An interpersonal model of psychotherapy: linking patient and therapist developmental history, therapeutic process, and types of outcome.

This study empirically evaluated a 3-stage causal model based on interpersonal theory that relates patient and therapist early parental relations, the therapeutic alliance, and outcome. Data were from the Vanderbilt II database and encompassed 64 psychodynamic psychotherapies. Interpersonal variables were assessed using the Structural Analysis of Social Behavior. Initial support for the model was found, suggesting a direct effect of patient early parental relations on process and outcome, a direct effect of therapist early parental relations on process, and a direct effect of process on outcome--and thus indirect effects of both patient and therapist early parental relations on outcome mediated by the process. The psychotherapy process was assessed from 3 perspectives: patient and therapist self-report and reports by independent observers. Little convergence was found between the 3 perspectives.

The evolution of psychotheroapy training: reflections on manual-based learning and future alternatives.

Although psychotherapists-in-training may rely significantly on their clinical intuitions when first beginning to practice therapy, they quickly discover that much more is required to conduct effective treatment. Increasingly over the past two decades, training manuals have been used to impart explicit guidelines to beginning psychotherapists. In addition, manuals offer a means for helping more experienced therapists to learn new approaches, while also allowing careful research on the relative efficacy of different psychotherapies. In some instances, manuals have been designed specifically to address troublesome transference and countertransference issues (e.g., Time-Limited Dynamic Psychotherapy; Strupp & Binder, 1984). But even manualized treatments that target hostile interactions between therapist and patient are sometimes of limited use in teaching therapists to work with difficult patients, as illustrated by the Vanderbilt II Psychotherapy Research Project. Experimental research on the distinctions between implicit learning and explicit learning (e.g., Lee & Vakoch, 1996) helps explain the constraints of manualized treatments. By relying on explicit, clearly articulated guidelines, treatments conducted in accordance with manuals may interfere with tacit reasoning processes. As a consequence of the strong emphasis that manuals place on explicit rules for treatment, this type of training can hinder the development of complex clinical judgments. Future generations of novice psychotherapists may benefit from training experiences that are designed to promote an integration of implicit and explicit learning.

Recommendations for the future of training in brief dynamic psychotherapy.

The results of 2 large surveys (of practitioners and graduate school/internship training directors) indicate that there is a considerable amount of brief therapy being conducted by psychodynamically trained therapists. However, their training in this specialization does not appear to be adequate. Eleven recommendations (e.g., addressing therapists' attitudes toward brief therapy, studying training processes and outcomes, using videotapes for teaching and supervision) are set forth to foster improvements in such training. We conclude that it is critical that the sizeable number of psychodynamic therapists conducting brief therapy receive continuing in-depth training in this challenging and demanding field.

The tripartite model and the Consumer Reports study.

This article relates the Consumer Reports (1995) study to the framework of the tripartite model of mental health and therapeutic outcomes (H. H. Strupp & S. W. Hadley, 1977) and calls attention to major unsolved problems in the assessment of therapeutic change. The model envisions three perspectives for evaluating outcomes: adaptive behavior (society), sense of well-being, and personality structure. The self-report perspective is viewed as having its own validity; however, it needs to be complemented by the other two perspectives of the model. Integration of the three perspectives has remained a somewhat elusive goal.

The ecology of psychotherapy research.

The ecology of psychotherapy research was examined with patient reports of demand characteristics and awareness of research instrumentation. Patients were part of the Vanderbilt II project that explored the effectiveness of manualized training. A total of 59 patients from the pretraining and posttraining phases of the project were interviewed after termination assessments were made. Patients who were highly aware of their role as a "subject" in an experiment had outcomes that were consistent with the primary hypotheses of the study, although training did not significantly improve outcomes. In the pretraining cohort, patients who were highly aware of their "subject" role had poorer outcomes and engaged less in exploratory process. In the posttraining cohort, patients who were highly aware had good outcomes and engaged in more exploratory processes. Interestingly, therapists of these patients offered a positive relationship but failed to adhere to the principles taught during training. Demands of the research, especially how the patient defines his or her role, may affect results in significant ways.

The Vanderbilt psychotherapy studies: synopsis.

The psychotherapy studies completed at Vanderbilt University had their antecedents in research begun by Strupp in the 1950s. Initially focused on the empirical study of therapeutic techniques, the work soon drew attention to therapists' attitudes toward the patient and the manner in which these attitudes were intertwined with therapists' clinical judgments and their communications to the patient. Negative complementarity, in particular, emerged as fateful for progress and outcome, and it became the leitmotif of that work. Vanderbilt I focused on the relative contribution of specific and nonspecific factors in therapy, whereas Vanderbilt II sought to study the effects of training in time-limited dynamic psychotherapy on process and outcome.

Effects of training in time-limited dynamic psychotherapy: changes in therapist behavior.

