Moment-by-moment interpersonal behaviors in poor vs. good psychodynamic psychotherapy outcomes: Does complementarity say it all?

Submitted: February 12, 2020
Accepted: June 29, 2020
Published: September 17, 2020
Abstract Views: 665
PDF: 429
HTML: 50
Publisher's note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Authors

Can patient-therapist moment-by-moment transactions uncover contrary treatment outcomes? The current study answers this question by analyzing the transcripts from eight therapy sessions of 20 patients each, for a total of 160 sessions and nearly 30,000 units of analysis. Patients were matched into ten pairs, each having the same diagnosis and the same clinician but with opposite treatment results: Ten patients were classified as responders (i.e., good-outcome patients) and as many as nonresponders (i.e., poor-outcome patients). Patient and therapist behaviors were coded using the Structural Analysis of Social Behavior (SASB) model. Overall, patients and therapists engaged in complementary relational patterns: Good-outcome patients tended to adopt loving and protecting interaction styles, similarly, therapists treating good-outcome cases employed protection and self-disclosure behaviors. In contrast, poor-outcome patients tried to interpersonally separate from the therapist, and both—patients and therapists alike—exhibited attacking and recoiling behaviors. However, when taking a closer look, i) separation appeared to be disruptive per se, that is, beyond any evidenced interpersonal asymmetry; ii) self-disclosure on the therapist side turned out to be supportive of therapeutic complementarity; iii) when facing failure, highly experienced therapists seemed to indulge into noncomplementary or even hostile behaviors. Findings confirm that the target of the patient- therapist transferential transactions should be distinguished from transactions regarding other people or other life circumstances in order to avoid misleading interpretation of data and, consequently, conducting therapy based on misleading grounds.

Dimensions

Altmetric

PlumX Metrics

Downloads

Download data is not yet available.

