Psychotherapy Process Research
Attachment & Defenses
Patients’ defensive functioning and attachment security are thought to be important moderators of change in psychotherapy, as well as in the development of psychopathology such as depression. There are various suggested links between defensive processes and attachment. First, attachment theory is arguably a two-person theory of conflict and defense. In contrast to an intrapsychic theory of defense, attachment theory and research locates the ontogeny of defenses in an intersubjective field, as it emphasizes the coping or defensive processes required to deal with fearful arousal within a particular set of relationships. Despite the theoretical links between attachment and defenses, relatively little is known empirically about the patients’ level of attachment security and its changes, in relation to their defensive functioning throughout treatment for depression. Clients with insecure attachment patterns may be less capable of connecting with a therapist and making substantial treatment gains. Studies indicate that individuals with insecure attachments function less optimally over the course of various types of treatment. Similarly, defense mechanisms serve as an individual’s characteristic response to internal or external stressors. Previous analyses have determined that change in defense mechanisms over the course of treatment predicts better treatment.
Ongoing project (together with Dr Bekes & Dr Talia)
The primary aim of our study was to investigate the relationship between depressed patients’ attachment security and their level of defensive functioning as well as the patterns of change over time, in relation to treatment outcome. Specifically, we aim to (1) examine the relationship between patients’ attachment style and defensive functioning at baseline as well as post-treatment. We hypothesized that patients’ secure attachment will be associated with a higher prevalence of mature individual defenses, higher defense levels, as well as higher overall defensive functioning, whereas insecure attachment patterns will be associated with lower level, more immature defenses and lower overall defensive functioning. In addition, we aim to (2) examine whether improvement in defensive functioning is accompanied by improvement in attachment security. We hypothesized that as with improvement in defensive functioning, patients will become more securely attached. Finally, we aim to conduct an exploratory analysis to (3) identify specific relations between the use of particular individual defense mechanisms and particular attachment styles. We use data from a previously conducted randomized controlled study of 30 patients with major depression. Nineteen participants (63%) were female, participants’ mean age was 41 years (SD = 12). Session transcripts have been previously coded for defense mechanisms using the Defense Mechanisms Rating Scales (Perry, 1990), and data about depression severity were collected by the clinician-rated HRSD-17 (Hamilton, 1960) and the self-report BDI-II (Beck, Steer & Brown, 1996) at baseline and at the end of treatment.
Several other projects on the coding of defenses and attachments are on its way.
Defensive Functioning in Psychotherapies for Borderline Personality Disorder
Borderline personality disorder (BPD) is costly, painful, debilitating, and deadly, and thus represents a serious clinical public health concern. For these reasons, clinicians and researchers are interested in understanding how best to treat patients with BPD. A number of promising clinical treatments have been developed and found to be efficacious (Linehan et al. 1991; Bateman & Fonagy, 1999; Clarkin et al., 2007; Geisen-Bloo et al., 2006; Levy et al., 2006). However, the probative value of such studies for understanding a treatment's putative mechanisms of change are indirect and limited.
Theory of some psychotherapies for BPD, and especially Transference-Focused Psychotherapy (TFP) suggests that defensive functioning might be a potential mechanism of change/outcome. We would expect to see an improvement of defense use from the more immature splitting defenses to more mature repression level defenses (pre-post change). We would also expect patients with higher level of defenses to be able to make more use of treatment and show more effective treatments (moderator). Also, comparing good and bad outcome cases, we would expect more effective treatments (symptom reduction) to show more improvement in defensive functioning over treatment.
In order to examine our research questions with regards to defensive functioning, we will start with conducting a small-scale pilot study to identify defenses and defensive change over treatment in a subsample of the larger RCT on TFP, using 30 early TFP sessions and 21 Late TFP sessions. The pilot study will then be extended to include additional sessions from the same patients as well as from patients in the two additional arms of the study (Dialectical Behavior Therapy and Supportive Psychodynamic Psychotherapy).
