Is IPT Time-Limited Psychodynamic Psychotherapy?vuir.vu.edu.au/19368/22/vol7no3.pdfpsychodynamic...

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Markowitz JC, Svartberg M, Swartz HA: Is IPT time-lim- ited psychodynamic psychotherapy? J Psychother Pract Res 1998; 7(3):____–____ Interpersonal Psychotherapy (IPT); Psychotherapy, Brief; Psychotherapy Psychodynamic Is IPT Time-Limited Psychodynamic Psychotherapy? J OHN C. M ARKOWITZ , M.D. M ARTIN S VARTBERG , M.D., P H .D. H OLLY A. S WARTZ , M.D. Interpersonal psychotherapy (IPT) has sometimes but not always been considered a psychodynamic psychotherapy. The authors discuss similarities and differences between IPT and short-term psychodynamic psychotherapy (STPP), comparing eight aspects: 1) time limit, 2) medical model, 3) dual goals of solving interpersonal problems and syndromal remission, 4) interpersonal focus on the patient solving current life problems, 5) specific techniques, 6) termination, 7) therapeutic stance, and 8) empirical support. The authors then apply both approaches to a case example of depression. They conclude that despite overlaps and similarities, IPT is distinct from STPP. (The Journal of Psychotherapy Practice and Research 1998; 7:185–195) I nterpersonal psychotherapy (IPT), 1 a man- ual-based treatment for particular psychia- tric populations, has been alternately included in and rejected by the psychodynamic com- munity. Some see it as founded on psychody- namic principles, while others dismiss it as a lightweight alternative to the psychodynamic tradition, a Band-aid therapy that misses the larger point of treating character. Until recently IPT was almost entirely a research interven- tion, described in clinical research trials but otherwise unfamiliar to practicing clinicians. Many may not really know what IPT is. (Per- haps that explains why so many inadvertently mislabel it “ITP.”) In contrast, psychodynamic therapy has been widely used but less re- searched. This article differentiates two terms that are too often loosely used: (brief) “psychody- namic” and “interpersonal” psychotherapy. The issue of whether IPT is a form of short- term dynamic psychotherapy (STPP) has been frequently broached in clinical workshops but never fully confronted in the literature, and ambiguity about the issue is evident even in the IPT manual. This issue deserves examina- tion for several reasons: R EGULAR A RTICLES Received April 21, 1997; revised November 21, 1997; accepted November 26, 1997. From Cornell University Medical College, New York, New York; Norwegian Uni- versity of Science and Technology, Trondheim, Norway; and Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania. Address correspondence to Dr. Mark- owitz, 445 East 68th Street, Suite 3N, New York, NY 10021; e-mail: [email protected] Copyright © 1998 American Psychiatric Press, Inc. JOURNAL OF PSYCHOTHERAPY PRACTICE AND RESEARCH

Transcript of Is IPT Time-Limited Psychodynamic Psychotherapy?vuir.vu.edu.au/19368/22/vol7no3.pdfpsychodynamic...

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Markowitz JC, Svartberg M, Swartz HA: Is IPT time-lim-ited psychodynamic psychotherapy? J Psychother PractRes 1998; 7(3):____–____Interpersonal Psychotherapy (IPT); Psychotherapy, Brief;Psychotherapy Psychodynamic

Is IPT Time-Limited PsychodynamicPsychotherapy?

J O H N C . M A R K O W I T Z , M . D .M A R T I N S V A R T B E R G , M . D . , P H . D .H O L L Y A . S W A R T Z , M . D .

Interpersonal psychotherapy (IPT) hassometimes but not always been considered apsychodynamic psychotherapy. The authorsdiscuss similarities and differences betweenIPT and short-term psychodynamicpsychotherapy (STPP), comparing eightaspects: 1) time limit, 2) medical model, 3)dual goals of solving interpersonal problemsand syndromal remission, 4) interpersonalfocus on the patient solving current lifeproblems, 5) specific techniques, 6)termination, 7) therapeutic stance, and 8)empirical support. The authors then applyboth approaches to a case example ofdepression. They conclude that despiteoverlaps and similarities, IPT is distinctfrom STPP.

(The Journal of Psychotherapy Practiceand Research 1998; 7:185–195)

Interpersonal psychotherapy (IPT),1 a man-ual-based treatment for particular psychia-

tric populations, has been alternately includedin and rejected by the psychodynamic com-munity. Some see it as founded on psychody-namic principles, while others dismiss it as alightweight alternative to the psychodynamictradition, a Band-aid therapy that misses thelarger point of treating character. Until recentlyIPT was almost entirely a research interven-tion, described in clinical research trials butotherwise unfamiliar to practicing clinicians.Many may not really know what IPT is. (Per-haps that explains why so many inadvertentlymislabel it “ITP.”) In contrast, psychodynamictherapy has been widely used but less re-searched.

This article differentiates two terms thatare too often loosely used: (brief) “psychody-namic” and “interpersonal” psychotherapy.The issue of whether IPT is a form of short-term dynamic psychotherapy (STPP) has beenfrequently broached in clinical workshops butnever fully confronted in the literature, andambiguity about the issue is evident even inthe IPT manual. This issue deserves examina-tion for several reasons:

R E G U L A R A R T I C L E S

Received April 21, 1997; revised November 21, 1997;accepted November 26, 1997. From Cornell UniversityMedical College, New York, New York; Norwegian Uni-versity of Science and Technology, Trondheim, Norway;and Western Psychiatric Institute and Clinic, Pittsburgh,Pennsylvania. Address correspondence to Dr. Mark-owitz, 445 East 68th Street, Suite 3N, New York, NY10021; e-mail: [email protected]

Copyright © 1998 American Psychiatric Press, Inc.

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1. The growing prominence of IPT as a re-search and clinical treatment2 suggests theneed to define it relative to other psycho-therapies.

2. If IPT differs significantly from STPP, itmay require a distinct course of training.Such IPT training has been defined, al-though few trainees and clinicians have re-ceived it.3 If the two do not greatly differ,any well-trained STPP psychotherapistmay be able to deliver IPT without inten-sive training.