Citations

Accordini, M., Browning, S., Gennari, M., McCarthy, K., & Margola, D. (2017). Till the ocean do us part: Italian and American therapists’ representations of stepfamilies in treatment. Research in Psychotherapy: Psychopathology, Process and Outcome, 20, 187–200. DOI: https://doi.org/10.4081/ripppo.2017.271
Ackerman, S. J., & Hilsenroth, M. J. (2001). A review of therapist characteristics and techniques negatively impacting the therapeutic alliance. Psychotherapy, 38, 171–185. DOI: https://doi.org/10.1037/0033-3204.38.2.171
Ahmed, M., Westra, H. A., & Constantino, M. J. (2012). Early therapy interpersonal process differentiating clients high and low in outcome expectations. Psychotherapy Research, 22, 731–745. DOI: https://doi.org/10.1080/10503307.2012.724538
Aliprandi, M., Capelli, L., & Marchesi, L. (2009). Analisi Strutturale del Comportamento Sociale (SASB) [Structural Analysis of Social Behavior (SASB)]. In M. Vigorelli (Ed.), Laboratorio didattico per la ricerca in psicoterapia [The psychotherapy research lab] (pp. 14–22). Milan, Italy: Cortina.
Allport, G. W. (1937). Personality: A psychological interpretation. New York, NY: Holt.
Amadei, G. (2001). Il paradigma celato. Il modello interpersonale nella psicologia dinamica [The hidden paradigm: Interpersonal models in dynamic psychology]. Milan, Italy: Unicopli.
American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders: Text revision (4th ed.). Washington, DC: American Psychiatric Association.
Anchin, J. C., & Kiesler, D. J. (1982). Handbook of interpersonal psychotherapy. New York, NY: Pergamon.
Anderson, T., Knobloch-Fedders, L. M., Stiles, W. B., Ordoñez, T., & Heckman, B. D. (2012). The power of subtle interpersonal hostility in psychodynamic psychotherapy: A speech acts analysis. Psychotherapy Research, 22, 348–362. DOI: https://doi.org/10.1080/10503307.2012.658097
Benjamin, L. S. (1974). Structural Analysis of Social Behavior. Psychological Review, 81, 392–425. DOI: https://doi.org/10.1037/h0037024
Benjamin, L. S. (1979). Use of Structural Analysis of Social Behavior (SASB) and Markov chains to study dyadic interactions. Journal of Abnormal Psychology, 88, 303–319. DOI: https://doi.org/10.1037/0021-843X.88.3.303
Benjamin, L. S. (1984). Principles of prediction using Structural Analysis of Social Behavior. In R. A. Zucker, J. Aronoff, & A. J. Rabin (Eds.), Personality and the prediction of behavior (pp. 121–173). New York, NY: Academic Press.
Benjamin, L. S. (1994). SASB: A bridge between personality theory and clinical psychology. Psychological Inquiry, 5, 273–316. DOI: https://doi.org/10.1207/s15327965pli0504_1
Benjamin, L. S. (2002). Interpersonal diagnosis and treatment of personality disorders (2nd ed.). New York, NY: Guilford.
Benjamin, L. S. (2003). Interpersonal reconstructive therapy: Promoting change in nonresponders. New York, NY: Guilford.
Benjamin, L. S., Rothweiler, J. C., & Critchfield, K. L. (2006). The use of Structural Analysis of Social Behavior (SASB) as an assessment tool. Annual Review of Clinical Psychology, 2, 83–109. DOI: https://doi.org/10.1146/annurev.clinpsy.2.022305.095337
Beutler, L. E. (2000). David and Goliath: When empirical and clinical standards of practice meet. American Psychologist, 55, 997–1007. DOI: https://doi.org/10.1037/0003-066X.55.9.997
Beutler, L. E., Rocco, F., Moleiro, C. M., & Talebi, H. (2001). Resistance. Psychotherapy, 38, 431–436. DOI: https://doi.org/10.1037/0033-3204.38.4.431
Beutler, L. E., Malik, M., Alimohamed, S., Harwood, T. M., Talebi, H., Noble, S., & Wong, E. (2004). Therapist variables. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed., pp. 227–306). New York, NY: Wiley.
Bion, W. R. (1963). Elements of psycho-analysis. New York, NY: Jason Aronson.
Blomberg, J., Lazar, A., & Sandell, R. (2001). Long-term outcome of long-term psychoanalytically oriented therapies: First findings of the Stockholm outcome of psychotherapy and psychoanalysis study. Psychotherapy Research, 11, 361–382. DOI: https://doi.org/10.1093/ptr/11.4.361
Capelli, L., Fava, E., Taglietti, S., Aliprandi, M., Arduini, L., Freni, S., Schadee, H., & Vigorelli, M. (2005). Relazione interpersonale ed esiti terapeutici: applicazioni del metodo SASB [Interpersonal relationship and therapeutic outcome: Applications of the SASB method]. Ricerca in Psicoterapia, 8, 195–236.