Understanding Psychoanalytic Process: Comparing the PQS with the APS-DIS
Building on the recent pre-post outcome studies of psychoanalyses, it is useful to further examine precisely just how analysts help patients and to distinguish the presumed benefits of psychoanalytic treatment compared to other forms of psychotherapy. To provide a basic language for the description and comparison of therapy processes in a form suitable for quantitative analysis, Waldron and colleagues previously developed the Analytic Process Scales (APS) and Dynamic Interaction Scales (DIS) recently compressed into six identifiable APS-DIS factors. However, it remains currently unknown how these analytic process items relate to processes identified in psychotherapy process research across different modalities.
The Psychotherapy Process Q-set (PQS), is a comprehensive 100-item observer-rated instrument designed to describe the overall process of therapy in empirical yet clinically relevant terms. It is a commonly used, well-validated observer measure of psychotherapy process, relevant to psychoanalysis, and has previously been applied to a wider spectrum of psychotherapy modalities. Expert prototypes have been developed for different treatment modalities, to generate an ideal treatment process that adheres to the principles of their theoretical perspective.
The current research examines a collection of process analyses of PQS ratings of a sample of 27 psychoanalyses (540 sessions; 20 sessions per treatment). This sample of transcribed sessions is the largest collection available of recorded psychoanalyses. The PQS profiles of these psychoanalytic treatment sessions will further illustrate the nature of these psychoanalyses and allow for comparisons with previously theoretically derived psychoanalytic and psychodynamic PQS prototypes, as well as other treatment modalities. Given the fact that these psychoanalytic treatment sessions were previously coded on the APS-DIS, the comparison with the pan-theoretical PQS will also provide a validation for the APS-DIS and implicate their relative strength and weaknesses related to measuring long term psychoanalytic treatment processes.
We are also currently coding the SWAP, PDM & PACS which will allow us to assess personality change over the course of the analyses.
Dyadic Processes in Psychoanalyses
The therapeutic alliance reflects interactive elements of the counseling process to which both the client and the therapist contribute, (e.g., Horvath & Bedi, 2002). It can be thought of as a measure of fit or match (Kantrowitz et al., 1989), and varies across time depending on the contribution to it by both parties, something that is an ongoing result of the interaction between the client and therapist. To operationalize the interactive and implicit aspects of the alliance in psychoanalytic psychotherapy, the Language Style Matching (LSM) metric is proposed, which is based on computerized text analyses performed using the software Linguistic Inquiry and Word Count (Gonzales, Hancock, & Pennebaker, 2010; Ireland & Pennebaker, 2010). Rather than content-based aspects of language (e.g., using the client’s description of feeling “livid” rather than “angry”), LSM represents the degree to which two people are producing similar rates of function words (e.g., pronouns, prepositions, and conjunctions) in their dialogue (Gonzales et al., 2010).
The levels of overall and reciprocal LSM were calculated for a subsample of seven 20-session treatments from the Psychoanalytic Research Consortium. Per treatment, 20 transcribed sessions were available, reflecting eight early sessions (first year of treatment), four mid sessions (third year of treatment), and eight late-phase sessions (fifth year of treatment). This resulted in a total of 140 examined sessions. In sum, in this treatment sample, early overall LSM appeared to be positively related to change in client functioning over treatment (on the PHI and GAF). Overall treatment levels of LSM appeared to be negatively related to levels of functioning on the GAF in these same early sessions but positively related to change in GAF. Notably, given the very small treatment sample (N _ 7 clients), indications of associations between variables are only exploratory in nature and need to be replicated in statistical analyses of larger samples before they can be interpreted with confidence.
