
Self-criticism has long been recognized as an important factor in psychological dysfunction, of particular significance in disorders such as depression and anxiety(Blatt and Zuroff, 1992).At least as far back as Freud it has been observed that in certain psychological states, such as morbid grief, some part of the self can turn on the self, mercilessly tormenting and berating it for its ostensible deficiencies. Self-criticism is both a cause and a consequence of pain and distress, becoming ever more severe as dysphoric mood worsens. It is also a feature of a number of dysfunctional interpersonal cycles, taking a toll on marriages and other significant relationships(Mongrain & Vettese, 1998).This panel proposes to address the theme of self-criticism. The papers explore the cognitive-affective roots of self-criticism and present research that describes a number of dimensions of the self-critical process as it is manifested experientially in a variety of situations. Each of the studies will, in different ways, attempt to describe and explain some of the psychological processes and characteristics which make up self-criticism. As well, the panel will look at the impact of self-criticism on the process of therapy and at therapeutic techniques for promoting change in self-criticism(Greenberg & Paivio, 1997).

Paper in Panel - Panel Session 12
Title: Clients’ Experiences of Silent Resistance: Re-framing Psychoanalytic and Object-Relations Theories
Author: Heidi Levitt
Address for Correspondence:
Heidi Levitt

Department of Psychology

University of Florida

114C Psychology Building

Gainesville, FL 3261

USA
ABSTRACT


This paper reviews the psychoanalytic and object relational perspectives on silences in psychotherapy in conjunction with clients’ reports of Disengaged Pauses within their therapy sessions. This type of pauses were identified in a qualitative analysis of clients’ descriptions of in-session pausing experiences gathered using interpersonal process recall interviews (e.g., Kagan, 1975). This study was informed by a method of analysis based on the grounded theory approach (Glaser & Strauss, 1967; Glaser, 1992) in which the Pausing Inventory Categorization System was formed (Levitt, 1998). Within the description of Disengaged Pauses, clients described processes of avoiding their emotion, of trying to recompose themselves after experiencing emotion, and of trying to redirect their therapist away from threatening issues. Techniques are suggested which can be useful in dealing with these moments in therapy, including the identification of Disengaged Pauses and the examination of self-critical and self-interruptive processes (e.g., Greenberg, Rice & Elliott, 1996).

Paper in Panel - Panel Session 12
Title: The Inner Critic in Client Centered/Experiential Psychotherapy: Empirical Illustration of a Micromodel
Author: Nele Stinckens
Address for Correspondence:
Nele Stinckens

Counseling Centrum

Blijde Inkomststraat 13

3000 Leuven

Belgium

E mail: Nele Stinckens@psy.kuleuven.ac.be


ABSTRACT
The term 'inner critic' describes the strong inner normative voice with which people block themselves. In experiential theory this voice is considered as a process disturbance that interferes with the organismic experiencing of the client. In the existing experiential literature, however, there has been little systematic research into the manner in which the inner critic appears

in the concrete therapy situation. An encompassing micromodel will be introduced in which diverse therapeutic and diagnostic insights are synthesized. With this model we illuminate the

intrapersonal and interpersonal characteristics of the inner critic, the repertoire of facilitating therapist interventions and the progress or possible stagnations of the therapy process. The micromodel will be illustrated with an 'in depth analysis' of an episode from a short term experiential therapy. By using a battery of qualitative and quantitative measuring instruments we show which process characteristics of the inner critic are manifested in this client, in what ways the therapist responds and what the impact is on the client process. Besides existing scales, like the SASB Introject, the Levels of Client Perceptual Processing and the Hill Counselor Verbal Response Category System, some new scales will be used to grasp the various process aspects. Finally, the limitations of our model will be indicated and suggestions and implications for future research and clinical application will be addressed.

