Abstract
Research shows that psychotherapy leads to improved outcomes, including a reduction in psychological symptoms, an increase in daily functioning, and improvement in subjective well-being and quality of life (American Psychological Association 2012; Shedler 2010; Barber et al. 2013). A new wave of research is moving beyond the question of whether treatment works and examining how and why treatment works by identifying the active ingredients.
Researchers have identified several predictors of successful outcomes and components of effective treatments, including alliance strength, therapist technique, and therapist countertransference (Owen, Hilsenroth, and Rodolfa 2013; Owen and Hilsenroth 2011; Imel et al. 2013; DeFife, Hilsenroth, and Gold 2008; Barber et al. 2013; Betan and Westen 2009).
Theorists, researchers, and clinicians alike have argued that the therapeutic relationship between client and therapist may be one of the most significant contributors to positive outcomes (Bordin 1994; Crits-Christoph, Gibbons, and Mukherjee 2013). In a meta-analysis of seventy-nine studies, Martin, Gaske, and Davis (2009) showed that the overall relationship between alliance and outcome is moderate but consistent, showing a correlation of .27 across many studies. Thus, the meta-analysis clearly showed that patients who have stronger relationships with their therapists consistently have better outcomes. Further, Falkenström, Granström, and Holmqvist (2013) found in a sample of 646 patients not only that stronger alliance is related to more positive outcomes across the overall span of treatment, but that higher patient alliance ratings after a given session are related to lower symptom ratings at the next session.
Another active ingredient in treatment is the therapist’s use of therapeutic techniques. Therapeutic techniques are the specific methods or interventions used by therapists to help patients make changes in themselves and in their lives. As noted by Hilsenroth et al. (2005), different therapeutic orientations (e.g., psychodynamic or cognitive-behavioral) stress the use of different techniques, especially when examined in experimental studies emphasizing adherence to treatment manuals. However, in the “real world” of psychotherapy as delivered in naturalistic settings such as clinics and hospitals, therapists may employ techniques from multiple orientations in order to maximize positive outcome. Research on therapist use of techniques demonstrates that a wide array of techniques foster positive outcomes. Some researchers (e.g., D’Andrea and Pole 2012, DeRubeis and Feeley 1990) stress the positive outcomes of specific types of treatment, such as CBT or psychodynamic psychotherapy, while others take a more integrative approach to understand which specific elements of different therapeutic techniques lead to symptom reduction and improved functioning.
Patients’ attitudes and expectations regarding relationships may be expressed and represented through the feelings they bring out in their therapist. Patients may also have beliefs about themselves that they elicit from their therapists (Klein 1946; Gabbard 1991). Thus, understanding how therapists feel about their patients can be informative and useful in conducting psychotherapy. In an attempt to lend empirical support to this concept, researchers have demonstrated that patients sensitive to self-criticism in fact tend to elicit criticism from others and thus confirm their expectations (Downey et al. 1998). Geisler, Josephs, and Swann (1996) demonstrated that in clinical settings depressed patients prefer to receive negative feedback that confirms their negative self-view. Therapist countertransference can thus be useful in understanding patient’s repetitive interpersonal patterns as they relate to psychological symptoms and distress. The understanding of therapist countertransference and how it relates to the interpersonal functioning of clients, as well as to therapeutic technique and alliance strength, could lead to further understanding of the mechanisms of psychotherapy.
Method
In this study patients complete measures at intake and termination, as well as at 3, 6, 12, 18, and 24 months throughout therapy. Measures assessing alliance and technique are included beginning at the three-month mark. Measures include the following.
Combined Alliance Short-Form (CASF; Hatcher and Barends 1996). Patients and therapists both report on alliance strength as measured by the CASF, which uses 31 items to assess four dimensions of alliance in patients: confident collaboration, agreement on goals and tasks, bond, and disagreement with therapist. The therapist version uses 40 items to assess seven dimensions of alliance: shared goals, bond, disagreement on goals and tasks, therapist confidence in treatment, patient working engagement, therapist understanding, and patient confidence and commitment.