The online therapist: searching for a silver lining during the time of Covid-19
The social restrictions during the COVID-19 crisis led to an en masse transition to remote therapies, despite some therapists’ concerns regarding its efficacy, technical challenges and their ability to build a strong therapeutic relationship online. We developed several online surveys and reached out to therapists via professional listservs and social media. We asked therapists about their experience of providing remote therapy (online via video conferencing and phone), about their perceptions of the therapeutic relationship (working alliance and real relationship) in video sessions compared to previous in-person therapy, their confidence in their professional competence (professional self-doubt) and anxiety related to video therapy, their attitudes towards video therapy technology in general, as well as their intention to continue using video therapy in the future. We received many responses from therapists across the world in April and May. The initial survey responses have been analyzed and are now reported in several publications (Aafjes-van Doorn et al., 2020; Aafjes-van Doorn & Bekes et al., 2020; Bekes & Aafjes-van Doorn, 2020; Bekes et al., 2020).
Taken together, our findings so far suggest that during this sudden switch to remote therapy, therapists and their patients have had relatively positive therapeutic experiences and might have a more positive mindset towards remote therapy going forward. More specifically, we found that: (1) during the pandemic, therapists prepared themselves and their patients for the transition in multiple ways; (2) compared to in-person sessions, the majority of therapists felt similarly confident and competent in their online sessions; (3) despite technical and relational challenges, therapists felt that the therapeutic relationship with their patients remained similarly strong, emotionally connected, and authentic during their online therapy sessions. However, (4) around 15% of therapists experienced high levels of vicarious trauma during the COVID-19 pandemic; and (5) younger and less experienced therapists were less confident and more anxious about providing therapy remotely, and more likely to experience vicarious trauma than more experienced/older therapists. Finally, (6) although the majority still thought that online therapy was less effective than in-person sessions, these experiences during the pandemic resulted in more positive views about online therapy in general, compared to views before. Thus, it seems that this forced transition to online therapy caused by the COVID-19 epidemic might turn out to have some silver lining; however, there is still a need for personal and professional support, especially for younger therapists with less experience, to help ameliorate the challenges of working remotely amidst a global health crisis.
Ongoing research (together with Dr Bekes & Dr Prout)
Our study of therapists’ experiences of online therapy is a work in progress. We are continuing to collect data, not only from therapists but also from patients. This will allow us to compare therapist and patient perspectives on remote therapies. Moreover, we have also started to collect follow-up data from therapists to track how their remote therapy experiences have changed since the start of the pandemic. This follow-up includes interviews with therapists in order to gain a richer insight into the subjective experiences of therapists who have transitioned to a remote therapy format. Taken together, this type of large-scale, longitudinal, mixed-method research design, drawn from multiple perspectives, will provide a comprehensive picture of the remote therapy experience, which will be useful for therapists, patients, and supervisors.
Current studies being analyzed and written up include:
What predicts resilience of therapists (vicarious trauma)?
International comparison of online therapy transitions
Validation of the UTAUT (scale to assess therapists’ attitudes to online therapy)
Defensive functioning and professional lives of online therapists during COVID-19
It has become increasingly clear that psychotherapy training, like therapy itself, is not one-size-fits-all. Research shows the effectiveness of therapy does not increase over time or with experience (see Miller, Hubbard & Chow, 2018 for a summary). Furthermore, evidence concerning the impact of supervision on client outcomes is mixed (Bernard & Goodyear, 2014; Rousmaniere, Swift, Babins‐Wagner, Whipple, & Berzins, 2016). These findings point to a critical question; how do we improve therapist effectiveness? Personalizing training might be an answer. Deliberate Practice (DP) and the Facilitative Interpersonal Skills (FIS) – may be applied to personalize therapist training.
