Attachment, Mentalization, Emotion Dysregulation, and Empathy in Eating Disorders: Comparing Anorexic and Bulimic Patients.

ABSTRACT: Eating disorders (EDs) represent a wide range of clinical symptoms related to food intake, body image, and weight issues, and include anorexia nervosa-restricting type (AN-R), anorexia nervosa-binge-purge type (AN-BP), and bulimia nervosa (BN). The aim was to investigate the characteristics of attachment, mentalization, emotion dysregulation, and empathy in a sample of 102 patients with EDs. A sample of 102 patients and therapists completed a series of measures for the assessment of ED pathology, mentalization, empathy, and emotion dysregulation. Pearson correlations and analysis of variance were used to test the characteristics of the variables among the groups. In relation to attachment and emotion dysregulation, no significant differences were found. In relation to mentalization, significant difference in good mentalization was found in AN-R subtype compared with the BN subtype. In relation to empathy, results showed significantly lower scores in BN subtype on affective empathy compared with the AN-BP subtype, and in AN-R subtype on cognitive empathy. Finally, we used Z -scores for each item ranked by value (higher to lower) to develop different clinical prototypes for each group. Our results point toward the clinical need to address the assessed variables, specifically mentalization, emotion dysregulation, and empathy, in the diagnosis and treatment of EDs.

Changes in mentalization in patients with personality disorders during sequential brief-Adlerian psychodynamic psychotherapy: The role of therapists' technique and countertransference.

Mentalization, that is the capacity to understand our and others' behaviors in terms of intentional mental states, represents one of the core features of personality disorders (PDs) and can be related to therapists' countertransference (CT) and interventions. AIMS: The aim of the present work was to study the relationship between therapists' technique, therapists' CT, and patients' mentalization, in a sample of patients with PDs undergoing a 40-session program of sequential brief-adlerian psychodynamic psychotherapy, a psychodynamic therapeutic model specifically developed for the treatment of PDs in public mental health services. METHOD: Eighty-seven patients with PD and their therapists completed ratings of mentalization (mentalization imbalances scale and reflective functioning questionnaire), CT (therapist response questionnaire), and therapists' intervention (comparative psychotherapy process scale) at five different time points (Sessions 5, 10, 20, 30, and 40). RESULTS: Results showed that patients' mentalizing problematics decreased over time. Moreover, we found a reduction of therapists' disengaged CT, and an increase in positive CT over time. Regarding therapists' techniques, psychodynamic-interpersonal interventions were on average higher than cognitive-behavioral, but both techniques were used increasingly over time. Our results also showed significant and clinically coherent interactions between therapist's CT and techniques and between patient's mentalization imbalance and therapist's response. Our results highlighted the importance of early stages in therapy, since the most significant relationships between the various process variables (patient's mentalizing imbalances, therapist's techniques, and emotional responses) are observed between t1 and t2, corresponding to the initial phases of the treatments. Clinical implications will be discussed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Personality and mentalization: A latent profile analysis of mentalizing problematics in adult patients.

BACKGROUND: The aim of this study was to investigate the relationship between patients' mentalizing problematics and their personality; specifically, it aimed to identify clusters of individuals characterized by specific patterns of mentalizing imbalances and to analyze the relationship between these and diagnosis of personality disorder (PD), nonmentalizing modes, emotion dysregulation, and interpersonal reactivity. METHODS: Four hundred therapeutic dyads were recruited. A part of these (n = 183) only completed clinician-report measures, Mentalization Imbalances Scale, and Modes of Mentalization Scale, while others (n = 217) also completed patients' self-report measures, which were Reflective Functioning Questionnaire, Difficulties in Emotion Regulation Scale, and Interpersonal Reactivity Index. RESULTS: A latent profile analysis enlightened the presence of four clusters with problematics in the dimensions of mentalization, indicated by cluster names: (1) Affective-self-automatic profile (ASA-P) (with higher percentage of PDs); (2) External profile (E-P) (with lower percentage of PDs); (3) Others-automatic-affective profile (OAA-P); (4) Cognitive-self-automatic profile (CSA-P). Multivariate analysis of variances confirmed that the four clusters differed in relation to the quality of mentalization, emotional dysregulation and interpersonal reactivity, with higher levels of nonmentalization modes, uncertainty about mental states and emotion dysregulation in ASA-P, higher levels of good mentalization in E-P, lower impulsivity in CSA-P, and greater empathic concern in OAA-P.