Caspar, F., Grossmann, C., Unmüssig, C., & Schramm, E. (2005). Complementary therapeutic relationship: Therapist behavior, interpersonal patterns, and therapeutic effects. Psychotherapy Research, 15, 91–102. DOI: https://doi.org/10.1080/10503300512331327074
Coady, N. F. (1991). The association between client and therapist interpersonal processes and outcomes in psychodynamic psychotherapy. Research on Social Work Practice, 1, 122–138. DOI: https://doi.org/10.1177/104973159100100202
Cohen, J. (1968). Weighted kappa: Nominal scale agreement with provision for scaled disagreement or partial credit. Psychological Bulletin, 70, 213–220. DOI: https://doi.org/10.1037/h0026256
Constantino, M. J. (2000). Interpersonal process in psychotherapy through the lens of the Structural Analysis of Social Behavior. Applied and Preventive Psychology, 9, 153–172. DOI: https://doi.org/10.1016/S0962-1849(05)80002-2
Critchfield, K. L., Henry, W. P., Castonguay, L. G., & Borkovec, T. D. (2007). Interpersonal process and outcome in variants of cognitive-behavioral psychotherapy. Journal of Clinical Psychology, 63, 31–51. DOI: https://doi.org/10.1002/jclp.20329
Derogatis, L. R. (1994). Symptom Checklist-90-R: Administration, scoring, and procedures manual (3rd ed.). Minneapolis, MN: National Computer Systems.
Fava, E., & Vigorelli, M. (2006). La valutazione del processo terapeutico attraverso un modello circomplesso: la SASB di Lorna Benjamin [The evaluation of therapeutic processes through a circumplex model: The Lorna Benjamin’s SASB model]. In N. Dazzi, V. Lingiardi, & A. Colli (Eds.), La ricerca in psicoterapia. Modelli e strumenti [Psychotherapy research: Models and instruments] (pp. 691–711). Milan, Italy: Cortina.
Ferrari, A., Pinzi, C., Camarda, P., & Roustayan, C. (2005). Valutazione a lungo termine dell’effectiveness della psicoterapia supportivo-espressiva in un contesto pubblico: esiti, follow-up, drop-out e predittori [Supportive-expressive psychotherapy long-term evaluation and effectiveness in an outpatients’ clinic: Outcomes, follow-ups, dropouts, and predictors]. Giornale Italiano di Psicopatologia, 11, 32–37.
Fleiss, J. L., & Cohen, J. (1973). The equivalence of weighted kappa and the intraclass correlation coefficient as measures of reliability. Educational and Psychological Measurement, 33, 613–619. DOI: https://doi.org/10.1177/001316447303300309
Freud, S. (1920). Beyond the pleasure principle. S.E., Vol. 18 (pp. 1–64). London, UK: Hogarth Press, 1991.
Frommer, J., & Rennie, D. L. (2001). Qualitative psychotherapy research: Methods and methodology. Lengerich, Germany: Pabst Science.
Gabbard, G. O., Horwitz, L., Allen, J. G., Frieswyk, S., Newsom, G., Colson, D. B., et al. (1994). Transference interpretation in the psychotherapy of borderline patients: A high-risk, high-gain phenomenon. Harvard Review of Psychiatry, 2, 59–69. DOI: https://doi.org/10.3109/10673229409017119
Gelso, C. J. (2009). The real relationship in a postmodern world: Theoretical and empirical explorations. Psychotherapy Research, 19, 253–264. DOI: https://doi.org/10.1080/10503300802389242
Henry, W. P. (1996). The Structural Analysis of Social Behavior as a common metric for programmatic psychotherapy research. Journal of Consulting and Clinical Psychology, 64, 1263–1275. DOI: https://doi.org/10.1037/0022-006X.64.6.1263
Henry, W. P., & Strupp, H. H. (1994). The therapeutic alliance as interpersonal process. In A. O. Horvath, & L. S. Greenberg (Eds.), The working alliance: Theory, research, and practice (pp. 51–84). New York, NY: Wiley.
Henry, W. P., Schacht, T. E., & Strupp, H. H. (1986). Structural Analysis of Social Behavior: Application to a study of interpersonal process in differential psychotherapeutic outcome. Journal of Consulting and Clinical Psychology, 54, 27–31. DOI: https://doi.org/10.1037/0022-006X.54.1.27
Henry, W. P., Schacht, T. E., & Strupp, H. H. (1990). Patient and therapist introject, interpersonal process, and differential psychotherapy outcome. Journal of Consulting and Clinical Psychology, 58, 768–774. DOI: https://doi.org/10.1037/0022-006X.58.6.768
Henry, W. P., Schacht, T. E., Strupp, H. H., Butler, S. F., & Binder, J. L. (1993). Effects of training in time-limited dynamic psychotherapy: Mediators of therapists’ responses to training. Journal of Consulting and Clinical Psychology, 61, 441–447. DOI: https://doi.org/10.1037/0022-006X.61.3.441