Paper in Panel - Panel Session 12
Title: Affective Processes of Self-Contempt in the Self-Criticism of Persons Vulnerable to Depression
Authors: William J. Whelton and Leslie S. GreenbergAuthors William J. Whelton and Leslie S. Greenberg
Address for Correspondence:
William J. Whelton

Department of Psychology, York University

4700 Keele St.

Toronto, Ontario, Canada M3J-1P3

wwhelton@yorku.ca
ABSTRACT
The aim of this project was to understand the affective components of self-criticism in persons vulnerable to depression. The study involved either a one or two hour research session with each of 60 participants. All had been previously selected using the Depressive Experiences Questionnaire (Blatt, D., Afflitti, & Quinlan, 1976). Thirty were high self-critics, fifteen high dependents and fifteen controls. After a mood induction exercise each participant was videotaped naturalistically criticizing him or herself for five minutes and responding to this criticism for five minutes. The thirty high self-critics then received a one-hour analogue of therapy focussed on their self-criticism. Fifteen were randomly assigned to receive cognitive therapy focussed on their automatic thoughts and fifteen to receive two-chair therapy focussed on both cognition and affect in an experiential framework. Before and after the session the participants filled out measures of depression, mood, self-empathy, and state self-esteem.
Two independent coders coded the videotapes for verbal and non-verbal expressions of affect using a modified version of the Specific Affect Coding System(Gottman,1996). The thirty self-critics were compared with the thirty non self-critics for expressions of contempt toward the self and for assertion and confidence in their response to the critic. The effects of the two therapeutic modalities in mitigating self-criticism were compared. The discussion considers the importance of hostility and contempt for the self in the genesis of depressive mood and of self-resiliency as a buffer to these hostile affects. The place of these emotion schemes in the self-organizations of those self-critically vulnerable to depression will be considered.


Panel Session 13 - Overall Summary


Title: CCRTs in Clinical Studies
Participants: Nikolaus Freymann, Hermann Staats, Michael Stasch, Manfred Cierpka, Alexander Wilczek, Robert M. Weinryb, Jacques P. Barber, J. Petter
Gustavsson, Marie Åsberg, Hermann Staats, Claudia Hoevelmann, and Ulrich Seidler
Moderator: Hermann Staats
Discussant: Larry Beutler
Address for Correspondence:
Hermann Staats

Psychosomatics and Psychotherapy, University of Goettingen Nikolausberger Weg 17

D - 37073 Goettingen
Tel.: ++/551/394595,

Fax: ++/551/394596,

E-mail: hstaats@gwdg.de

ABSTRACT
The Core Conflictual Relationship Theme (CCRT) and the Relationship-Episode-Paradigm (RAP) Interview have become widely used tools for studying relational patterns, transference and transference dispositions in clinical and non clinical samples.
In this panel we report on clinical studies involving patients from different diagnostic groups and of different psychopathology and on a study on gender differences, adding a new aspect to the CCRT method, which may become useful for testing clinical hypotheses. Limitations of the method are dealt with, especially, if narratives are recorded outside a therapeutic relationship; and special opportunities opened up by this approach are considered.
The contributions show, that one of the key concepts of the CCRT method, the “pervasiveness” of a theme, is not simply a sign of psychopathology but - depending on the context of the study and the diagnosis of the patient - may also be considered as an indicator of interpersonal resources.


Paper in Panel - Panel Session 13
Title: Pervasiveness of the CCRT – Does it Have Different a Clinical Meaning for Different Diagnostic Groups?
Authors: Nikolaus Freymann, Hermann Staats, Michael Stasch, and Manfred Cierpka

Address for Correspondence:
Nikolaus Freymann

Psychosomatics and Psychotherapy, University of Goettingen Nikolausberger Weg 17


D - 37073 Goettingen
Tel..: ++/551/394595,

Fax: ++/551/394596,

E-mail: hstaats@gwdg.de
ABSTRACT
In this study we examined correlations between the pervasiveness of the CCRT and the severity of disturbance in a group of young female patients. Severity of disturbance was assessed with regard to symptoms (SCL-90-R) and the quality of interpersonal relationships (Global Assessment of Relational Functioning Scale GARF). RAP Interviews with 29 patients were evaluated.
For the sample as a whole we found little evidence for a correlation between pervasiveness of the CCRT and severity of disturbance. However, results in diagnostic subgroups - ICD 10: depressed patients (n=7) and patients with eating disorders (n=20) - were different:
In the depressed patients we found a positive correlation with the severity of disturbance both for symptoms and relationship functioning. Contrary to expectations we found an inverse correlation in the subsample of patients with eating disorders. Here, rigidity of transference disposition correlated with a low symptom index and better functioning in relationships.
Opposing effects found in two different diagnostic groups obscured the relation between the rigidity of transference disposition and the severity of disturbance. In patients with eating disorders and possibly in other diagnostic groups, pervasiveness of a CCRT may be an indicator of a functional capability.