Attachment, Trauma, and Mentalization in Intimate Partner Violence: A Preliminary Investigation.

Intimate partner violence (IPV) has been examined from a range of theoretical perspectives, including attachment theory, with the aim of assessing psychosocial risk factors. Previous research has shown that a child's exposure to violence in the family is a major predictor of IPV victimization later in life. Furthermore, research on abused and traumatized adult samples has shown high frequencies of unresolved/disorganized attachment styles. In particular, disorganized attachment is associated with major problems of affect regulation and deficits in mentalizing ability. The present research had three aims: (a) to assess the childhood traumatic experiences of female victims of IPV; (b) to investigate and identify the attachment patterns of female victims of IPV; and (c) to examine reflective functioning and prementalistic modes in female victims of IPV, in relation to attachment and trauma. A sample of 31 women, recruited through anti-violence centers, were administered the Adult Attachment Interview (AAI) and the Reflective Functioning Questionnaire. The Complex Trauma Questionnaire and the Reflective Functioning Scale (RFS) were also applied to the AAI transcripts. Interviews were audio recorded and transcribed verbatim. Coding was conducted by two trained coders and certified as reliable for the AAI and RFS. Clinicians completed the Modes of Mentalization Scale (MMS) to assess participants' mentalization style. The data showed a high percentage of women with insecure attachment and lower reflective functioning. The results are discussed in terms of their clinical and theoretical implications-particularly their application to psycho-forensics, through the development of preventive programs and interventions for IPV. Efforts to understand the etiology of IPV and to intervene to prevent recidivism are fundamental in reducing this public health threat.

Countertransference responses mediate the relationship between patients' overall defense functioning and therapists' interventions.

Objective: The aim of this work was to investigate the relationship between therapists' techniques (supportive/expressive intervention level - ESIL), therapists' countertransference (CT) and patients' defense level of functioning (ODF). We hypothesized that CT could play a mediating role in the relationship between patients' ODF and therapists' ESIL. Method: 65 psychotherapy sessions were rated by two different raters each with the Psychodynamic Interventions Rating Scale and the Defense Mechanisms Rating Scale. Clinicians used the Therapist Response Questionnaire to provide information on their CT. The 65 sessions referred to 65 clinicians (25 = females, 40 = males; 38 = psychodynamic, 27 = cognitive). More than half of the patients (n = 40; 61.5%) had a diagnosis of personality disorder. Among clinical disorders the most frequent were mood (n = 12) and anxiety disorders (n = 11). Five patients had no diagnosis. Results: Four CT responses (parental; positive; criticized; overinvolved) completely mediated the relationship between patients' ODF and therapists' ESIL, while no effect resulted in relation to overwhelmed, helpless, sexualized and disengaged CTs. No effect of theoretical orientations on mediation pathways was found. Conclusion: Both positive and negative CT feelings seemed to play a crucial role in the relationship between therapists' interventions and patients' ODF.

Mentalizing Subtypes in Eating Disorders: A Latent Profile Analysis.