3. IPT was designed as a utilitarian psycho-therapy that codified existing practices.Klerman et al.1 wrote that “Many experi-enced, dynamically trained . . . psycho-therapists report that the concepts andtechniques of IPT are already part of theirstandard approach” (p. 17). A retro-spective analysis of the theoretical stanceof IPT may place it more firmly in rela-tionship to the historical and conceptualcontexts of earlier psychotherapies.

4. IPT has been included in some meta-analyses of psychodynamic outcome stud-ies. IPT could provide needed empiricaldata for psychodynamic treatments if thetwo modalities belong to the same family.If they do not, trials comparing themmight establish differential efficacies.

A debate arose in the research literaturewhen Crits-Christoph4 and Svartberg andStiles5 published meta-analyses of the efficacyof psychodynamic psychotherapy that yieldeddifferent results. Svartberg and Stiles6 notedthat one reason for their differing findings wasthat Crits-Christoph had included IPT amongpsychodynamic studies, bolstering his results.

Svartberg and Stiles maintained:

Although many dynamic psychothera-pists report that the concepts and tech-niques of interpersonal psychotherapyare part of their therapeutic skills, thereare vital differences between interper-sonal psychotherapy and brief dynamicpsychotherapy.6

They then cited the IPT manual:

For purposes of theoretical clarificationand of research design and methodology,we often find it useful to emphasize thedifference between interpersonal and psy-chodynamic approaches to human be-havior and mental illness.1 (p. 18).

Svartberg and Stiles present this distinc-tion as definitive, but to our ears the wordingthey cite sounds more cautious. Crits-Christoph,who earlier conceded that IPT “may be quitedistant from the psychoanalytically orientedforms of dynamic therapy more commonlypracticed”4 (p. 156), gave similarly incompletejustification for deeming IPT psychodynamic,namely that most IPT therapists in early trialswere psychodynamically trained and adaptedeasily to IPT.7 This hardly makes the therapiesidentical.

The IPT manual waffles on the issue.It contrasts IPT with “psychoanalyticallyoriented psychodynamic therapies,” citingdifferences in conceptualizing the patient’sproblem: IPT does not use transference inter-pretations or focus on childhood antecedents;IPT does not attempt personality change; andIPT therapists can accept small gifts from pa-tients without examination (pp. 166–167). Yetit also uses the words “another difference be-tween IPT and other psychodynamic psycho-therapies” (p. 167; our italics).

Should IPT be considered a brief psy-chodynamic psychotherapy? We shall brieflydefine the two approaches, then consider theiroverlap.

T H E T W O A P P R O A C H E S

C O M P A R E D

Brief PsychodynamicPsychotherapy

Psychodynamic psychotherapy is asprawling field, and even within STPP thereare numerous short-term variants. These in-clude drive/structural models,8–10 existential

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models,11 relational models,12–14 and integra-tive models.15,16 STPP is usually designed topromote insight rather than to treat specific dis-orders. No form of STPP has been developedspecifically to treat depression, as IPT was.

Although heterogeneous, STPP variantsshare the following aspects: 1) their theoryabout the origin of psychopathology is psycho-analytically grounded; 2) key techniques arepsychoanalytic, such as confrontation, inter-pretation, and work in the transference; 3) pa-tients are selected for treatment; 4) duringinitial sessions a dynamic case formulation isdeveloped, and a focus based on this formula-tion is established and maintained throughouttreatment.17

Although relationally focused STPPs maybe gaining ground, we believe that conflict-ori-ented approaches still hold sway: they appearto be most widely used and are probably whatmost clinicians think of as STPP. We thereforedefine STPP as a treatment of less than 40 sessionsthat focuses on the patient’s reenactment in currentlife and the transference of largely unconscious con-flicts deriving from early childhood.

InterpersonalPsychotherapy (IPT)

Compared with STPP, IPT is an essen-tially unified treatment with far less history andopportunity for diffusion. Developed by Kler-man, Weissman, and colleagues to treat outpa-tients with nondelusional major depression ina time-limited format, IPT has since beenadapted for other psychiatric disorders.18 In theinitial phase (1–3 sessions), the IPT therapistdiagnoses a psychiatric disorder and an inter-personal focus; links the two for the patient ina formulation; and obtains the patient’s explicitagreement to this formulation, which becomesthe treatment focus. In the middle phase, thetherapist employs practical, optimistic, for-ward-looking strategies to provide relief.

Possible interpersonal foci, derived frompsychosocial research on depression, are 1)grief (complicated bereavement), 2) role dis-pute, 3) role transition, and 4) interpersonal

deficits.1 A brief termination phase concludesacute treatment. Based on the premise that lifeevents affect mood, and vice versa, IPT offersstrategies that maximize the opportunity forpatients to solve what they often see as hopelessinterpersonal problems. If patients succeed inchanging their life situations, their depressionusually remits as well. A series of randomizedcontrolled treatment trials has demonstratedthat IPT both treats episodes of illness andbuilds social skills.2,19

Similarities and Differences

IPT is defined by its 1) time limit, 2) medi-cal model, 3) dual goals of solving interper-sonal problems and syndromal remission, 4)interpersonal focus on the patient solving cur-rent life problems, 5) specific techniques, 6) ter-mination, 7) therapeutic stance, and 8)empirical support. We shall compare each ofthese elements in turn with the features ofSTPP, focusing on depressionthe modal IPTdiagnosisas the treatment target. Table 1contrasts IPT and STPP.

1. Time Limit: IPT has a strict time limit, es-tablished at its outset, ranging for acute treat-ment from 12 to 16 weekly sessions. Althoughthis duration arose as a compromise betweenthe needs of psychotherapy and pharma-cotherapy in randomized trials, it has provedan adequate length and an important tool.Brevity of treatment pressures the depressedpatient and the therapist to work quickly.

Psychodynamic psychotherapy, like psy-choanalysis, was traditionally an open-endedtreatment. Malan,8 Sifneos,9 Davanloo,10

Mann,11 Luborsky,12 Horowitz et al.,20,21 Struppand Binder,22 and others developed short-termpsychodynamic interventions with more de-fined foci and limits. Their brevity is stated,but their exact duration is often not specified,at the outset. Some have variable10,12,22 or time-attendant9 lengths, based on evidence of thera-peutic progress.23 In contrast to the 12 to 16sessions of IPT, most STPPs comprise 20 to25 sessions.

