Psychotherapists' self-reports of their interpersonal functioning and difficulties in practice as predictors of patient outcome.

The need for psychotherapy research to understand the therapist effect has been emphasized in several studies. In a large naturalistic study (255 patients, 70 therapists), this topic was addressed using therapists' self-assessed difficulties in practice and interpersonal functioning in therapeutic work as predictors of patient outcome in three conventional outcome measures. Three-level growth curve analyses were employed to assess whether the therapist characteristics, measured by the Development of Psychotherapists Common Core Questionnaire (Orlinsky & Rønnestad, 2005), predicted the level of and change in patient symptom distress (SCL-90R), interpersonal problems (IIP-64), and observer-rated global functioning (GAF). Preliminary estimates of therapist effects in patient change indicated that 4% of change in general symptom distress (GSI), almost 21% of change in IIP global scores, and 28% of growth in GAF could be attributed to therapist differences. The results also demonstrated that certain therapist self-perceptions were clearly related to patient outcome. For example, therapists' scores on a type of difficulty in practice called "Professional self-doubt" (PSD) (denoting doubt about one's professional efficacy) were positively associated with change in IIP global scores. It is suggested that therapists' self-reported functioning can be of value in understanding how individual therapists contribute to therapeutic change although their influence is not necessarily exerted in expected directions.

Affect integration as a predictor of change: affect consciousness and treatment response in open-ended psychotherapy.

The present study investigated the relationship between baseline levels of affect integration and the magnitude of change during and after open-ended psychotherapy. Affect integration reflects the capacity for accessing and utilizing the adaptive properties of affects for personal adjustment, along with the more general capability of tolerating and regulating affective activation. It is thus a capacity with relevance for the postulated mechanisms of change in various treatment modalities. Overall, the results indicated that patients with more severe problems in affect integration had larger improvements in symptoms, interpersonal and personality problems in open-ended treatment than those with less severe problems. This was also the case when examining the predictive effects of the integration of specific affects on changes in interpersonal relatedness. It was indicated that increasing problems with the integration of discrete affects were associated with distinct patterns of change in different interpersonal problem domains.

Affect integration and reflective function: clarification of central conceptual issues.

The importance of affect regulation, modulation or integration for higher-order reflection and adequate functioning is increasingly emphasized across different therapeutic approaches and theories of change. These processes are probably central to any psychotherapeutic endeavor, whether explicitly conceptualized or not, and in recent years a number of therapeutic approaches have been developed that explicitly target them as a primary area of change. However, there still is important lack of clarity in the field regarding the understanding and operationalization of affect integration, particularly when it comes to specifying underlying mechanisms, the significance of different affect states, and the establishment of operational criteria for measurement. The conceptual relationship between affect integration and reflective function thus remains ambiguous. The present article addresses these topics, indicating ways in which a more complex and exhaustive understanding of integration of affect, cognition and behavior can be attained.

Therapist predictors of early patient-rated working alliance: a multilevel approach.

The present study investigated whether and how various therapists' (N = 68) self-reported characteristics relating to their therapeutic work predicted patients' (N = 335) early ratings of the working alliance in a naturalistic psychotherapy study. Results from multilevel modeling demonstrated that certain self-reports accounted well for the therapist effect in the early alliance. The effect of therapists' experiences of difficulties in practice was particularly strong: a negative influence of difficulties termed negative personal reaction (NPR) and a surprising positive influence of another factor, professional self-doubt (PSD), were found. The latter was interpreted as reflecting an attitude of therapist humbleness and sensitivity, which seems to facilitate alliance development. A negative impact of self-reported skills in using one's own and the patients' emotional reactions in the therapeutic relationship (advanced relational skills) was found when controlling for a warm interpersonal style. The negative effect of advanced relational skills depended on the level of NPR difficulties. The findings suggest that therapists should be cautious in using this kind of relational skill unless they experience relating to patients in a warm manner and report low levels of NPR in their practice.

Pretreatment patient characteristics related to the level and development of working alliance in long-term psychotherapy.

This study explored pretreatment patient characteristics associated with the level and growth of working alliance in therapies lasting up to 120 therapy sessions. The quality of working alliance was rated by both patients (N=201) and therapists (N=61) at Sessions 3, 12, and 20 and then at every 20th successive session. Patients reported that experience with good maternal care up to adolescence and better current interpersonal relationships were associated with positive ratings of working alliance throughout therapy. Higher global functioning was associated with growth of alliance over time. Higher levels of interpersonal problems of the cold/detached kind were associated with poorer early working alliance. On the other hand, this type of interpersonal problems was also associated with improvement of working alliance over time. Therapists' ratings of alliance were associated with patients' intrapsychic functioning. Implications for treatment and research are discussed.

Treatment failure in psychotherapy: the pull of hostility.

Client-therapist interactions were studied in 14 positive-change (PC) and 14 negative-change or nonchange (NC) therapies with the same therapists and similar clients. Aggregated structural analysis of social behavior (SASB) scores showed increasingly dissimilar interaction styles between client and therapist in NC therapies. First-lag transition analyses of SASB codings of Sessions 3, 12, and 20 showed the following differences: Stable hostile complementarity characterized NC within and across sessions. Hostile complementarity was nevertheless relatively rare. Therapists met clients' invitations to hostile responses most frequently in nonhostile ways, yet they initiated more belittling and ignoring interactions with NC clients, pointing to the subtly hostile therapeutic climate created. Rejection of therapists' interventions predicted negative outcome most strongly and escalated with time. Clients' skepticism may make therapists vulnerable to feelings of inadequacy and, if not dealt with therapeutically, may easily release the therapists' own hostility.