Paper in Panel - Panel Session 13
Title: The Core Conflictual Relationship Theme (CCRT) and Psychopathology in Patients Selected for Dynamic Psychotherapy
Authors: Alexander Wilczek, Robert M. Weinryb, Jacques P. Barber, J. Petter Gustavsson, and Marie Åsberg
Address for Correspondence:
Alexander Wilczek, MD.,

Bastugatan 19

S-118 25 Stockholm

Sweden


Telephone: +46 8 6585305

Fax: +46 8 196508

E-mail: alexander.wilczek@pi.ki.se
ABSTRACT
The present study examined the relation between core interpersonal patterns measured by the Core Conflictual Relationship Theme (CCRT) method and psychopathology.
Psychopathology was assessed by the presence of diagnostic categories, the self-report of symptoms and the character pathology. Fifty-five patients selected for a long-term dynamic psychotherapy participated in this naturalistic study.
Patients with different general kinds of DSM-III-R diagnoses did not differ in their CCRTs abstracted from the Relationship Anecdote Paradigm interview. Furthermore the degree of inflexibility ('pervasiveness') in the use of different CCRT components was not associated with psychiatric symptoms. In regard to the relation between character pathology and CCRT, only very few correlation's were found significant. Namely, patients with impaired character organization and patients with an impaired capacity to form stable relationships had more negative responses. Limitations of the CCRT method and the sample used are discussed.

Paper in Panel - Panel Session 13
Title: Relationship Themes and the People Involved. Object Specific Relationship Patterns in RAP-Interviews with Men and Women
Authors: Hermann Staats, Claudia Hoevelmann, Ulrich Seidler

Address for Correspondence:
Hermann Staats

Psychosomatics and Psychotherapy, University of Goettingen

Nikolausberger Weg 17

D - 37073 Goettingen

Tel.: ++/551/394595,

Fax: ++/551/394596,

E-mail: hstaats@gwdg.de

ABSTRACT
Objects of narratives and the age of the narrator at the time of a relationship episode are not included in the standard evaluation of a CCRT. These factors may be indicators of transference triggers and influence the expression of a CCRT. They are probably more influential, when narratives outside a clinical setting are evaluated, e.g transference dispositions in RAP interviews.
In an exploratory study we recorded CCRTs, the objects in the narratives and the life period, the narratives came from, in 39 RAP-interviews from a not clinically defined sample (18 men and 21 women). Objects could be described by using the 7 categories “partner”. “mother”, “father”, “friends”, “family”, authorities” and “strangers”. Correlating CCRT parameters and object categories lead to different relational patterns in the men and in the women and to different patterns for the life periods examined. Results found seem meaningful and are in line with developmental theories for the genders.
Evaluating the objects referred to in the narratives may be a useful addition to the CCRT-method and add to our knowledge about pervasive relationship patterns in clinically defined groups of patients.

Panel Session 14 - Overall Summary
Title: Qualitative Approaches in Psychotherapy Process Research
Participants: Brigitte Boothe, Michael B. Buchholz, Ulrich Streeck, Wolfgang Tschacher, Agnes von Wyl
Moderator: Wolfgang Tschacher
Address for Correspondence:
Agnes von Wyl

Psychological Institut of the University of Zurich

Departement of Clinical Psychology

Schmelzbergstrasse 40

CH-8044 Zurich

Tel.: 0041 1 634 30 86

e-mail: vonwyl@klipsy.unizh.ch
ABSTRACT
Four qualitative approaches in psychotherapy process research are presented. The first three approaches work with therapeutical transcripts. They focus on language: metaphors, narratives or conversation. The last project present multivariate time series analyses based on patients‘ as well as therapists’ therapy session reports.