Comparative Psychotherapy Process Scale (CPPS; Hilsenroth et al. 2005). The CPPS, given to both therapist and patient, rates therapist technique on 20 items along two subscales: Psychodynamic-Interpersonal, characterized by items emphasizing specific psychodynamic techniques (e.g., “My therapist encourages me to explore feelings that are hard for me to talk about [e.g. anger, envy, excitement, sadness, or happiness]),” and Cognitive-Behavioral, including items assessing CBT techniques (e.g., “My therapist gives me explicit advice or direct suggestions for solving my problems”).
Brief Symptom Inventory (BSI; Derogatis and Melisaratos 1983). Symptoms are measured by the BSI, a 53-item assessment of nine symptom domains: somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism, as well as a Global Severity Index that measures global symptom distress across domains.
Patient Estimate of Improvement (PEI; Hatcher and Barends 1996). The PEI, using items that ask patients to express subjectively how much they have generally improved over the course of therapy, indicates whether they have found the therapy helpful. “How much worse or better do you think you are getting along now, compared to when you began your therapy?” and “To what extent have your original complaints or symptoms improved?” are typical items.
Schwartz Outcome Scale (SOS; Blais et al. 1999). The SOS assesses overall psychological functioning by asking patients to rate statements that express general well-being (e.g.,“I am generally satisfied with my psychological health”; “I have peace of mind”).
Inventory of Interpersonal Problems (IIP; Horowitz et al. 2000). The IIP uses eight relationship dimensions to assess relational styles: vindictive/self-centered, domineering/controlling, cold/distant, socially inhibited, nonassertive, overly accomodating, self-sacrificing, and intrusive/needy.
Social Adjustment Scale (SAS; Weissman and Bothwell 1976). The SAS assesses functioning across many domains and types of relationships: work, housework, student work, social activities, extended family, parental, primary intimate relationship, and family unit.
Therapist Response Questionnaire (TRQ; Betan et al. 2005). This measure, given only to therapists, asks about feelings of countertransference across eight factors: overwhelmed/disorganized, helpless/inadequate, positive, special/overinvolved, sexualized, disengaged, parental/protective, and criticized/mistreated.
Results
Preliminary results suggest a relationship between therapist technique, alliance strength, therapist countertransference, and therapy outcomes at three months into psychotherapy. All results reported here are based on data collected from therapists and patients three months into treatment.
Alliance. Patients (n = 62) who experienced a strong alliance, as rated on the confident collaboration subscale of the CASF, experienced fewer depressive symptoms (r = –.368, p < .005) and fewer symptoms overall (r = –.299, p < .005), as rated on the BSI. They also perceived their therapy as being more helpful (r = .80, p < .005), as measured by the PEI, and experience more overall psychological health and well-being (r = .45, p <.005), as found on the SOS.
Technique. Therapist technique also appears to be related to outcome. Patients who rated their treatment as more psychodynamic on the CPPS reported fewer somatization symptoms on the BSI at three months (r = –.32, p < .01). They also perceived their therapy as being more helpful overall (r =.34, p < .01), as measured by the PEI.
Patient ratings of alliance strength were related to more frequent use of psychodynamic techniques (r = .40, p < .005). Patient ratings of psychodynamic technique were related to therapist ratings of alliance strength (r = .27, p < .05), whereas patient ratings of cognitive-behavioral technique were not correlated with therapist ratings of alliance strength.
Interestingly, more frequent use of cognitive-behavioral techniques, as measured by patient reports on the CPPS, was correlated with a more vindictive relational style and more hostile dominance on the IIP (r = .35, p < .001).
Therapist countertransference. Similar to alliance and technique, therapist countertransference was found to be related to certain patient characteristics, symptom profiles, and treatment outcomes. On the TRQ, therapists tended to report feeling less overwhelmed (r = –.34, p < .01) and criticized (r = –.34, p < .01) in treatments with patients who reported more overly accommodating and self-sacrificing styles on the IIP. They also felt less disengaged (r = –.361, p < .01) with patients experiencing more hostile symptoms, such as being easily angered and argumentative. Lastly, therapists tended to feel more overinvolved, regarding the patient as more special (r = .66, p < .01), and to have more parental feelings (r = .70, p < .01) with patients reporting high levels of problems in their primary relationship (with partner or spouse) on the SAS.