Background: Mentalizing, the mental capacity to understand oneself and others in terms of mental states, has been found to be reduced in several mental disorders. Some studies have suggested that eating disorders (EDs) may also be associated with impairments in mentalizing. The aim of this work is to investigate the possible presence of mentalizing subtypes in a sample of patients with EDs. Method: A sample of patients with eating disorders (N = 157) completed a battery of measures assessing mentalization and related variables, including the Reflective Functioning Questionnaire (RFQ), the Difficulties in Emotion Regulation Strategies (DERS), the Interpersonal Reactivity Index (IRI). Clinicians rated patients in relation to imbalances in different dimensions of mentalization to prementalizing modes and attachment style by using the Mentalization Imbalances Scale, the Modes of Mentalization Scale (MMS), and the Adult Attachment Questionnaire. A latent profile analysis was conducted to test the possible presence of different subgroups. MANOVA was used to test the possible differences between the four mentalizing profiles in relation to emotion dysregulation (DERS), empathy (IRI), and adequate and impairments in mentalizing (MMS and RFQ). Results: The latent profile analysis suggested the presence of four different profiles in relation to impairments in the dimensions of mentalization: (1) affective/self/automatic imbalances, (2) external imbalance, (3) cognitive/self/automatic imbalances, and (4) cognitive/other/automatic imbalances. Patients belonging to profile 1 are characterized by the prevalence of affective mentalization that overwhelms the capacity to reflect on mental states with an imbalance on the self-dimension; profile 2 patients are excessively focused on the external cues of mentalization; profile 3 patients are characterized by an over-involvement on the cognitive and self-facets of mentalization, with an impairment in adopting the other mind perspective; and profile 4 patients have similar impairments compared to profile 3 patients but with an excessive focus on others and deficits in self-reflection. These profiles were heterogeneous in terms of EDs represented in each group and presented significant differences on various variables such as attachment style, emotion dysregulation, empathy, interpersonal reactivity, and reflective function. This study represents, so far, the first work that confirms the presence of different mentalizing patterns in ED patients. Conclusions: ED patients can be classified in relation to impairments in different dimensions of mentalization above and beyond ED diagnosis.

Further data on the reliability of the mentalization imbalances scale and of the modes of mentalization scale.

The aim of this study was to provide data on the Inter-Rater Reliability (IRR) and the test-retest reliability of the Mentalization Imbalances Scale (MIS) and the Modes of Mentalization Scale (MMS) in two different studies. Three junior raters and two senior raters assessed blindly 15 session transcripts of psychotherapy of five patients, using both the MIS and the MMS. The same 15 sessions were rated after the junior raters completed a training at the use of the scales and after on month from the end of the training to assess testretest reliability. Four therapists used the MIS and the MMS to provide different ratings of 22 patients undergoing a psychotherapy in different settings. Intraclass Correlation Coefficient (ICC) values ranged from sufficient to good and increased after the training. Test re-test reliability was sufficient for both scales (Study 1). ICC values ranged from sufficient to good, and were globally higher than the ones found in the first study sample (Study 2). Our results provide support to the inter-rater reliability of the MIS and the MMS.

An Italian validation of the Comparative Psychotherapy Process Scale: Reliability and validity.

The Comparative Psychotherapy Process Scale (CPPS) is an instrument designed to measure therapist interventions in a psychotherapy session. The scale includes 20 items divided into two subscales: the PI (psychodynamic-interpersonal) scale, which describes psychodynamic-interpersonal techniques; and the CB (cognitive-behavioural) scale, which includes cognitive-behavioural interventions. The aim of the study was to examine the psychometric properties of the CPPS, comparing the PI and CB subscales with the psychodynamic, cognitive and STTP prototypes, as described by the Psychotherapy Process Q-set(PQS). The sample comprised 94 sessions (N = 94) of psychodynamic and cognitive-behavioural orientation. Two groups of independent raters with excellent interrater reliability (ICC = .78) evaluated the sessions. The results suggest that the CPPS is a valid and reliable instrument that provides a clinically sensitive and psychometrically robust evaluation of a therapist's techniques. The clinical and research implications of the results are discussed.

Assessing alliance ruptures and resolutions: Reliability and validity of the Collaborative Interactions Scale-revised version.