Paper in Panel - Panel Session 14
Title: The Change of Patient’s Metaphors During Psychotherapy
Author: Michael B. Buchholz

Address for Correspondence:
Michael B. Bucholz

Friedländer Weg 11

D-37085 Goettingen

Germany


phone: ++49 551 5005 278

phone: ++49 171 2689 613

e-mail: buchholz.mbb@t-online.de

ABSTRACT
Metaphors are a powerful tool in psychotherapeutic dialogue. Therapists and patients are using them while interacting with each other. The change of metaphors for such central domains as self, interaction, and therapy can be seen as an indicator for therapeutic change. A 30-hour therapy is evaluated along these guidelines by qualitative analysis. The theoretical rationale is cognitive linguistics as outlined by Lakoff and Johnson which gives a useful and comprehensive understanding of what metaphor is and how it works.
Paper in Panel - Panel Session 14
Title: Narratives as Dynamic Self-Presentations in Psychotherapeutic Dialogue
Author: Brigitte Boothe

Address for Correspondence:
Brigitte Boothe

Psychological Institut of the University of Zurich

Departement of Clinical Psychology

Schmelzbergstrasse 40

CH-8044 Zurich

phone: 0041 1 634 30 86

e-mail: boothe@klipsy.unizh.ch
ABSTRACT
A systematic sequential case study of a psychotherapeutic process is presented which is organized around patient’s narratives. By narrative analysis, we study the articulated organization of psychodynamic conflict and its modification during psychotherapy.


Paper in Panel - Panel Session 14
Title: Narrative Analysis of Relationships in Patients‘ Stories
Author: Agnes von Wyl
Address for Correspondence:
Agnes von Wyl

Psychological Institut of the University of Zurich

Departement Clinical Psychology

Schmelzbergstrasse 40

CH-8044 Zurich

phone: 0041 1 634 30 86

e-mail: vonwyl@klipsy.unizh.ch
ABSTRACT
Analyzing 30 patients stories told in the course of therapy two different main patterns of interaction between the figure of the narrator and other figures are found. One pattern, “searching for relationship”, shows one or two other actors beside the narrator himself. The other pattern, “support and dependency”, shows mostly one ore no other actor. These patterns are compared with other results of the narrative analysis and with the diagnose of the patients.

Paper in Panel - Panel Session 14
Title: The Interative Production of Transference Resistance
Author: Ulrich Streeck

Address for Correspondence
Ulrich Streeck

Herzberger Landstr. 53

D-37085 Goettingen

Germany


phone: 0049 551 5005 210

fax: 0049 551 5005 301

e-mail: ustreeck@t-online.de
ABSTRACT
The first version of the concept of resistance as a force of the patient against which Freud had to summon psychic work already names an interactive process. The examination of a therapeutic dialogue by means of conversation analysis may show how transference resistance is not just embedded in the interpersonal relationship but is a co-production of patient and psychotherapist created by verbal and gestural means with which both participants handle their interaction. What is called transference resistance of the patient reveals – in a certain sense – an elaborated interative competence.
Ways and means of interactive production are described with a micro analysis of sequences from an psychodynamic psychotherapy of a patient with the diagnosis of compulsive personality disorder.
Paper in Panel - Panel Session 14
Title: The Sequential Flow of Psychotherapy: A Time Series Approach to Study Therapy Process
Authors: Wolfgang Tschacher and Klaus Grawe
Address for Correspondence:
Wolfgang Tschacher, PD Ph.D.

University of Bern Psychiatric Services

Laupenstrasse 49

CH-3010 Bern

tschacher@spk.unibe.ch

fax +41 31 382 9020


ABSTRACT
In an ongoing project we examine the sequential flow of psychotherapy. In this present study, multivariate time series analyses based on patients' as well as therapists' therapy session reports were implemented. Drawing on the extensive data set of the Bern psychotherapy study, the courses of N=91 psychotherapies were analyzed in this way.
The sample consists of various therapy modalities, namely cognitive behavior therapy, client-centered and heuristic psychotherapy, and schema-oriented psychotherapy which combined insight and mastery-oriented procedures. The therapies included were selected exclusively on the basis of the number of sessions (the criterium was a minimum of 20 sessions per therapy; the mean duration of therapies in this sample was approx. 40 sessions).
We first applied principal component analysis to condense the session report items into a set of factors which then served as the basis for further analysis. Four factors were found: 'Coping capacity', 'commitment of patient', 'therapeutic bond' and 'therapist competence'. The time series analyses were then conducted using the state space approach; the analyses yielded a dynamical model for the time-lagged interrelations of these factors in each of the 91 therapy courses.
Results show that coping capacity was the core factor in the sequential flow of the therapies investigated here. Changes of coping capacity at any session t significantly preceded changes in all the other factors at session t+1. This time-lagged association may be cautiously interpreted as a causal link.
In a further step, the relationship of this dynamics with therapy outcome was investigated. This addresses questions such as, "Which sequential model is found in therapies with the best outcome?" and "Do different therapy modalities have different models?" were investigated.