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2. Medical Model: The IPT focus is illnessbased. The patient’s problem is defined as amedical illness: a mood disorder may be use-fully compared to hypertension, diabetes, andother medical disorders that respond to behav-ioral and pharmacological interventions. Giv-ing the patient a medical diagnosis and the“sick role”1,24 is a formal aspect of the firstphase of IPT. These maneuvers aim to helpdepressed patients recognize depressivesymptoms as ego-dystonic and to relieve self-criticism by helping them to blame an illness(and an interpersonal situation), rather thanthemselves, for their difficulties. The sick rolealso entails responsibility to work to recoverthe lost, healthy role. IPT therapists, whileoften using psychodynamic knowledge to“read” psychological patterns of patients, care-

fully avoid prejudging whether patients whopresent with Axis I disorders such as majordepression or dysthymic disorder have per-sonality disorders.25

The IPT approach relieves guilt and di-minishes the risk that depressed patients mayunfairly blame their character rather than ill-ness or circumstances. It avoids the potentialconfusion of depressive state with, say, maso-chistic traits.25 In contrast, STPP often focuseson intrapsychic conflicts, unconscious feelings,and character defenses rather than formal di-agnoses and the concept of illness. Many STPPpractitioners may deem depressive symptomsless important than do IPT therapists, seeingsuch symptoms not as outcome variables butas epiphenomena of underlying charac-terological issues. Whereas for IPT therapists

TABLE 1. IPT and brief psychodynamic psychotherapy

Domain IPT Psychodynamic

Underlying model Medical illness Dynamic unconsciousGoals Remission of syndrome Conflict resolution

Symptom relief (Limited) personality changeFramework Time limit Always (typically 12–16 weeks) Variable Structure Structured by: Relatively unstructured

1. Time limit 2. Opening question 3. Interpersonal problem area

Focus Temporal “Here and now” “There and then”

Relatively acute: recent past, but mostly Relatively chronic: remote past, present and future albeit in some relation to present

Spatial Outside office Inside office (transference) Material Interpersonal Largely intrapsychicFormulation Explicitly stated Often largely tacitTherapeutic stance Supportive, encouraging, optimistic ally Supportive vs. neutral observerTechniques Interpretation No Yes Dream interpretation No Yes Trial intervention No Yes Communication analysis Yes Yes, to a degree Support Yes Yes, variably Catharsis Yes Yes Exploring options Yes Yes, but not systematically Role playing Yes No Psychoeducation Yes Not in medical senseTermination Focus on patient’s successes; relapse Focus on transference; often a

prevention; a concluding phase crucial phase

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the Axis I diagnosis is paramount, STPP psy-chotherapists often focus on characterologicaldefenses, informally diagnosed “Axis II.”

Following the medical model, IPT usesDSM-IV diagnosis as its inclusion criterion.Inclusion criteria for STPP tend to be factorssuch as feasibility of establishing a therapeuticfocus, ability to form an emotional attachment,and motivation for change.23

3. Goals: IPT has dual aims: to solve a mean-ingful interpersonal problem, and (thereby) torelieve an episode of mood disorder. The IPTtherapist defines these two targets during theinitial phase, links them in an interpersonalformulation,26 and obtains the patient’s agree-ment on this formulation as a focus beforeproceeding into the main treatment phase.The formulation, a non-etiologic linkage ofmood and environmental situation, explicitlystates the therapist’s understanding of the case:

As we determined by DSM-IV, you aregoing through an episode of major de-pression, a common illness that is not yourfault. To me it seems that your depressiveepisode has something to do with yourfather’s death and your difficulty inmourning him. Your symptoms startedshortly after that. I suggest that over thenext 12 weeks we try to solve your prob-lem with mourning, which we call com-plicated bereavement. If we solve that,your depression will very likely improve.

STPP seeks to increase the patient’s un-derstanding of his or her internal functioning.External change implicitly follows, but it is notthe prime focus of treatment.

In summary: the goal for IPT is to treat aspecific psychiatric syndrome by helping thepatient to change a current life situation; thegoal for STPP is to increase understanding ofintrapsychic conflict. These approaches reflectdiffering concepts of psychopathology. Im-plicit in these definitions of therapeutic goalsare their indications. IPT is indicated only forsyndromes for which its efficacy has been em-pirically demonstrated (major depression,

bulimia). STPP has been less concerned withspecific diagnoses, although Horowitz and co-workers do focus on stress and bereavementsyndromes.20,21 Some forms of STPP deem sig-nificant symptomatology a contraindication.9

4. Interpersonal Focus: IPT focuses on eventsin the patient’s current life (“here and now”)outside the office and on the patient’s reactionto these life events and situations. Patient prob-lems are categorized within the four interper-sonal problem areas, usually elaborated by apersonalized metaphor.25 STPP, even whenemphasizing events,20 focuses on transferencein the office and the linking of extrasessioninterpersonal events to the transference. Thephrase “here and now” in a psychodynamiccontext refers to what happens in STPP ses-sions. IPT instead concentrates on recognitionof recent traumatic life events, grieving theircosts but simultaneously emphasizing thepositive potentials of the present and future.IPT is “coaching for life” more than introspec-tion.

5. Specific Techniques: IPT is more innovativein its use of focused strategies than unique inits particular techniques. For each interper-sonal problem area there is a coherent set ofstrategies. Nonetheless, several key techniquesare frequently used. Some, but not all, derivefrom psychodynamic practice (see Table 1).

Sessions begin with the question, “Howhave things been since we last met?” This fo-cuses the patient on the interval between ses-sions and elicits either a mood or an event. Thetherapist then helps the patient to link the two.Depressed patients soon learn to connect en-vironmental situation and mood and to recog-nize that they can control both through theiractions. Starting with a recent, affectivelycharged event allows sessions to move to theinterpersonal problem area, maintaining thefocus without rendering the discussion intel-lectualized or affectless.

Having discovered a recent life situation,the therapist asks the patient to elaborateevents and associated feelings to determine

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where things might have gone right or wrong(communication analysis). The therapeuticdyad explores what happened, how the patientfelt, what the patient wanted in the situation,and what options the patient had to achieve it.If the patient handled the situation less thanoptimally, role playing may prepare the pa-tient to try again.

