Profiles of adherence and flexibility in psychodynamic psychotherapy: A cluster analysis.

Abstract

We used cluster analysis, a mixed dimensional-categorical design (Ward, 1963), to provide profiles of technique adherence and flexibility in psychodynamic therapy to examine the relationship between such profiles and outcome. A 4-cluster solution representing a 2 3 2 categorical model was predicted. Forty-six outpatients were consecutively enrolled in individual psychodynamic psychotherapy and received a DSM-IV Axis I diagnosis of a depressive spectrum disorder. Patients were assessed pre-and posttreatment through self-report of depressive symptoms. Treatment was videotaped, two early sessions were independently rated for use of PI (psychodynamicinterpersonal) and CB (cognitive-behavioral) techniques with excellent interrater reliability (ICC . .75). Mean technique ratings were calculated per case. A hierarchical cluster analysis was used and surprisingly produced a 3-cluster solution: (1) Adherent and Minimally Flexible, (2) Somewhat Adherent and Somewhat Flexible, and (3) Adherent and Somewhat Flexible. While all clusters demonstrated improvement in symptoms, it appears that psychodynamic therapists who incorporate CB techniques should be mindful of doing so at the expense of their primary modality. Minimally technique-flexible therapists seem to cluster as a group that is focused on adherence and not necessarily limited in overall technique use and engagement. However, adherent and somewhat flexible therapists appear to have significantly higher rates (85%) of clinically significant change compared to either less flexible or less adherent therapists (45% and 38%, respectively). Further research is needed to establish consistent clusters of adherence/flexibility and clarify how much of the relationship between adherence, flexibility, and outcome can be accounted for by other treatment factors, such as therapist engagement.

You never know what you are going to get: Large-scale assessment of therapists’ supportive counseling skill use.

“…For example, one client may prefer a more didactic, solution-focused style while another client may prefer an exploratory, flexible style that utilizes reflections and questions extensively (Beutler et al, 1991). Indeed, rigidity to a specific treatment approach can be detrimental to outcomes (Castonguay et al, 2010), while therapists' flexibility or responsiveness (Constantino et al, 2020;Stiles & Horvath, 2017;Watson & Wiseman, 2021) is linked to positive process and outcomes (Katz et al, 2019(Katz et al, , 2021Li et al, 2020;Owen & Hilsenroth, 2014). In this situation, it is a therapist's skill in itself to be able to flexibly use these nonspecific skills depending on clients.…”

How are expert therapists similar, different, and integrative in the treatment of borderline personality disorder?

“…Currently, there exists a gap in studies examining how integrative and traditional therapies differ at the level of technique and at different points across the treatment process. Such research may shed further light on the extent to which therapist adherence and/or flexibility with regard to a particular modality affects outcome (Katz et al, 2019; Katz et al, 2020; Owen & Hilsenroth, 2014). Clinicians would also benefit from studies examining expert therapist techniques in relation to common factors, such as alliance, to better assess the particular therapist actions and training initiatives that might yield the greatest benefit for psychotherapy patients.…”

“…The reliability and clinical validity of the CPPS has been well established. Recent studies using the CPPS have demonstrated significant relationships between technique use and global improvements in treatment (Levy et al, 2015; Owen & Hilsenroth, 2011; Owen et al, 2013; Owen et al, 2012), patient self-esteem and object relations (Kuutmann & Hilsenroth, 2012; Mullin et al, 2017), depression (Katz et al 2018, 2019, 2020; Hilsenroth et al, 2003, 2007), and anxiety symptoms (Pitman et al, 2014; Pitman, Hilsenroth et al, 2017; Slavin-Mulford et al, 2011). PI use measured by the CPPS has also been found to be positively associated with graduate clinician training and structured supervision in psychodynamic psychotherapy (Hilsenroth et al, 2015).…”