OBJECTIVE: This study presents the revised version of the Collaborative Interactions Scale (CIS) [Colli, A., & Lingiardi, V. (2009). The Collaborative Interactions Scale: A new transcript-based method for the assessment of therapeutic alliance ruptures and resolutions in psychotherapy. Psychotherapy Research, 19(6), 718-734.], an observer-rated measure for the assessment of therapeutic-alliance ruptures and resolutions. Intensive use of the previous scale resulted in three criticisms: (i) excessive time required to perform evaluations, (ii) the low occurrence of some items, and (iii) the scale's low capacity to capture some patient-therapist interactions in fine detail. In this study, we aimed to describe the scale revision process and evaluate interrater reliability and scale validity by comparing sessions of patients with and without personality disorders (PDs). METHOD: Three raters conducted a blind evaluation of a sample of 60 sessions (180 segments; 3607 narrative units) with 30 patients (15 had a PD diagnosis and 15 had a DSM-5 clinical syndrome diagnosis without a PD). RESULTS: Interrater reliability results ranged from acceptable to excellent and were comparable to those of the former version. Patients with PDs showed a greater number of alliance ruptures and a smaller number of collaborative processes than patients without PDs. Moreover, therapists presented more negative interventions with the PD sample than with the non-PD sample. CONCLUSIONS: The results indicate that the revised CIS is a reliable rating system that is useful for both empirical research and clinical assessments. Clinical or methodological significance of this article: The CIS-R is a reliable rating system that is suitable for both empirical research and clinical assessment. It is useful for recognizing rupture and resolution processes, both in clinical everyday practice and in psychotherapists' training. Application of the CIS-R promotes clinical reflection on the therapeutic action used to manage ruptures in a session.

Patient Personality and Relational Patterns in Psychotherapy: Factor Structure, Reliability, and Validity of the Psychotherapy Relationship Questionnaire.

The aim of this study was to examine the factor structure and the psychometric properties of the Psychotherapy Relationship Questionnaire (PRQ; Bradley, Heim, & Westen, 2005 ), a clinician report instrument that measures a wide spectrum of thoughts, feelings, motives, conflicts, and behaviors expressed by patients toward their therapists in psychotherapy. A national sample of psychiatrists and clinical psychologists (N = 314) of different theoretical orientations completed the PRQ, as well as the Shedler-Westen Assessment Procedure-200 (SWAP-200; Westen & Shedler, 1999a , 1999b ) to assess the personality of a patient in their care. Factor-analytic procedures identified 6 transference dimensions that showed excellent internal consistencies: (a) hostile, (b) positive/working alliance, (c) special/entitled, (d) anxious/preoccupied, (e) avoidant/dismissing attachment, and (f) sexualized. Factor scores were significantly related to patients' personality characteristics and psychological functioning, regardless of the clinicians' orientations. The findings support that the PRQ is a valid and reliable tool for evaluating the patients' relational patterns emerging in clinical practice in a clinically coherent and psychometrically robust way. Clinicians' careful understanding of these patterns can be very useful for making accurate diagnostic formulations, as well as for providing a roadmap for effective therapeutic intervention.

Assessing mentalization in psychotherapy: first validation of the Mentalization Imbalances Scale.

The aim of this study was to provide data on the preliminary validation of a clinician-report multidimensional assessment measure of mentalization (Mentalization Imbalances Scale, MIS). A random national sample of psychotherapists (N=190) completed the MIS to identify mentalization imbalances, and the Personality Disorder Checklist to assess the personality disorders (PDs) of randomly selected patients currently in their care. Factor analysis confirmed the presence of six factors that represented different imbalances of mentalization: cognitive, affective, automatic, external, imbalance toward others, and imbalance toward self. We found several significant relationships between patients' mentalization imbalances and personality pathology. Paranoid, schizoid, and schizotypal PDs were predicted by an imbalance toward self, an imbalance the patients shared with histrionic, avoidant, and obsessive compulsive PDs, whereas dependent, borderline, and histrionic PDs were related to an imbalance toward others. Cognitive imbalance was related to schizoid, narcissistic, and obsessive compulsive PDs, whereas affective imbalance predicted antisocial, borderline, narcissistic and histrionic PDs. Automatic imbalance was related to schizotypal, antisocial, and borderline PDs. MIS represents a reliable and valid measure that can help clinicians at understanding patients' specific difficulties of mentalization.