IPT does not use STPP interventions suchas genetic or dream interpretations. Both ap-proaches pull for affect and catharsis. But forIPT, catharsis alone is insufficient: the patientmust also transmute feeling into life changes.Catharsis in STPP may lead the patient to anincreased sense of safety in sessions, facilitatingsubsequent deeper exploration of conflictedfeelings. The goal is increased self-knowledgeon which the patient may act independently.Life change might be considered a good out-come of STPP, but it would come as a by-prod-uct of insight. By contrast, IPT emphasizesaction rather than exploration and insight, inpart because mobilization and social activitybenefit depressed patients. The IPT therapistactively supports the patient’s pursuit of his orher wishes and interpersonal options.

STPP therapists help patients focus ontransferential and interpersonal themes (e.g.,Luborsky’s Core Conflictual RelationshipTheme12); however, sessions are less structuredby the therapist and more dependent on thepatient’s generating materialwhich it mightbe difficult for depressed patients to do pro-ductively.

6. Termination: In IPT, termination meansgraduation from therapy, the bittersweetbreakup of a successful team. It is a coda totreatment, important but secondary to themiddle phase. The final sessions address thepatient’s accomplishments, the patient’s com-petence independent of the therapist, and re-lapse prevention.

Termination in STPP is a more importantphase than in IPT and concentrates far moreon the patient’s responses to therapy ending:indeed, the therapy often turns on this.8 A keySTPP technique is working through the sepa-

ration issues of termination, especially as mani-fested in the transference.

7. Therapeutic Stance: STPP tends towardtherapist neutrality and relative abstinence inorder to allow the transference to develop,whereas the IPT therapist assumes the openlysupportive role of ally. A practical, optimistic,and helpful approach is deemed necessary tocounter the negative outlook of depressed pa-tients. Although encouraging patients to de-velop their own ideas, IPT therapists offersuggestions when needed. When the patientdoes something right, the therapist offers con-gratulationsa “cheerleading” style thatmight disconcert some STPP therapists.

IPT and STPP share some attributes:time constraint, narrow focus, and modality-trained therapists. Both use support, a warmalliance, and careful exploration of interper-sonal experiences. They share a positive, em-powering, collaborative stance. Most STPPtherapists use traditional analytic techniques(transference or genetic interpretation, clari-fication, confrontation, defense analysis) tohelp patients explore and understand themesor conflicts. IPT also might use clarificationto aid a depressed patient’s understanding ofan interpersonal dispute. Some STPPs spec-ify that therapists should be relatively sup-portive11 or active.8

An illustrative difference between the twoapproaches might arise with an irritable, de-pressed patient at risk to develop a negativetransference to his therapist. The STPP thera-pist would allow the transference to develop,then interpret it to the patient to explore itsmeaning. The IPT therapist would focus thepatient on interpersonal relationships andevents in the patient’s outside life that mightprovoke anger or irritability, and would alsoblame the depressive disorder itself whenappropriate. This active, outward-looking ap-proach minimizes the opportunity for a nega-tive transference to build: rather, the therapistbecomes the patient’s ally in fighting depres-sion and outside problems. (This reverses thepsychoanalytic principle that transference

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brings into the therapeutic relationship pat-terns that the patient enacts everywhere.In IPT, if the patient has feelings about thetherapist, there is probably a culprit else-where.) Resolving outside problems and de-pressive symptoms cements the therapeuticalliance, so that negative transferencewhichmay reflect the patient’s clouded depressiveoutlookfades. If the patient’s feelings un-avoidably perturb the therapeutic alliance, theIPT therapist explores them as interpersonal,real-life, here-and-now issues rather than astransference.

If a patient repeatedly arrives late for ses-sions, the STPP therapist might explore as-pects of the patient’s character and feelingsabout the therapist that might contribute to thelateness. From the IPT perspective, this riskspotentially reinforcing the patient’s already ex-cessive self-blame. The IPT therapist wouldexcuse the patient, sympathizing that it’s hardto get out of bed and arrive punctually whenyou feel depressed and lack energy, and ac-knowledging that the patient’s level of anxietymight make it hard to contemplate sittingthrough a full session. The IPT therapist wouldthus blame the depression, not the pa-tientwho feels bad enough already. Thetherapist would mention the time limit (“Un-fortunately we only have eight sessions left,and we really need to use all the remainingtime to find ways to fight your depression”) inorder to discourage future tardiness. Latenessin other relationships might be explored withthe goal of building interpersonal skills (self-assertion, expression of anger) in these exter-nal settings.

STPP treats the patient’s “resistance” toemploying healthy solutions as meaningful;IPT treats the “resistance” as illnessnamely,depression. The IPT “corrective emotional ex-perience” lies partly outside the office, in theamelioration of interpersonal situations exter-nal to therapy. The STPP corrective emotionalexperience lies primarily inside the office, inthe patient’s newfound ability to expresswarded-off feelings to an optimally responsiveperson.

8. Empirical Support: The demonstrated effi-cacy of IPT in treating mood and other psy-chiatric syndromes in randomized clinicaltrials2 sets it apart from most STPP treatments,for which empirical evidence of efficacy intreating particular syndromes is meager.5,23

Luborsky and co-workers produced impres-sive results in treating opiate-maintained pa-tients with STPP,27 an area where IPT failed.28

This indirect comparison suggests differencesbetween the approaches. There have been nodirect comparisons of IPT and STPP in treat-ing major depression. Some reports suggest,however, that psychodynamic psychotherapymay not be the ideal treatment for mood dis-orders.3,29 Efficacy data provide an importantfoundation permitting the IPT therapist tomeet the depressed patient’s pessimism withequal and opposite optimism. Consonant withan empirical approach, many IPT therapistsserially administer depression rating instru-ments during treatment.

A case example may highlight differencesbetween IPT and STPP.

Case Example

Ms. A., a 34-year-old married businesswoman,presented with the chief complaint, “I’m feelingdepressed.” She reported that 5 months earliershe had received a long-sought promotion, whichincreased her responsibility at work. Her longerworking hours and heightened career opportuni-ties increased ongoing tension with her husbandover whether to have a second child. She becameincreasingly doubtful about another pregnancy;her husband became more insistent upon it. Shereported that over the past 3 to 4 months she hadexperienced depressed mood, early and mid-insomnia, decreased appetite and libido, an 8-pound weight loss, low self-esteem, and greaterguilt. She felt anxious and irritable with her 35-year-old computer programmer husband, her 8-year-old son, and co-workers.