Sixteen therapists participated in a year-long manualized training program as part of the Vanderbilt II study of time-limited dynamic psychotherapy. Changes in therapist behavior were measured with the Vanderbilt Therapeutic Strategies Scale (an adherence measure), the Vanderbilt Psychotherapy Process Scale (VPPS), and interpersonal process codings using the Structural Analysis of Social Behavior (SASB). The training program successfully changed therapists' technical interventions in line with the manualized protocol. After training, there was increased emphasis on the expression of in-session affect, exploration of the therapeutic relationship, an improved participant-observer stance, and greater use of open-ended questions. There was also an indication of unexpected deterioration in certain interpersonal and interactional aspects of therapy as measured by the VPPS and SASB ratings. These results question the assumption that greater control of the therapy variable is straightforwardly achieved with manuals and adherence scales. Changing or dictating specific therapist behaviors to achieve technical adherence may alter other therapeutic variables in unexpected and even counterproductive ways.

Effects of training in time-limited dynamic psychotherapy: mediators of therapists' responses to training.

Sixteen therapists were enrolled in a year-long manualized training program as part of the Vanderbilt II study of time-limited dynamic psychotherapy (TLDP). The training program successfully changed therapists' interventions in line with prescriptions of the TLDP manual, but some unanticipated changes ran counter to the intent of the training, including increased negative interpersonal transactions as indicated by process measures such as the Structural Analysis of Social Behavior (SASB). We examined therapist variables, patient variables, and training variables that appeared to mediate therapist responses to the training program. Results indicate that patient difficulty may mediate certain aspects of therapists' responses to training. Therapists with self-reported hostile and controlling introjects showed the greatest technical adherence, which was intriguing because prior research has linked hostile therapist introject to greater frequency of counter-therapeutic interpersonal process. Of special interest were differences in effects of training associated with individual training faculty. This finding, if generalizable, has important implications for manualized therapy research, especially multisite trials.

Patient and therapist values in psychotherapy: perceived changes, assimilation, similarity, and outcome.

This study investigated (a) the nature and extent of perceived changes in patients' values (reported retrospectively), (b) the relationship between patients' assimilation of their therapists' values and outcome, and (c) the relationship between the similarity of patient-therapist values (posttherapy) and outcome. A great deal of perceived values change was reported by the patients, but (contrary to expectations) not primarily in values concerning interpersonal morality. Values assimilation demonstrated a fairly substantial positive correlation with therapist's outcome assessment, but not with other measures of outcome, suggesting that the phenomenon may be related more to the therapist's rating bias than to genuine improvement. Patient-therapist dyads whose values were moderately similar showed the most improvement, indicating that an intermediate range of values similarity may function as a predictor of positive outcome. Secondary findings (including the seemingly unique role of religious values) and suggestions for future research directions are discussed.

[German version of the Vanderbilt Psychotherapy Scales: description and use in two brief psychotherapies]. / Deutschsprachige Version der Vanderbilt-Psychotherapie-Skalen: Beschreibung und Anwendung in zwei Kurztherapien.

The Vanderbilt-Psychotherapy-Scales appeared to be useful instruments for the identification of process characteristics determining the outcome of brief dynamic psychotherapies. The German versions of the two scales measuring important components of the psychotherapeutic process and of negative indicators are described in this article. It could be shown that--similar to the original versions--both scales can be used economically and that rater agreement soon reaches satisfactory levels. To demonstrate the potential use of the scales, their application in two different short term treatments are described which are presently analysed in a multi-center study of "single case oriented process research" using a variety of different methods. The example demonstrates that both scales are useful to discriminate both different theoretical foundations of the treatments as well as specific features of the patients and their therapists. The usefulness of the scales in a broader context is mainly based upon the experience that they reveal a lot of important informations about the psychotherapeutic process with a minimum of expense.

Patient and therapist introject, interpersonal process, and differential psychotherapy outcome.

The Structural Analysis of Social Behavior (SASB; Benjamin, 1974, 1982, 1984) system was used to study the interpersonal process between patient and therapist in the 3rd session of 14 therapeutic dyads. Dyads were grouped into good and poor outcomes cases (n = 7) on the basis of the amount of change in the patients' introject as measured by the INTREX Introject Questionnaire (Benjamin, 1983). Strong support was found for the following hypotheses based on interpersonal theory, linking therapists' introject state, interpersonal process in therapy, and outcome: (a) Poor outcome cases (no introject change) were typified by interpersonal behaviors by the therapist that confirmed a negative patient introject; (b) the number of therapists' statements that were subtly hostile and controlling was highly correlated with the number of self-blaming statements by the patients; (c) therapists with disaffiliative introjects tended to engage in a much higher level of problematic interpersonal processes that have been associated with poor outcome. Implications for future research and therapist training are discussed.

Matchmaking in psychotherapy: patient-therapist dimensions and their impact on outcome.