Hill, C. E., & Knox, S. (2009). Processing the therapeutic relationship. Psychotherapy Research, 19, 13–29. DOI: https://doi.org/10.1080/10503300802621206
Hilliard, R. B., Henry, W. P., & Strupp, H. H. (2000). An interpersonal model of psychotherapy: Linking patient and therapist developmental history, therapeutic process, and types of outcome. Journal of Consulting and Clinical Psychology, 68, 125–133. DOI: https://doi.org/10.1037/0022-006X.68.1.125
Hilsenroth, M. J., & Segal, D. L. (Eds.) (2004). Comprehensive handbook of psychological assessment. Vol. 2. Personality assessment. New York, NY: Wiley.
Høglend, P., & Gabbard, G. O. (2012). When is transference work useful in psychodynamic psychotherapy? A review of empirical research. In R. A. Levy, J. S. Ablon, & H. Kächele (Eds.), Psychodynamic psychotherapy research: Evidence-based practice and practice-based evidence (pp. 449–470). Totowa, NJ: Springer.
Horney, K. (1936). The problem of the negative therapeutic reaction. Psychoanalytic Quarterly, 5, 29–44. DOI: https://doi.org/10.1080/21674086.1936.11925271
Horvath, A. O., Del Re, A. C., Flückiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48, 9–16. DOI: https://doi.org/10.1037/a0022186
Howard, K. I., Kopta, S. M., Krause, M. S., & Orlinsky, D. E. (1986). The dose-effect relationship in psychotherapy. American Psychologist, 41, 159–164. DOI: https://doi.org/10.1037/0003-066X.41.2.159
Jacobson, N. S. (1988). Defining clinically significant change: An introduction. Behavioral Assessment, 10, 131–132.
Jacobson, N. S., Follette, W. C., & Revenstorf, D. (1984). Toward a standard definition of clinically significant change. Behavior Therapy, 17, 308–311. DOI: https://doi.org/10.1016/S0005-7894(86)80061-2
Keijsers, G. P., Schaap, C. P., & Hoogduin, C. A. (2000). The impact of interpersonal patient and therapist behavior on outcome in cognitive-behavior therapy: A review of empirical studies. Behavior Modification, 24, 264–297. DOI: https://doi.org/10.1177/0145445500242006
Lambert, M. J., & Barley, D. E. (2001). Research summary on the therapeutic relationship and psychotherapy outcome. Psychotherapy, 38, 357–361. DOI: https://doi.org/10.1037/0033-3204.38.4.357
Lambert, M. J., & Ogles, B. M. (2004). The efficacy and effectiveness of psychotherapy. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed., pp. 139–193). New York, NY: Wiley.
Lepper, G., & Riding, N. (2006). Researching the psychotherapy process: A practical guide to transcript-based methods. London, UK: Palgrave Macmillan. DOI: https://doi.org/10.1007/978-1-137-03872-2
Lingiardi, V., & Muzi, L. (2018). Il Manuale Diagnostico Psicodinamico (PDM-2): un’occasione di dialogo interdisciplinare [The Psychodynamic Diagnostic Manual (PDM-2): An opportunity to enhance an interdisciplinary dialogue]. Giornale Italiano di Psicologia, 45, 781–804.
Lingiardi, V., Muzi, L., Tanzilli, A., & Carone, N. (2018). Do therapists’ subjective variables impact on psychodynamic psychotherapy outcomes? A systematic literature review. Clinical Psychology and Psychotherapy, 25, 85–101. DOI: https://doi.org/10.1002/cpp.2131
Lord, F. M., & Novick, M. R. (1968). Statistical theories of mental test scores. Reading, MA: Addison-Wesley.
Luborsky, L., & Crits-Christoph, P. (1990). Understanding transference. The CCRT method. New York, NY: Basic Books.
Luca M., Ruta S., Signorelli M., Petralia A., & Aguglia E. (2015). Variabili psicologiche e consumo di alcol in un campione di studenti di medicina: differenze di genere [Psychological variables and alcohol consumption in a sample of students of medicine: Gender differences]. Rivista di Psichiatria, 50, 38–42.
Lutz, W., Lambert, M. J., Harmon, S. C., Tschitsaz, A., Schürch, E., & Stulz, N. (2006). The probability of treatment success, failure, and duration: What can be learned from empirical data to support decision making in clinical practice? Clinical Psychology and Psychotherapy, 13, 223–232. DOI: https://doi.org/10.1002/cpp.496
Mahrer, A. R. (1999). Embarrassing problems for the field of psychotherapy. Journal of Clinical Psychology, 55, 1147–1156. DOI: https://doi.org/10.1002/(SICI)1097-4679(199909)55:9<1147::AID-JCLP11>3.0.CO;2-E