Deliberate Practice" refers to a specific method of training in psychotherapy. In many professions and skills that require excellence (e.g. music, sports, surgery, chess), people practice over and over with micro-skills - for example, in music, doing scales, practicing chords, studying music theory, doing transpositions. Deliberate practice for psychotherapy, introduced by Rousmaniere and colleagues, is a training approach that emphasizes repeated practice and feedback on target skills, which can be individualized to improve therapist effectiveness. In psychotherapy training, we don't usually have many opportunities to practice these things with immediate feedback from an expert, to re-watch our performance and reflect on it, and then to try again. So much of what we do is on-the-job training. So, deliberate practice gives practitioners (of any experience level) an opportunity to practice in a very specific and targeted way. In the child psychodynamic practicum, for example, we use it to help students increase their ability to tolerate difficult and painful affect, reflect on their own countertransference, explore the impulses/urges/wishes they have with regard to the patient, and to connect to their somatic/physiological experience during intense clinical moments. There is also a book coming out from APA that focuses on deliberate practice for psychodynamic psychotherapy and members of Division 39 have been involved with this. The approach has great synergy with psychoanalytic work and it can be really helpful in your clinical practice and work as a supervisor. The deliberate practice website has a lot of resources on it that probably explain it much better than I can! www.dpfortherapists.com . Expert therapist Jon Frederickson also has a website specifically designed for these types of deliberate practice exercises (https://deliberatepracticeinpsychotherapy.com)
Ongoing project (in collaboration with Dr Bate & Dr Prout)
There is preliminary evidence that deliberate practice (DP) improves self-efficacy in interpersonal skills, alliance, and patient outcomes; however, there are no published studies of DP in doctoral-level psychodynamic psychotherapy training. This presentation will report on the development and implementation of a DP curriculum in a clinical psychology doctoral program, and the impact of utilizing deliberate practice techniques on therapist interpersonal skills and experiential avoidance. Two forms of DP were implemented in a year-long practicum course in psychodynamic child psychotherapy. The first semester focused on development of intrapsychic skills using Rousmaniere’s handbook, while the second semester emphasized practicing interpersonal skills using the online platform Theravue. Self-reported and observed therapist qualities were assessed at baseline, midyear, and at the end of the academic year. Forty trainees have participated in this ongoing project thus far. We expect that trainees will report increased mindfulness, reflective functioning, and emotional processing and decreased emotional avoidance and affect phobia after 15 weeks of exercises. We expect trainees will demonstrate significant improvements on facilitative interpersonal skills (FIS) in their video simulation responses (as coded by independent raters). Finally, we predict trainees will report an increasing range of countertransference feelings over the course of the training. Implications and recommendations for clinical training and assessment of clinical skills will be discussed. Attendees will be encouraged to participate in discussion of how we can build greater clinical competence among trainees and how DP and FIS can be utilized to personalize training and improve outcomes.
Evidence-based psychodynamic psychotherapy graduate training
In therapy, we expect patients to reflect on their experience and tolerate the anxiety of the unknown therapeutic process and outcome. Therapists and administrators of mental health services should take even greater responsibility for examining and tolerating their own anxieties around the complexities of the psychotherapeutic process. It is important to remember that empirically supported treatments are only one aspect of evidence-based practice; patient involvement and clinical expertise are also critical aspects of evidence-based practice. Fully integrating all three aspects into the psychotherapeutic work may introduce greater anxiety in all parties involved, but the benefits of doing so are worth the cost. Many clinicians hold misperceptions about evidence-based practice , and evidence-based psychodynamic therapy (PDT) in particular. It is important to address these beliefs and attitudes in postgraduate training and help students to consider interventions from a range of theoretical orientations.
Ongoing project (in collaboration with Dr Prout)
We continuously examine the pre-post change following a required 15-week course in evidence-based PDT within two graduate psychology doctoral programs. As of now, around 100 students completed measures of attitudes toward EBP and PDT prior to the first class and after the final class. As expected, following the course, student attitudes became more favorable toward specific aspects of EBP and towards PDT overall. Interestingly, the students who were in personal therapy held more positive views about PDT and sustained their positive attitude during the course. Students who identified as PDT-oriented prior to the course, had a less favorable attitude towards EBP, but this did not impact the level of change in attitude towards EBP. The opposite was true for CBT-oriented students who viewed PDT less positively before the course, but attitudes became more favorable after the course. The results support the use of postgraduate training in evidence-based PDT to improve attitudes toward specific aspects of EBP and PDT, and highlight the potential importance of personal therapy and pre-training identified orientation. Future research is warranted to examine if these graduate courses lead to use of more effective practices with patients following training.