Patient-therapist matching was investigated using recent theoretical and methodological developments to overcome some of the limitations that have hindered similar past efforts. Two hypotheses were tested: (a) Therapeutic outcome is affected by the interaction between patients' and therapists' self-concepts, and (b) increasing anticomplementarity between therapist self-concept and therapists' perceptions of patients' behavior is negatively associated with patient improvement. Data from the first 2 cohorts of the Vanderbilt II Psychotherapy Project were analyzed. They included the therapies of 16 experienced therapists, who saw a total of 48 patients (38 women and 10 men) in time-limited psychotherapy. Patients' ages ranged from 24 to 64 years (M age = 40). Outcome was measured from the perspective of the patient, therapist, and evaluating clinician. Each hypothesis was supported, but not across all 3 outcome perspectives.

[Structural analysis of social behavior in training and research. A contribution to the "functional histology" of the psychotherapy process]. / Die strukturale Analyse sozialen Verhaltens (SASB) in Ausbildung und Forschung. Ein Beitrag zur "funktionellen Histologie" des psychotherapeutischen Prozesses.

To be able to identify qualitative differences in the results of psychotherapeutic activity and to establish a relationship between those results and the particularities of the treatment process involved, the problems of the patient, the relevant events during therapy, and therapeutic results must be interrelatable both terminologically and theoretically (P-T-O congruence; Strupp et al., 1989). If, therefore, the relevant qualities of the relationships involved in interpersonal transactions during the therapeutic process are to be represented adequately and independently of schools, an appropriate instrument is required for both clinical and research use. This instrument is introduced here in the form of the Structural Analysis of Social Behavior (SASB) after Lorna Smith Benjamin by means of the key question: Who acts how toward whom and how does the latter react to this?

Converging evidence for identification of recurrent relationship themes: comparison of two methods.

The therapeutic process is complex, and researchers and clinicians alike search for organizing principles or underlying structures that will reduce this complexity and thereby augment the efficacy of their respective endeavors. As other papers in this issue indicate, one such organizing principle is the concept of a recurring relationship theme that can be identified in the patient's descriptions of current and past relationships, as well as observed in the patient's interaction with the therapist. This concept has its origins in Freud's discovery of the transference phenomenon (1912), wherein the patient reenacts early relationships with significant others in the relationship with the analyst, and in Sullivan's interpersonal theory of psychiatry, with its central tenet that "personality is the relatively enduring pattern of recurrent interpersonal situations which characterize a human life" (1953, pp. 110-11). In the psychoanalytic and interpersonal therapies, these recurrent interpersonal themes, associated with the patient's difficulty in living and characterized as self-defeating and self-perpetuating, can potentially serve three main purposes: diagnosing and describing patients' difficulties, focusing therapeutic interventions, and measuring change on an individual basis. However, until recently, research on transference and rigidity of interpersonal style has been hampered by the lack of objective and clinically relevant measures for quantifying this clinical phenomenon (Kiesler 1986; Luborsky and Spence 1978). Luborsky (1977) developed the first reliable method for operationalizing the transference concept. Since then, as the companion papers in this issue point out, several different methods have been developed (e.g., Gill and Hoffman 1982; Horowitz 1979; Schacht et al. 1984). Although these methods differ in the postulated structural composition or components of the transference theme or recurrent relationship theme, they operate from similar methods of assessment. This paper presents the results of an initial investigation into convergent validity (Cronbach and Meehl 1955) of two of the major relationship theme methods--the Core Conflictual Relationship Theme (CCRT) of Luborsky and colleagues (Luborsky 1977), and the Cyclical Maladaptive Pattern (CMP: formerly called the "dynamic focus") of the Vanderbilt group (Schacht et al. 1984; Schacht and Henry, in press). In our investigation, developers of the approaches independently applied their methods to the same interview with a depressed patient. It was hypothesized that aside from differences due to the structural composition, the two methods would identify a similar relationship theme.

Psychotherapy. Can the practitioner learn from the researcher?

Psychotherapy research has often been criticized by practitioners who believe that it has little to offer that can be used in professional practice. However, there is increasing evidence to show that contemporary research in psychotherapy is becoming increasingly relevant for practice. In this article, drawing on extensive research experience, I cite examples illustrating this thesis. My collaborators and I have called particular attention to the damaging consequences of communications that are experienced by patients as pejorative, and we believe that the development of therapist's skills in dealing with patients' negative transference should receive particular attention in training programs.

An appraisal of selection criteria for dynamic psychotherapies and implications for setting time limits.

Practitioners of short-term dynamic psychotherapies commonly hold the working assumption that through rigorous selection procedures the progress to be expected in a specified length of time can be predicted. We question this assumption and draw upon relevant findings from the psychotherapy research literature, as well as from our own clinical and research experiences, to support our skepticism. Without minimizing the demonstrated effectiveness of short-term therapies, we propose that setting prearranged time limits be either replaced or supplemented by the implementation of a "time limited attitude." We further propose that this attitude can contribute to more efficiently conducted treatment, regardless of length. The concept of a time-limited attitude is defined, and the suggestion is made to arrange therapy in defined but flexible durations of treatment rather than by either setting initial termination dates or leaving the time open-ended. Finally, we suggest that the initially proposed length of treatment be determined by the clarity with which a treatment focus can be established. Clinical vignettes are provided to illustrate the relationship between clarity of focus and initially proposed length of treatment.