“It was hard work every session”: Therapists’ view of successful psychoanalytic treatments

Abstract

Successful therapeutic work presupposes positive expectations, an active therapeutic stance and assiduous work session-by-session. Therapist expertise may involve the ability to mobilize and work effectively with patient-specific resources and obstacles from the beginning of treatment. In addition to identifying the characteristics and actions of effective therapists, research should also focus on processes emerging within effective therapeutic dyads. Clinical or methodological significance of this article: Our study indicates several factors that seem to characterize therapist expertise and can inform psychotherapy training. Successful therapeutic work presupposes positive expectations, an active therapeutic stance, courage to challenge the patient, and assiduous work session-by-session. Therapist expertise may involve the ability to mobilize and work effectively with patient-specific resources and obstacles from the beginning of treatment. In addition to identifying the characteristics and actions of effective therapists, research should also focus on processes emerging within effective therapeutic dyads.

“It was like having half of the patient in therapy”: Therapists of nonimproved patients looking back on their work

“…More surprisingly, some of the themes in the present study were also present in a parallel study of therapists' experiences of the therapeutic process in successful cases, drawn from the same total patient population (Werbart et al, 2017). In both cases, the therapists felt especially motivated to be this particular patient's therapist and they reported having worked more actively than with other patients.…”

“…Five of the patients reached criteria for DSM IV-TR (American Psychiatric Association, 2000) Axis I diagnoses and four patients had Axis II diagnoses; one patient had no psychiatric diagnosis (Table I). The mean GSIscore pretreatment was 1.59 (SD = 0.50) and did not differ from a YAPP subsample of 16 successful cases (M = 1.56; SD = 0.51; Werbart et al, 2017). The mean time in therapy was 19.0 months (range 7-48; SD = 8.49), as compared to 27.6 months average treatment duration in successful cases.…”

“…Whereas patients in successful therapy described a secure relationship (Palmstierna & Werbart, 2013), nonimproved patients described it as "artificial" (Werbart et al, 2015). In contrast to successful cases (Werbart et al, 2017), the therapists of nonimproved patients could not maintain an equidistant stance and balance between supporting the patient's more mature parts and adequately confronting her more distorted parts. Therapists in our study tried to address these problems, but experienced that their patients avoided the closeness needed to create sustainable change.…”

“…Furthermore, in cases of nonimprovement the therapists in the present study seem not to have succeeded in adjusting their technique to their patients' level of functioning, despite their attempts to meta-communicate. In contrast, in successful cases, the therapists described monitoring from the beginning the patient's resistances and ways of being with the therapist, as well as their own ways of being with the patient (Werbart et al, 2017), thus possibly being more able to work through ruptures in the working alliance and potentially prevent negative outcomes.…”

“…Looking at the psychotherapy process as interplay between patient, therapist, and therapeutic approach can help us understand which specific factors can lead to improvement, stagnation or deterioration. In previous studies, we investigated nonimproved patients' view of the therapeutic processes (Werbart, von Below, Brun, & Gunnarsdottir, 2015), as well as how therapists experience and reflect on their own clinical work in successful cases of psychoanalytic psychotherapy (Werbart, Missios, Waldenström, & Lilliengren, 2017). The therapists' experiences of their work with nonimproved patients might be a rich source of clinically relevant knowledge of negative processes.…”