Psychodynamic Approach: An STPP therapistwould begin by developing a dynamic formu-

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lation of the case. This formulation wouldcomprise a specific constellation of dynamicelements: defenses, anxiety, and unconsciousimpulse/feeling, as well as their interrelation-ships. Central to the case is Ms. A.’s inabilityto express anger adaptively toward her hus-band. The reason for this might be anxiety-based fantasies about hurting and possiblylosing her husband if the angry impulses werereleased. These impulses are defended againstthrough 1) deflecting the impulse and direct-ing it inward (causing depression); 2) actingout (being irritable, which is not adaptive an-ger); 3) displacement onto her son and co-workers; and possibly 4) taking the victim role(a self-pitying, “poor me” attitude, which isalso maladaptive).

Treatment would begin with the therapistpointing out impulses, anxious fantasies, anddefenses in relation to a current person (hus-band), a past person (father, mother), and thetherapist. If the patient came late to sessions,the therapist might interpret this transferentialmanifestation of unexpressed anger, linking itto anxiety about expressing anger directly toher husband, or to her domineering parents inthe past. Recognition of this conflict would beconsidered inherently therapeutic. The aim isto help the patient recognize how she defendsherself against frightening angry impulses. Thenext step, at a deeper level, is to explore theangry impulses: to have her experience the fullfeeling of anger and to facilitate its expressionin the transference. In the presence of a non-judgmental therapist, this represents a correc-tive emotional experience for the patient and,as such, is considered key to alleviating symp-toms and to limited personality change.

IPT Approach: The patient meets criteria for aDSM-IV major depressive episode,30 an indi-cation for IPT. If exploration revealed no otherprecipitant (such as complicated bereave-ment), the therapist would link the onset of themood disorder to one of two probable inter-personal problem areas: either a role transi-tion (the job promotion and its consequences)or a role dispute (with the husband over

having another child). Depending on which ofthese intertwined themes emerged as mostsalient to the patient, the therapy might focuson either or both. From the presentation, itappears that her conflicts are at home (roledispute) rather than with the job per se.

The therapist would present this linkageto the patient (“Your depression seemed to startafter you got your promotion and you and yourhusband began to argue about having anotherchild”) and would give the patient the sick role.If the patient accepted the formulation as a fo-cus for time-limited treatment, the therapistwould then discuss with the patient what shewanted: How could she balance work andhome? How much pleasure does work giveher? Are there ways to resolve the marital dis-pute? Once her wishes are determined, whatoptions does the patient have to resolve theseproblems? In a role dispute with the husband,the goal would be to explore the disagreement,to see whether the couple is truly at an impasse,and to explore ways to resolve it. Addressingthe role dispute might well require exploringhow the patient expresses anger, which couldbe fine tuned through role-play in the office.With therapist support, Ms. A. would attemptto renegotiate her current life situation to arriveat a satisfactory new equilibrium. Achieving it,or at least trying to the best of her ability (herhusband might be unreasonable, but she couldat least handle her side of the matter appropri-ately), would very likely lead to remission ofher mood disorder.

D I S C U S S I O N

IPT bears similarities to some forms of STPP,but it differs sufficiently that it should be con-sidered distinct. IPT was developed to treatdepression, STPP for a range of psycho-pathologies. The IPT rationale does not pre-tend to explain etiology. Rather, IPT is apragmatic, research-proven approach that ad-dresses one important aspect of depressivesyndromes and frequently suffices to treatthem. To the extent that IPT invokes theory, itrelies on psychosocial research findings (for

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example, the association of marital conflictsand depressed wives1) and commonsense butclinically important ideas, such as “life eventsaffect mood.”

IPT and STPP may (should?) ultimatelyaddress overlapping problem areas, with thedistinction that STPP seeks intrapsychic as wellas interpersonal patterns. STPP uses historyand transference to determine the focal prob-lem. IPT sticks to history: although the pa-tient’s interpersonal behaviors in sessions mayconvey important information, the transfer-ence is not addressed. To a greater extent thanSTPP, IPT emphasizes finding concrete solu-tions and changing relationships, using tech-niques such as role playing to prepare thepatient for such steps. Reflecting these distinc-tions, the NIMH Treatment of Depression Col-laborative Research Program31 developedadherence measures that distinguish IPT from“tangential” psychodynamic techniques.32

We conclude:

1. IPT has distinct emphases. A psychodynamicbackground, which most IPT therapists (be-ginning with Klerman and Weissman) havehad, is helpful to “read” patients, to subtlymanipulate (rather than interpret) the transfer-ence. But the IPT conceptualization of depres-sion as an illness, and its focus on depressiveillness rather than on characterological“roots,” represents a significant differencefrom STPP. The emphasis on outcome and onsuccess experiences in the patient’s life hasalso been less characteristic of STPP. In teach-ing IPT to psychodynamic therapistsevenSullivanian (“interpersonal”) psychoana-lystswe sometimes see them struggling toadjust to the IPT approach.

2. IPT is not simply “supportive” dynamic therapy.IPT does share some features with supportivetherapies. But “supportive” has been a pejorativepsychoanalytic term for any not-formally-ex-pressive, not-insight-oriented psychother-apy.33 As such, “supportive” encompasses notonly formal psychodynamic approaches tosupportive therapy,34 but almost anything else:

the term roughly translates to “not psychoana-lytic.” IPT is more active, has more ambitiousgoals (syndromal remission; helping patientsto rapidly change interpersonal environ-ments), and very likely accomplishes morethan typical (if there is such a thing) supportivetherapy. This was our finding in comparingIPT and a supportive, quasi-Rogerian psycho-therapy in treating depressed HIV-positive pa-tients.35 If IPT is not psychodynamic, it is notexactly “supportive,” either, although IPTtherapists do provide support.

3. IPT is distinct in its interpersonal focus.STPP can have a strong interpersonal focus,but it need not. Even when it does, techniquesand focus differ from those of IPT: for exam-ple, outside interpersonal relationships are fre-quently linked to transference. STPP as awhole may be moving toward a more interper-sonal focus. (Lacking a consensus, it is hard toknow.) If so, it is probably more skewed in thatdirection than much other psychodynamicpsychotherapy.