Paper Session 1
Title: Systematic Treatment Selection for Long-Term Psychodynamic Psychotherapy. Results from a Prospective Longitudinal Study in 25 Psychotherapists in Private Practice
Authors: Carl E. Scheidt, Karin Seidenglanz, and Michael Wirsching
Address for Correspondence:
Carl E. Scheidt

Department of Psychosomatics and Psychotherapeutic Medicine

University Hospital of Freiburg

Hauptstr. 8

79104 Freiburg, Germany

Phone: 49-761/270-6512

Fax: 49-761/270-6885

e-mail ces@pss1.ukl.uni-freiburg.de


ABSTRACT
Treatment selection for long-term psychodynamic psychotherapy is a complex and often idiosyncratic decision, which is influenced by a variety of patient and therapist variables (Beutler and Clarkin 1990). In a prospective longitudinal study we investigated treatment selection for long-term psychodynamic psychotherapy in 25 psychotherapists in private practice. Treatment selection processes were studied on three levels: 1) Acceptance for psychotherapy or referral to other therapists or therapeutic institutions after the initial assessment. 2) Acceptance for long-term (50 sessions or more) or for short-term psychotherapy (25 sessions or less)? 3) Termination or continuation of psychotherapy after 25 sessions.
215 patients in 25 private psychotherapeutic practices participated in the study. 79 of these were seen only for initial assessment. 68 patients were accepted for long-term psychotherapy immediately. Additional 68 patients were taken into short-term psychodynamic psychotherapy. Based on a comparison of these groups patient characteristics and features of the therapists assessment are described which predict the decision for treatment selection.
After termination of short-term psychotherapy a substantial proportion of the patients continued in long-term psychotherapy (with the same therapist). Which therapies were finished after 25 sessions and in which therapies the treatment plan was changed and the therapy continued? Based on these data the issue of an adaptive approach to treatment selection will be discussed. Empirical evidence on the issue of treatment selection is of crucial importance in order to convince health care insurance companies that the available therapeutic resources are used rationally.
Paper Session 1
Title: Therapist Factors as Predictors of Intervention Profiles in General Hospital Mental Health Care
Authors: Barbara Stein, Thomas Herzog & the European Consultation Liaison Workgroup
Address for Correspondence:

Dept. of Psychosomatics and Psychotherapeutic Medicine,

University Hospital, Hauptstr. 8, D-79104 Freiburg, Germany

e-mail:stein@pss1.ukl.uni-freiburg.de


ABSTRACT

The generic model of psychotherapy emphasizes the influence of input factors on the process and outcome of psychotherapy. Beside patient and therapist variables external factors like the therapeutic setting or the service delivery system are relevant context conditions. In a naturalistic field study of mental health care delivery in the general hospital by psychiatric and psychosomatic consultation liaison services (CL) we studied the impact of therapist, patient and contextual input factors on therapeutic intervention patterns. Although mental health care in the general hospital is highly structured by the limitating factors of the hospital´s setting, there is an enormous variety in diagnostic and therapeutic action for patients with similar clinical problems. The CL therapists, mostly psychiatrists with intensive psychotherapy training, see the referred patients only for 1 to 3 sessions focusing on patient, her/his relatives, and consultees for diagnostic and treatment aspects.

CL therapists filled in a comprehensive questionnaire (sociodemographic data, professional training and activities, CL practice, therapeutic goals, theoretical orientation, etc.). During a one-year period, consecutive CL patient episodes were reliably documented. Each patient was described by sociodemographic, anamnestic and administrative data, diagnoses, Cl interventions and health status. We focused on a subsample of patients with neurotic, stress related or somatoform disorders (ICD-10 F4, F54), who had comparable level of psychosocial disturbances (Global Assessment of Functioning Scale (GAF) > 30). Based on central patient, therapist and referral characteristics, a logistic regression was performed to identify factors predicting therapist intervention.