Empirically Derived Relational Pattern Prototypes in the Treatment of Personality Disorders.

BACKGROUND: Patient transference patterns play a central role in the psychotherapy of personality disorders. OBJECTIVE: The aims of this study were to: (1) explore the relationship between patients' personality disorders and specific relational patterns and (2) construct empirically derived prototypes of relational patterns for each personality disorder. SAMPLING AND METHODS: A random national sample of 314 clinicians completed the Psychotherapy Relationship Questionnaire, which evaluates patients' relational patterns, and the Shedler-Westen Assessment Procedure-200, which assesses personality disorders in a randomly selected patient currently in the clinician's care and with whom the clinician has worked for a minimum of 8 sessions and a maximum of 6 months (1 session per week). RESULTS: The avoidant/counterdependent transference pattern was associated with all cluster A personality disorders; the angry/entitled transference pattern was strongly positively associated with all cluster B personality disorders, and the anxious/preoccupied transference pattern was positively associated in a significant way with all cluster C personality disorders. Moreover, our empirically derived prototypes showed how the transference phenomena characteristic of each personality disorder are strongly coherent with the personality traits and mental and relational functioning of each specific disorder. CONCLUSIONS: The results strongly support a fundamental hypothesis that the patterns emerging in the therapeutic relationship are not arbitrary, and they clearly reflect patterns seen elsewhere in patients' lives that can be crucial to address. Regarding limitations, the same clinician provided data on both the personality pathology and the transference phenomena for each patient.

Therapeutic interventions in the treatment of eating disorders: A naturalistic study.

This study used naturalistic data from psychodynamic (PD) and cognitive-behavioral (CB) clinicians in the community to offer a portrait of treatments for eating disorder (ED) patients as provided in everyday clinical practice. The research aims were (1) to examine the therapeutic interventions reported by PD and CB clinicians working with ED patients; and (2) to assess the impact of different variables (such as patient personality styles, ED symptomatology, and therapists' theoretical orientation and experience) on the technique use reported by clinicians. A national sample of PD and CB clinicians (N = 105) completed the Shedler-Westen Assessment Procedure-200 (SWAP-200; Westen & Shedler, 1999a, 1999b) to assess personality disorders of a female patient with EDs in their care, as well as the Comparative Psychotherapy Process Scale-Bulimia Nervosa (CPPS-BN; Thompson-Brenner & Westen, 2005) to describe the characteristic interventions used in their treatments. Results showed that PD clinicians tended to use primarily PD interventions, while CB clinicians employed CB techniques supplementing them with a wider range of PD strategies. However, clinicians from both theoretical orientations used adjunctive treatment techniques for EDs at a similar level. In addition, use of PD interventions was strongly associated with the personality styles of ED patients regardless of therapists' orientation, primarily being used more often when patients exhibited dysregulated and impulsive styles. Conversely, use of CB interventions was primarily related to a clinicians' CB orientation, patients with more explicit symptoms of anorexia nervosa, and negatively related to clinicians' years of experience. The clinical implications of these findings were discussed. (PsycINFO Database Record

Factor structure, reliability, and validity of the Therapist Response Questionnaire.