Some STPP variants clearly have more in-terpersonal emphasis than others, and thus ar-guably overlap more with IPT. One exampleis the time-limited psychodynamic psycho-therapy (TLDP) of Strupp and Binder.22 De-velopment of this approach was influenced bypsychoanalysts such as Alexander and French,Gill, and Klein as well as STPP theorists suchas Malan, Sifneos, Davanloo, and Mann.36

During initial sessions, TLDP therapists for-mulate a salient maladaptive interpersonal pat-tern as it relates to (in order of priority) thetherapist, current others, and past others.Throughout treatment, TLDP therapists iden-tify the influence of this pattern on the patient–therapist relationship: how the patient’sexpectations about self and others are enactedin the transference. As described by Elkin atal.,31 “TLDP therapists’ technical approachemphasizes the analysis of transference andcountertransference in the here and now” (p.144).

Although TLDP has an interpersonaltherapeutic focus, it differs drastically from the

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IPT therapist’s practical, outside-the-officeemphasis and interventions. Indeed, TLDPmay more closely resemble psychoanalysisproper than IPT in its heavy emphasis on trans-ference and countertransference.37

4. IPT and STPP differ markedly in their treatmentrange. IPT is intended as a limited interven-tion addressing particular Axis I syndromes.STPP derives from an all-encompassing psy-chodynamic approach to psychopathology,yet paradoxically has often specified ex-tremely limiting selection criteria for its appli-cation (see Sifneos,9 for example). Absentcomparative research data, we know littleabout the differential therapeutics38 of STPPand its indications relative to IPT for particulardiagnostic groups.

An important exception to this rule is theSTPP of Horowitz and colleagues.20,21 This fo-cuses on one of IPT’s four foci, grief reactions,but addresses them differently. Horowitz’s ap-proach is characterized by 1) general principlesdefined by Malan, Sifneos, and Mann, includ-ing clarification; confrontation; interpretationof impulses, anxiety, and defenses; separationand loss issues regarding the therapist and cur-rent and past others; and 2) specific principlesabout the handling of affects and views of selfand other activated by the traumatic event,such as reality testing of fantasies, abreaction,and catharsis. The active use of the transfer-ence, the reliance on traditional psychody-namic techniques, and the aim of modifyinglong-standing personality patterns are but a

few features differentiating this approach fromIPT.

5. Training for IPT requires a distinct approach.We teach IPT separately, as a form of time-lim-ited therapy distinct from STPP. This suggestsimportant heuristic differences. Indeed, forreasons already articulated (see Table 1), con-ceptual and technical differences would makeit difficult to teach IPT as a subtype of STPP.

6. Despite overlap, IPT and STPP are distinct.A participant in an IPT workshop said: “IPTisn’t psychodynamic, but it isn’t anti-dynamic,either.” This puts it as well as anyone has. Theobvious overlap in these therapies includes the“nonspecific” factors of psychotherapies 39 aswell as the backgrounds of most of the IPTtherapists trained to date. Yet differences ingoals, techniques, outlook, and research dataare meaningful. IPT should not be groupedwith STPP. Although it may have roots inpsychodynamic soil, it differs sufficiently in itsoutlook and practice to deserve to be consid-ered apart.

Alan Barasch, M.D., a colleague at the PayneWhitney Clinic, provided important concepts andarguments in an early form of this paper. DavidDunstone, M.D., of Michigan State University,Kalamazoo, MI, provided the final quote. This work was supported by Grants MH46250and MH49635 from the National Institute of Men-tal Health and by a fund established in the NewYork Community Trust by DeWitt-Wallace.

R E F E R E N C E S

1. Klerman GL, Weissman MM, Rounsaville BJ, et al:Interpersonal Psychotherapy of Depression. NewYork, Basic Books, 1984

2. Weissman MM, Markowitz JC: Interpersonal psycho-therapy: current status. Arch Gen Psychiatry 1994;51:599–606

3. Markowitz JC: Teaching interpersonal psychotherapyto psychiatric residents. Academic Psychiatry 1995;19:167–173

4. Crits-Christoph P: The efficacy of brief dynamic psy-chotherapy: a meta-analysis. Am J Psychiatry 1992;

149:151–158 5. Svartberg M, Stiles TC: Comparative effects of short-

term psychodynamic psychotherapy: a meta-analysis.J Consult Clin Psychol 1991; 59:704–714

6. Svartberg M, Stiles TC: Efficacy of brief dynamic psy-chotherapy (letter). Am J Psychiatry 1993; 150:684

7. Crits-Christoph P: Dr. Crits-Christoph replies (letter).Am J Psychiatry 1993; 150:684–685

8. Malan DH: The Frontier of Brief Psychotherapy. NewYork, Plenum, 1976

9. Sifneos PE: Short-Term Dynamic Psychotherapy.

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New York, Plenum, 197910. Davanloo H (ed): Short-Term Dynamic Psychother-

apy, vol I. New York, Jason Aronson, 198011. Mann J: Time-Limited Psychotherapy. Cambridge,

MA, Harvard University Press, 197312. Luborsky L: Principles of Psychoanalytic Psychother-

apy: A Manual for Supportive/Expressive Treatment.New York, Basic Books, 1984

13. Strupp HH, Hadley SW: Specific vs. non-specific fac-tors in psychotherapy: a controlled study of outcome.Arch Gen Psychiatry 1979; 36:1125–1136

14. Weiss J, Sampson H: The Psychoanalytic Process:Theory, Clinical Observations, and Empirical Re-search. New York, Guilford, 1986

15. Gustafson JP: An integration of brief dynamic psycho-therapy. Am J Psychiatry 1984; 141:935–944

16. Vaillant LM: Changing Character: Short-term Anxi-ety-Regulating Psychotherapy for Restructuring De-fenses, Affects, and Attachment. New York, BasicBooks, 1997

17. Crits-Christoph P, Barber JP (eds): Handbook ofShort-term Dynamic Psychotherapy. New York, BasicBooks, 1991

18. Klerman GL, Weissman MM (eds): New Applicationsof Interpersonal Therapy. Washington, DC, AmericanPsychiatric Press, 1993

19. Weissman MM, Klerman GL, Prusoff BA, et al: De-pressed outpatients: results one year after treatmentwith drugs and/or interpersonal psychotherapy. ArchGen Psychiatry 1981; 38:52–55