92 CL therapists of 48 CL services in 11 European countries provided 2.137 consultation episodes. The therapists differed widely in professional experience, psychotherapeutic and CL specific training, profiles of professional activities, perception of the CL practice and theoretical orientations. Exclusively psychosocial interventions for patients with neurotic, stress related or somatoform disorders could be more explained by therapist variables (professional experience and activities) than patient variables (age, GAF) or referral characteristics (urgency of referral, time for episode). All together, however, they explained 10 % of the variance. The results underline the role of professional experience in adapting interventions to the needs of patients. Furthermore, the large amount of variance remaining unexplained points to the impact of the service delivery system and local practice on intervention patterns. Further research is needed to explore relevant background factors for therapeutic processes.



Paper Session 1
Title: Attitude to Psychotherapy by General Practitioners and its Impact on Willingness and Ability to Identify Neurotic Disorders. An Empirical Study in Two Stages
Authors: Brigitte Montau, Dan Pokorny, and Wolfram Ehlers
Address for Correspondence:
Brigitte Montau (c/o Dan Pokorny)

Dept. of Psychotherapy and Psychosom. Medicine, Univ. of Ulm

Am Hochstraess 8, D 89081 Ulm, Germany

email Brigitte Montau c/o:pokorny@sip.medizin.uni ulm.de


ABSTRACT
The study investigates the association between the attitude of general practitioners to the field of psychotherapy on the one hand and on the other hand their willingness to identify neurotic disorders as well as ability to identify them correctly.

In the first stage of the study, all male general practitioners in one German city not having a special additional psychotherapeutic training were asked to fill out the questionnaire concerning attitude to psychotherapy. The psychometric analysis of 57 questionnaires allowed the global scale of general attitude to be constructed. We chose 4 practitioners with extremely high scores on the scale who are considered (additionally to their somatic training) open to psychotherapy. We call them ÑP practitioners. On the other extreme of the scale we chose 4 practitioners with extremely low scores who we considered to be concentrated solely on somatic questions. We call them ÑS practitioners.

In the second stage of the study these 4+4 practitioners completed a short questionnaire about their judgment of total 409 patients who visited the surgery on selected days: Were there conspicuous psychotherapeutic disorders and was the treatment being recommended? It was found that all P practitioners diagnosed disorders and recommended treatment more frequently than all S practitioners. This was interpreted as an association between attitude and willingness.

Additionally, each patient was independently investigated by the researcher with the screening questionnaire for neurotic disorders BFB. The ability was operationalized as an agreement between results of the screening instrument and the practitioners judgment. The agreement was measured by the kappa coefficient and we have proposed a procedure for the statistical comparison of kappa coefficients for this purpose. P practitioners generally reached a significantly better agreement then S practitioners. Hence, we have found the association between attitude and ability, too. However, we will demonstrate that the Psychotherapy friendly attitude itself does not lead to the high ability automatically.

Studies such as the present raise questions on the communication between general practitioners and psychotherapists, application of screening instruments in general surgery, quality control and psychotherapeutic educational practices in the medicine.
Paper Session 1
Title: Provision of Psychotherapy and Other Mental Health Services by Primary Care Physicians
Authors: Michael Scherer, Kenneth Howard and John Lyons
Address for Correspondence:
Michael Scherer

Dept. of Psychiatry, University of California

400 Parnassus, ACC846

San Francisco, CA 94143-0348, U.S.A.


ABSTRACT
Training for primary care physicians increasingly emphasizes the administration of "behavioral" or mental health care. Relatively little is known, however, about the actual provision of mental health services and, more specifically, psychotherapy services by primary care physicians (PCPs). This paper uses the health plan database of a large corporation to examine the types of mental health care provided by primary care practitioners and the characteristics of those who receive these services.
Between 1990 and 1994, 4% of all individuals who sought any type of mental health care, and 7% of individuals who sought psychotherapy services, received such care exclusively from their PCP. Findings related to the mental health care provided to these individuals are compared with the practices and patient population characteristics of psychologists and psychiatrists. Comparisons are also made for individuals receiving services from more than one of these providers.
We examined the frequency of different types of mental health services provided, rates for various doses of psychotherapy administered, differences in the medical and psychiatric composition of respective patient populations, and patient characteristics between the different provider types.
Findings suggest that significant differences exist in the health, medical expenses and ages of individuals who seek mental health care exclusively through PCPs. Differences also exist across provider types in the comorbid medical conditions of the patients they treat and in the diagnostic compositions of the respective patient populations. For individuals receiving psychotherapy services, PCPs tend to vary least in their administration of psychotherapy services when compared with psychiatrists. PCPs administer fewer sessions on average than psychologists, however. PCPs see a greater percentage of their patients for one session only compared to both psychiatrists and psychologists. Psychologists retain significantly more patients for moderate treatment doses than PCPs. As therapy dose increases beyond 8 sessions, however, percentages of patients retained become more similar across provider types.