The aim of this study was to examine the stability of the factor structure and psychometric properties of the Therapist Response Questionnaire (Betan, Heim, Zittel Conklin, & Westen, 2005; Zittel Conklin & Westen, 2003), a clinician report instrument able to measure the clinician's emotional reactions to the patient in psychotherapy. A national sample of psychiatrists and clinical psychologists (N = 332) of psychodynamic and cognitive-behavioral orientation completed the Therapist Response Questionnaire, as well as the Shedler-Westen Assessment Procedure-200 (Westen & Shedler, 1999a, 1999b), to assess personality disorders and level of psychological functioning, regarding a patient currently in their care. They also administered the Symptom Checklist-90-Revised (Derogatis, 1994) to the patients. Exploratory and confirmatory factor analyses revealed 9 distinct countertransference factors that were similar to 8 dimensions identified in the original version of the measure: (a) helpless/inadequate, (b) overwhelmed/disorganized, (c) positive/satisfying, (d) hostile/angry, (e) criticized/devalued, (f) parental/protective, (g) special/overinvolved, (h) sexualized, and (i) disengaged. These scales showed excellent internal consistencies and good validity. They were especially able to capture the quality and intensity of emotional states that therapists experience while treating personality-disordered patients, as well as to better differentiate them; additionally, they tapped into the complexity of clinicians' reactions toward patients experiencing severe psychiatric symptomatology. Results seem to confirm that Therapist Response Questionnaire is a valid and reliable instrument that allows to evaluate patterns of countertransference responses in clinically sensitive and psychometrically robust ways, regardless of therapists' orientations. The clinical and research implications of these findings are addressed.

Eating Disorders and Therapist Emotional Responses.

The aims of this study were to identify (a) patterns of clinicians' emotional responses to patients with eating disorders (ED); (b) patient, clinician, and treatment variables associated with therapist emotional responses; and (c) the influence of patient personality on therapist emotional responses. A random national sample of psychodynamic and cognitive-behavioral psychotherapists (N = 149) was asked to examine one patient (>18 years old) with an ED. Clinicians completed the SWAP-200, the Therapist Response Questionnaire, and the Clinical Questionnaire-Eating Disorder Form to provide general information about themselves, patients, and therapies. Results suggested a therapist pattern of emotional response in relation to different ED diagnosis and indicated meaningful influence of therapist experience and patient variables (such as sexual abuse, dissociative symptoms, and self-harm) on therapist emotional reactions. Finally, regression analysis suggested that therapist responses are more related to patient personality than ED symptoms. This study confirms the importance of patient personality in evoking specific therapists' reactions.

Does the severity of psychopathological symptoms mediate the relationship between patient personality and therapist response?

Countertransference can be viewed as a source of valuable diagnostic and therapeutic information and plays a crucial role in psychotherapy process and outcome. Some empirical researches have showed that patients' specific personality characteristics tend to evoke distinct patterns of emotional response in clinicians. However, to date there have been no studies examining the impact of patients' symptomatology on the association between their personality and therapists' responses. This research aimed to (a) investigate the relationship between patients' symptom severity and clinicians' emotional responses; and (b) explore the possible mediated effect of symptom severity on the relationship between patients' personality pathology and countertransference responses. A sample of psychiatrists and clinical psychologists (N = 198) of different theoretical orientations completed the Shedler-Westen Assessment Procedure-200 and the Therapist Response Questionnaire on a patient currently in their care, who then completed the Symptom Checklist-90-Revised. The findings showed that patients' symptomatology partially mediates the relationship between their specific personality disorders (in particular, schizotypal, borderline, histrionic, and avoidant) and therapists' emotional responses, but in general, the impact of symptom severity is less sizable than one aroused by patients' personality style. Higher levels of patients' symptom severity are most associated with an intense feeling of being overwhelmed, disorganization, helplessness, and frustration in clinicians. These countertransference reactions are not accounted for by therapists' different therapeutic approaches and other variables (as gender, age, profession, and experience). The clinical implications of these results are addressed.

Patient personality and therapist countertransference.