Facilitative Interpersonal Skills
Interpersonal skills are critical to the effectiveness of mental health care, across a range of modalities and disciplines. Thus, trainings to improve interpersonal skills may improve patient care and outcomes.
The Facilitative Interpersonal Skills paradigm (FIS; Anderson et al., 2009; 2015; 2016) operationalizes relational factors that can be observed in therapists’ responses to a standardized set of videos of therapeutic situations, and offers a lens to identify and provide feedback on skills. The measurement of FIS is based on a performance-based method that simulates situations in psychotherapy. In the FIS performance analysis method, participants are asked to imagine that they are in the middle of an interpersonal exchange. Participants watch several video recorded clips of actual therapy sessions that are performed by actors. At critical points, the video recording stops and participants are asked to respond to the client on the tape as if they were the therapist. These responses are recorded and coded by raters using the FIS coding manual. The performance analysis is used to rate helpers and therapists' job performance in this artificial, but realistic situation. The potential use of performance-based data is that it differs from self-reports of the participants (therapists) and also has shown some validity in predicting aspects of actual psychotherapy. As one example of these self-report issues in psychotherapy, all psychotherapists assessed that their psychotherapy outcomes were – on average – in the upper 50th percentile (Lambert, 2010). The initial development of FIS was for the practical purpose of selecting therapists in an initial study of therapist skills (Anderson, Crowley, et al., 2016).
Facilitative Interperonal Skills (FIS) are relevant to most psychological interventions and arguably should be taught in all basic therapy skills trainings. However, at the moment, FIS training has limited scaleability because coding and feedback to students about their responses to the stimulus clips is time consuming. Also, codings remain subjective and somewhat variable even with reliable coders. To help solve this problem, recent developments in machine learning can be applied to FIS coded-data (training algothitms on larger multi-coded datasets of responses to these brief standardized stimulus clips) and possibly generate automated FIS codings. First we will report on the development of a proof of concept where machine learning algorithms based on the analysis of the trainee’s facial expression and speech patterns provide near-time feedback on some of the FIS dimensions. These advanced FIS training methods will allow a trainee to compare their responses with the average ratings as well as a designated gold standard responses. Second, we will highlight opportunities to improve process coding, such as the FIS by a) developing more detailed observable operationalizations of rating scales, and b) show exploratory machine learning analyses that identify novel observable charactistics not yet specified in the existing rating scale descriptions. Ultimately, we aim to develop a machine learning algorithm that will offer a quick and reliable clinical feedback that could be used for deliberate practice there and then, without the help of a supervisor.
Training in Interpersonal skills
The current research project aims to expand the application of these two bodies of research that both inform the development of training in relational, interpersonal, and alliance focused skills by testing out a training model called Facilitative Interpersonal Relationship Skills Training (FIRST), which utilizes video-based practice and experiential exercises to target internal and behavioral skills that aim to increase FIS. Based on Anderson’s Facilitative Interpersonal Skills (FIS) paradigm the FIRST is a four-module workshop that uses the FIS task to guide assessment, development and of eight interpersonal skills.
Ongoing research (in collaboration with Dr Bate)
This ongoing research will evaluate the effectiveness of training modalities (workshops and supervision) that aim to increase staff’s interpersonal and relational skills in their clinical practice, within a naturalistic hospital setting. Before and after the training, participants will complete the FIS task, and self-report measures of empathy, mindfulness, adaptive affective functioning, and burnout. We hypothesize that in both groups FIRST will be associated with increases in FIS scores, as well as self-reported emotion-related capacities. Discussion will focus on initial results, pedagogical challenges and successes training interpersonal skills in the hospital setting, and personalization of training for target groups.