Paper Session 2
Title: Evidence of Structural Change in Long-Term Psychodynamic Psychotherapy
Authors: Jeremy W. Bloomfield, Zoran Martinovich, and Kenneth I. Howard
Address for Correspondence:
Jeremy W Bloomfield, MA

Chicago School of Professional Psychology

806 South Plymouth Court

Chicago, IL 60605

USA
ABSTRACT

This study examined presenting therapeutic assets and their patterns of change in time-unlimited psychodynamic psychotherapy using Daskovsky’s Therapeutic Assets Questionnaire (TAQ, 1988). This questionnaire is composed of five therapist-rated scales measuring (1) capacity to delay gratification, (2) psychological mindedness, (3) level of object relations, (4) willingness to engage in treatment, and (5) degree of distress. The scales themselves were derived from research on qualities associated with engagement and effective outcomes in psychoanalytically-oriented therapies. The first three scales represent structural qualities not traditionally thought of as amenable to change in short-term treatments.


As part of the Northwestern-Chicago Psychotherapy Research Program, a naturalistic study of psychotherapy outcomes and processes, therapists were asked to complete the TAQ at an intake assessment, on a fixed schedule of session numbers during treatment, and at termination. Patterns of change in the TAQ scales were examined for short-term cases (between 8 and 20 sessions), medium-term cases (between 20 and 40 sessions), and long-term cases (more than 40 sessions). Repeated measures analyses within each of the treatment duration groups suggested that psychological mindedness and level of object relations do not show short-term change, but do show improvement in the latter phases of treatment for the long-term cases. The TAQ scales at intake did not predict treatment response as measured by a multi-item symptom inventory. However, the pattern of change suggests that these scales may be meaningful measures of long-term outcomes in traditional psychodynamically-oriented therapies.


Paper Session 2
Title: Patterns of Change in Coping Style in Time-Unlimited Psychodynamic Psychotherapy
Authors: Renanah Kaufman, Zoran Martinovich, and Joanna S. Burg
Address for Correspondence:
Renanah Kaufman

Department of Psychiatry & Behavioral Sciences

Division of Psychology

Northwestern University

303 E. Chicago Avenue, Suite 9-217

Chicago, IL USA 60611


ABSTRACT
This study examined presenting coping styles and their patterns of change in time-unlimited psychodynamic psychotherapy using Tobin’s Coping Strategies Inventory (CSI, 1985). This inventory asks persons to rate coping strategies for a personally stressful event. The items load on eight primary scales: Problem solving, cognitive restructuring, express emotions, social contact, problem avoidance, wishful thinking, self-criticism, and social withdrawal. The CSI includes secondary scales assessing whether coping styles are problem vs. emotion focused and engaging vs. disengaging.
As part of the Northwestern-Chicago Psychotherapy Research Program, patients were asked to complete the CSI before, during, and at the termination of treatment. Based on a sample of 492 cases, prior to a first session, patients were more likely to use the emotion-focused disengagement strategies (social withdrawal and self-criticism) than the problem-focused engagement strategies (problem solving and cognitive restructuring). The two problem-focused disengagement strategies (wishful thinking and problem avoidance) were used at different rates. Wishful thinking showed reliably higher rates than all but one other primary scale and problem avoidance showed lower rates than all the other primary scales.
Problem solving and cognitive restructuring showed the greatest increase during treatment for both moderate and long-term cases, but did not show any signs of increased use among patients who terminated within the first 10 sessions. With respect to problem avoidance and wishful thinking, both long-term and short-term cases showed a reliable decrease. For the long-term cases, however, this decrease was only noted after at least one year of weekly therapy. The emotion-focused coping strategies did not show reliable change. Implications of coping style assessment for the evaluation of psychotherapy outcomes are discussed.
Paper Session 2
Title: Patterns of Outcome Change During Interpretive Versus Supportive Forms of Brief Individual Psychotherapy
Authors: Anthony S. Joyce, John Ogrodniczuk, William E. Piper, and Mary McCallum

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