PURPOSE OF REVIEW: The purpose of this review is to provide a comprehensive and critical examination of the empirical literature about the relation between patient personality and therapist countertransference. RECENT FINDINGS: The therapist's countertransference can play a crucial role in psychotherapy outcomes, especially in the treatment of personality disorders. The therapist's emotional responses to patients can accomplish the following: inform the clinician about the patient's personality, impact therapy outcome, influence patient resistance and elaboration, mediate the influence of the therapist's interventions and influence therapeutic alliance. SUMMARY: In the last years, several studies have empirically demonstrated the presence of a specific pattern of therapist responses that are related to different patient personality disorders. Other works showed how the effects of the therapist's technique depend on the emotional context in which they are delivered and in particular countertransference experiences. Moreover, researchers suggest that the therapist's emotional responses occur across all kinds of therapy and are independent of the therapist's theoretical preferences.

Patient personality and therapist response: an empirical investigation.

OBJECTIVE: The aim of this study was to examine the relationship between therapists' emotional responses and patients' personality disorders and level of psychological functioning. METHOD: A random national sample of psychiatrists and clinical psychologists (N=203) completed the Therapist Response Questionnaire to identify patterns of therapists' emotional response, and the Shedler-Westen Assessment Procedure-200 to assess personality disorders and level of psychological functioning in a randomly selected patient currently in their care and with whom they had worked for a minimum of eight sessions and a maximum of 6 months (one session per week). RESULTS: There were several significant relationships between therapists' responses and patients' personality pathology. Paranoid and antisocial personality disorders were associated with criticized/mistreated countertransference, and borderline personality disorder was related to helpless/inadequate, overwhelmed/disorganized, and special/overinvolved countertransference. Disengaged countertransference was associated with schizotypal and narcissistic personality disorders and negatively associated with dependent and histrionic personality disorders. Schizoid personality disorder was associated with helpless/inadequate responses. Positive countertransference was associated with avoidant personality disorder, which was also related to both parental/protective and special/overinvolved therapist responses. Obsessive-compulsive personality disorder was negatively associated with special/overinvolved therapist responses. In general, therapists' responses were characterized by stronger negative feelings when working with lower-functioning patients. CONCLUSIONS: Patients' specific personality pathologies are associated with consistent emotional responses, which suggests that clinicians can make diagnostic and therapeutic use of their responses to patients.

Exploration of session process: relationship to depth and alliance.

This study investigates the relationship between the Depth of elaboration, the therapeutic alliance, and dimensions of the psychotherapy process--the therapist interventions, the patient contributions, and patient/therapist patterns of interaction. Sixty psychotherapy sessions that were audio-taped and transcribed were rated by external judges by using a battery of instruments that included the Psychotherapy Process Q-Set (Jones, 1985, 2000), the Working Alliance Inventory-Observer (Horvath, 1981, 1982; Horvath & Greenberg, 1989), and the Depth Scale of Session Evaluation Questionnaire (Stiles & Snow, 1984a). The results show a significant positive correlation between Depth and therapeutic alliance, as well as between Depth, therapeutic alliance, and some variables of the therapeutic process. The findings indicate the importance of therapist interventions that focus on the patient's affects, relational patterns, and the "here and now" of the relationship in the increase of the Depth of elaboration and therapeutic alliance. The clinical implications of this study will be discussed.

The Collaborative Interactions Scale: a new transcript-based method for the assessment of therapeutic alliance ruptures and resolutions in psychotherapy.

The authors present a new transcript-based method for the assessment of therapeutic alliance ruptures and resolutions in psychotherapy-the Collaborative Interaction Scale (CIS)-and discuss the structure and theoretical background of the scale and the rating procedure. To assess interrater reliability, three raters independently evaluated 32 psychotherapy sessions (2,984 patient utterances and 2,984 therapist utterances) using the CIS, which demonstrated good interrater reliability (average kappa=.66-.81). In evaluating the relationship between therapist interventions and patient alliance rupture and collaborative processes, the authors found significant correlations between therapist negative interventions and patient alliance ruptures and among therapist positive interventions, patient collaborative processes, and indirect rupture markers. Results indicate that the CIS is a reliable rating system, useful in both empirical research and clinical assessments.