Scaling up Session-by-Session feedback by using Machine Learning Tools
Feedback is important for all clinicians, no matter their level of experience or therapeutic approach. However, in clinical practice and clinical training it is sometimes hard to find the time to review session recordings and determine exactly which patients, or what skills to focus on. Also, session-by-session feedback has traditionally been based on patient or therapist self-report and observer-rated measures that are biased are very time-consuming. To make it easier for therapists to engage in effective deliberate practice, more objective and instant indicators of treatment process and progress are needed. We propose that recent developments in machine learning, when applied to audio/video recorded treatments, can empower the therapist and facilitate their professional development. In a recent scoping review of machine learning applications in psychotherapy and identify ways in which machine learning can advance therapist training and practice. We will also present several proof of concept empirical applications of natural language processing, and analyses of speech and facial movements that might benefit the therapist’s supervision and skill development. With the help of these advanced computerized tools, therapists can use objective data of therapy adherence, common factors and symptom change for supervision and deliberate practice and thus help their professional development and patient wellbeing flourish.
Psychodynamic Skills Training for Licensed Clinicians
It has long been known that therapists are not uniformly effective (Nissen-lie et al. 2016), there is relatively little research on training in psychotherapy, there is very little known about how licensed therapists can be trained to become more effective therapists. When it comes to training and supervision for experienced therapists, two facts are apparent. The first, is that most practicing therapists want to get better at what they do. This is not only a shared goal; it is a core value. The second is that the current state of the empirical literature on training effects for experienced therapists and their patients remains surprisingly underdeveloped in this era of ‘evidence-based practice’. The effectiveness of training and supervision may be assessed with regards to different types of outcomes, conceptualized by the Therapist Training Evaluation Outcomes Framework (TTEOF; Decker Jameson, & Naugle, 2011).
An important aspect of the practice of ISTDP is its intense deliberate practice supervision that the ISTDP therapists undertake throughout their professional careers. ISTDP therapists usually attend at least one Core training program (which includes 4 training weekends a year for 3 years, with detailed feedback from a master therapists on videorecorded therapy sessions in between training weekends), and continue to videorecord their therapy sessions for regular supervision by an expert therapist. For ISTDP therapists the recording of therapy sessions for training purposes is the norm, and consistent with training and best practices in the field of clinical psychology (Gaudiano, Dalrymple, D’Avanzato, & Bunaciu, 2016). Many of these training recordings are being used for research purposes in posthoc psychotherapy studies using observer-based process measures (Town et al. 2012).
The general aim of this research is to evaluate a 3-year long ISTDP Core training program not only with regards to self-reported skills of the participating therapists, but also by tracking their subsequent patient treatment outcomes. Besides collecting therapist self-report data at the time of each of the 12 training weekends, we aim to create a databank comprised of psychotherapy session videos and session-by-session questionnaire measures collected by the therapists who attend the ISTDP Core training program. During the course of the ISTDP Core training program participating therapists will obtain patient consent to allow for videos and session-by-session outcome measures to be kept and utilized for future research studies. Maintaining these data for research purposes would create valuable opportunities for psychotherapy research projects on the processes and the effectiveness of ISTDP psychotherapy training and treatment sessions, thus informing future mental health care delivery and clinician training. More specifically, we aim to evaluate the effect of the ISTDP Core training program for therapists by tracking the progress of 8 participating therapists and their patients in private practice. We aim to evaluate the effect of training on the following dimensions: 1) Therapist self-reported changes assessed 4 times per year before each training weekend in an online survey. 2) Patient self-reported session-by-session process (after each session: WAI-P-SF & SEQ) and outcome (before each session: OQ-45); 3)Analyses of video-recorded sessions for observer-coded treatment adherence and process analyses over time.