Margola, D. (2020). I disturbi di personalità. Per una sintesi clinicamente fondata: il Basic and Continuum-focused Diagnostic Model (BCDM) [Personality disorders. Towards a clinically informative synthesis: The Basic and Continuum-focused Diagnostic Model (BCDM)]. In D. Margola, Introduzione alla psicopatologia. Dalla nosografia individuale al legame di coppia [Introduction to psychopathology: From individual nosography to the couple relationship] (pp. 17–22). Milan, Italy: EDUCatt.
Margola, D., Donato, S., Accordini, M., Emery, R. E., & Snyder, D. K. (2018). Dyadic coping in couple therapy process: An exploratory study. Family Process, 57, 324–341. DOI: https://doi.org/10.1111/famp.12304
McWilliams, N. (2011). Psychoanalytical diagnosis. Understanding personality structure in the clinical process. New York, NY: Guilford.
Norcross, J. C., & Wampold, B. E. (2011). Evidence-based therapy relationships: Research conclusions and clinical practices. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed., pp. 423–430). New York, NY: Oxford University Press.
Orlinsky, D. E., Rønnestad, M. H., & Willutzki, U. (2004). Fifty years of psychotherapy process-outcome research: Continuity and change. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed., pp. 307–389). New York, NY: Wiley.
Pincus, A. L., Dickinson, K. A., Schut, A. J., Castonguay, L. G., & Bedics, J. (1999). Integrating interpersonal assessment and adult attachment using SASB. European Journal of Psychological Assessment, 15, 206–220. DOI: https://doi.org/10.1027//1015-5759.15.3.206
Riviere, J. (1936). A contribution to the analysis of the negative therapeutic reaction. The International Journal of Psychoanalysis, 17, 304–320.
Samstag, L. W. (1998). Difficult dyads and unsuccessful treatments: A comparison of dropout, poor, and good outcome groups in brief psychotherapy. ProQuest Dissertations & Theses.
Samstag, L. W., Muran, J. C., Wachtel, P. L., Slade, A., Safran, J. D., & Winston, A. (2008). Evaluating negative process: A comparison of working alliance, interpersonal behavior, and narrative coherency among three psychotherapy outcome conditions. American Journal of Psychotherapy, 62, 165–194. DOI: https://doi.org/10.1176/appi.psychotherapy.2008.62.2.165
Schmitz, N., Hartkamp, N., Brinschwitz, C., Michalek, S., & Tress, W. (2000). Comparison of the standard and the computerized versions of the Symptom Checklist (SCL-90-R): A randomized trial. Acta Psychiatrica Scandinavica, 102, 147–152. DOI: https://doi.org/10.1034/j.1600-0447.2000.102002147.x
Schurle Bruce, A., & Arnett, P. A. (2008). Longitudinal study of the Symptom Checklist 90-Revised in multiple sclerosis patients. The Clinical Neuropsychologist, 22, 46–59. DOI: https://doi.org/10.1080/13854040601064518
Stein, D. M., & Lambert, M. J. (1984). On the relationship between therapist experience and psychotherapy outcome. Clinical Psychology Review, 4, 1–16. DOI: https://doi.org/10.1016/0272-7358(84)90025-4
Tanzilli, A., Muzi, L., Ronningstam, E., & Lingiardi, V. (2017). Countertransference when working with narcissistic personality disorder: An empirical investigation. Psychotherapy, 54, 184–194. DOI: https://doi.org/10.1037/pst0000111
Tasca, G. A., Foot, M., Leite, C., Maxwell, H., Balfour, L., & Bissada, H. (2011). Interpersonal processes in psychodynamic-interpersonal and cognitive behavioral group therapy: A systematic case study of two groups. Psychotherapy, 48, 260–273. DOI: https://doi.org/10.1037/a0023928
Thompson, K., Schwartzman, D., D’Iuso, D., Dobson, K. S., & Drapeau, M. (2018). Client and therapist interpersonal behaviour in cognitive therapy for depression. Canadian Journal of Counselling and Psychotherapy, 52, 229–249.
von der Lippe, A. L., Monsen, J. T., Rønnestad, M. H., & Eilertsen, D. E. (2008). Treatment failure in psychotherapy: The pull of hostility. Psychotherapy Research, 18, 420–432. DOI: https://doi.org/10.1080/10503300701810793
Waddington, L. (2002). The therapy relationship in cognitive therapy: A review. Behavioural and Cognitive Psychotherapy, 30, 179–191. DOI: https://doi.org/10.1017/S1352465802002059
Wong, K., & Pos, A. E. (2012). Interpersonal processes affecting early alliance formation in experiential therapy for depression. Psychotherapy Research, 1, 1–11.

How to Cite

Margola, D., Accordini, M., & Fava, E. (2020). Moment-by-moment interpersonal behaviors in poor vs. good psychodynamic psychotherapy outcomes: Does complementarity say it all?. Research in Psychotherapy: Psychopathology, Process and Outcome, 23(2). https://doi.org/10.4081/ripppo.2020.454