20. Horowitz MJ: Short-term dynamic therapy of stressresponse syndromes, in Handbook of Short-term Dy-namic Psychotherapy, edited by Crits-Christoph P,Barber J. New York, Basic Books, 1991, pp 166–198

21. Horowitz MJ, Marmar C, Weiss D, et al: Brief psycho-therapy of bereavement reactions. Arch Gen Psychi-atry 1984; 41:438–448

22. Strupp H, Binder J: Psychotherapy in a New Key: AGuide to Time-Limited Dynamic Psychotherapy. NewYork, Basic Books, 1984

23. Svartberg M: Characteristics, outcome, and process ofshort-term psychodynamic psychotherapy: an up-dated overview. Nordic Journal of Psychiatry 1993;47:161–167

24. Parsons T: Illness and the role of the physician: a so-ciological perspective. Am J Orthopsychiatry 1951;21:452–460

25. Markowitz JC: Interpersonal Psychotherapy for Dys-thymic Disorder. Washington, DC, American Psychi-

atric Press, 199826. Markowitz JC, Swartz HA: Case formulation in inter-

personal psychotherapy of depression, in Handbookof Psychotherapy Case Formulation, edited by EellsTD. New York, Guilford, 1997, pp 192–222

27. Woody GE, Luborsky L, McLellan AT, et al: Psycho-therapy for opiate addicts: does it help? Arch Gen Psy-chiatry 1983; 40:639–645

28. Rounsaville BJ, Glazer W, Wilber CH, et al: Short-term interpersonal psychotherapy in methadone-maintained opiate addicts. Arch Gen Psychiatry 1983;40:629–636

29. Vaughn SC, Roose SP, Marshal RD: Mood disordersamong patients in dynamic therapy. Presented in Sym-posium 121: Character and Chronic Depression: Lis-tening to Data, at the annual meeting of the AmericanPsychiatric Association, New York, NY, May 1996

30. American Psychiatric Association: Diagnostic and Sta-tistical Manual of Mental Disorders, 4th edition. Wash-ington, DC, American Psychiatric Association, 1994

31. Elkin I, Shea MT, Watkins JT, et al: National Instituteof Mental Health Treatment of Depression Collabo-rative Research Program: general effectiveness oftreatments. Arch Gen Psychiatry 1989; 46:971–982

32. Hollon SD: Final report: system for rating psychother-apy audiotapes. Bethesda, MD, US Department ofHealth and Human Services, 1984

33. Hellerstein DJ, Pinsker H, Rosenthal RN, et al: Sup-portive therapy as the treatment model of choice. JPsychother Pract Res 1994; 3:300–306

34. Rockland LH: Supportive Therapy. New York, BasicBooks, 1989

35. Markowitz JC, Klerman GL, Clougherty KF, et al: In-dividual psychotherapies for depressed HIV-positivepatients. Am J Psychiatry 1995; 152:1504–1509

36. Binder J, Strupp H: The Vanderbilt approach to time-limited dynamic psychotherapy, in Handbook ofShort-term Dynamic Psychotherapy, edited by Crits-Christoph P, Barber J. New York, Basic Books, 1991,pp 137–165

37. Swartz HA, Markowitz JC: Time-limited psychother-apy, in Psychiatry, vol 2, edited by Tasman A, Kay J,Lieberman J. Philadelphia, WB Saunders, 1997, pp1405–1417

38. Frances A, Clarkin JF, Perry S: Differential Therapeu-tics in Psychiatry: The Art and Science of TreatmentSelection. New York, Brunner/Mazel, 1984

39. Frank J: Therapeutic factors in psychotherapy. Am JPsychother 1971; 25:350–361

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Kernberg PF, Chazan SE, Normandin L: The Children’sPlay Therapy Instrument: description, development, andreliability studies. J Psychother Pract Res 1998; 7(3):____–____Psychotherapy of Children and Adolescents; Rating In-struments; Play Therapy

The Children’s Play TherapyInstrument (CPTI)Description, Development, and Reliability Studies

P A U L I N A F . K E R N B E R G , M . D .S A R A L E A E . C H A Z A N , P H . D .L I N A N O R M A N D I N , P H . D .

The Children’s Play Therapy Instrument(CPTI), its development, and reliabilitystudies are described. The CPTI is a newinstrument to examine a child’s play activityin individual psychotherapy. Threeindependent raters used the CPTI to rateeight videotaped play therapy vignettes.Results were compared with the authors’consensual scores from a preliminary study.Generally good to excellent levels of interraterreliability were obtained for the independentraters on intraclass correlation coefficients forordinal categories of the CPTI. Likewise,kappa levels were acceptable to excellent fornominal categories of the scale. The CPTIholds promise to become a reliable measure ofplay activity in child psychotherapy. Furtherresearch is needed to assess discriminantvalidity of the CPTI for use as a diagnostictool and as a measure of process and outcome.

(The Journal of Psychotherapy Practiceand Research 1998; 7:196–207)

The Children’s Play Therapy Instrument(CPTI) was constructed to assess the play

activity of a child in psychotherapy. It is in-tended to be of use to clinicians and researchersas an additional criterion for diagnosissincechildren with different diagnoses tend to havedifferent forms of play1,2and as an objectiveinstrument to measure change and outcome inchild treatment. The purpose of this article isto describe the instrument and the initial reli-ability studies.

T H E C P T I

Although several scales have recently beenwritten to measure the play of children,3–5 theCPTI is specifically intended to be a compre-hensive measure of a child’s play activity inpsychotherapy. The CPTI adapts several es-tablished scales6–9 in order to measure play ac-tivity from a variety of perspectives. The CPTIprovides a tool to describe, record, and analyzea child’s play activity equivalent to a mentalstatus formulation of a child’s overall function-

Received March 26, 1997; revised January 6, 1998; ac-cepted January 7, 1998. From The New York Hospital-Cornell Medical Center, Westchester Division, WhitePlains, New York, and Laval University, Quebec, Can-ada. Address correspondence to Dr. Kernberg, The NewYork Hospital-Cornell Medical Center, 21 BloomingdaleRoad, White Plains, NY 10605.

Copyright © 1998 American Psychiatric Press, Inc.

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ing following a clinical interview. Anoutline of the CPTI appears in Table 1.

Level One:Segmentation

Level One analysis addresses thedifferent types of activity the child en-gages in during the psychotherapysession by segmenting the child’sactivity into four categories. These fourcategories are Pre-Play, Play Activity,Non-Play, and Play Interruption. Seg-mentation of the child’s activity resultsin an overview of the distribution andspan of time of various categories of thechild’s activity in therapy. For example,segmentation delineates a child whodoes not play from a child who does; itregisters the activity of a child who un-dergoes play interruptions and con-trasts it with that of a child who iscapable of sustained play activity. Itprovides information on the ratio be-tween play activity and non-play activ-i ty. During the session, clinicalexperience suggests that a child withsignificant emotional problems willtend to spend less time engaged in playactivity and will experience interrup-tions due to anxiety or aggression.

Pre-Play is defined as the activity inwhich the child is “setting the stage” forplay. She may pick up a toy and ma-nipulate it, arrange play materials, ortry out a character’s voice or actions.The predominant purpose of pre-playactivity is preparation. Pre-play may beprolonged in compulsive or depressedchildren. In some instances, the childwill not progress beyond pre-play.

Play Activity begins if the child be-comes engrossed in playful activityoften indicated by the adult or child ex-hibiting one or a combination of the fol-lowing behaviors: 1) an expression ofintent (e.g., “Let’s play.”); 2) actions in-dicating initiative, such as definition of

TABLE 1. Outline of the Children’s Play TherapyInstrument (CPTI)

Level One: Segmentation of Child’s ActivityNon-Play ActivityPre-Play ActivityPlay ActivityInterruption

Level Two: Dimensional Analysis of the Play Activity

Descriptive Analysis* Category of Play Activity* Script Description of Play Activity* Sphere of Play Activity

Structural Analysis Affective Components of Play Activity

* Child’s Affects Modulation* Affects Expressed by Child While in the Play* Therapist’s Affective Tone

Cognitive Components of Play Activity* Role Representation* Stability of Representation (People & Play Object)* Use of Play Object* Style of Role Representation (People & Play Object)

Dynamic Components of Play Activity* Topic of the Play Activity* Theme of the Play Activity

* Level of Relationship Portrayed within the Play Activity* Quality of Relationship within the Play Activity* Use of Language (Child and Therapist)

Developmental Components of Play Activity* Estimated Developmental Level of Play* Gender Identity of Play* Psychosexual Phase Represented in the Play* Separation-Individuation Phase Represented in the Play* Social Level of Play

Adaptive AnalysisCoping and Defensive Strategies

Cluster I — Cluster II — Cluster III — Cluster IV*Normal *Neurotic *Borderline *Psychotic

*Awareness

Level Three: Pattern of Child Activity Over TimeContinuity and Discontinuity in Play Narrative(s)

2*Subscale of the CPTI.

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roles (e.g., “This dolly will be the teacher”;“Let’s climb the mountain”); 3) an expressionof specific positive or negative affects such asglee, delight, pleasure, surprise, anxiety, fear,disgust, or boredom; 4) focused concentration;5) use of toy objects or the physical surround-ings to develop a narrative.

Normal Play in children is generally an age-appropriate, joyful, absorbing activity. It is in-itiated spontaneously, with a developingtheme carried to a resolution; there is a naturalending and then a move on to another activity.In contrast, pathological play of children withthe diagnosis of severe disruptive disorders hasbeen described as compulsive, joyless, andmonotonous; the play of autistic children isjoyless, nonreciprocal, repetitive, with no evi-dent narrative and no sense of resolution; andthe play of psychotic children is characterizedby drivenness, sudden fluid transformations ofthe characters in the play, and play disruption.From the perspective of segmentation, a childoptimally involved in play can consistently de-velop play after pre-play preparation and canunfold a play narrative ending naturally in playsatiation.10 If the length of the segments of playis sufficient for the expression of the child’snarratives, the patient therapy session is beingused optimally and/or the patient has im-proved in her capacity to play.

Non-Play refers to a variety of activities orbehaviors of the child outside the realm of theplay activity, such as showing reluctance, eat-ing, reading, doing homework, or conversingwith the therapist. All of these activities or be-haviors have in common the absence of in-volvement in play activity and may havepositive or negative implications in relation totherapeutic alliance and phase of treatment.

Play Interruption is operationally defined asany abrupt cessation in a play activityfor ex-ample, if the child must go to the bathroom orabruptly ends the play activity because of someextraneous distraction. The time interval of 18to 22 seconds was pragmatically chosen be-cause raters agreed it was a minimum intervalthat could be reliably timed without instru-ments.

Once the therapy session has been seg-mented, a detailed description of one play ac-tivity segment, based on the videotape, iswritten. This constitutes a “play narrative” thatincludes the setting of the play, relevant dia-logue, associated affects, the child’s playthemes, and the child’s attitudes and involve-ment in the play activity and with the therapistwhile playing. The play narrative is a centralintegrating database to which the rater returnswhen rating any of the individual subscales.The emphasis is on a frame-by-frame analysisintegrating all the distinctive features of thechild’s play activity and concomitant affects.

Level Two:Dimensional Analysis

The Dimensional Analysis examines theplay activity segment using three distinct pa-rameters: Descriptive, Structural, and Adap-tive.

Descriptive Analysis: The Descriptive Analysisincludes the following subscales: 1) Categoryof the Play Activity, which lists non–mutuallyexclusive types of play activity: gross motoractivity, construction fantasy, game play;2) Script Description, which measures thechild’s initiatives to play, the contribution ofthe adult to the unfolding of the child’s play,and the interaction between child and thera-pist in composing the play; this subscale pro-vides information regarding the child’sautonomy and reciprocity as well as a measureof therapeutic alliance between therapist andchild; and 3) Sphere of the Play Activity, whichindicates the spatial realms within which theplay activity takes place: Autosphere (therealm of the body); Microsphere (the realm ofsmall toys), or Macrosphere (the realm of theactual surroundings).8 This subscale may havespecific clinical reference in terms of bounda-ries, reality testing, maturity, and perspectivetaking.

Structural Analysis: The structural analysis in-cludes the following measures of a child’s play

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activity: 1) Affective Components, 2) Cogni-tive Components, 3) Dynamic Components,and 4) Developmental Components.

Affective Components of Play Activity. Thetypes and range of emotions brought by thechild to her play reflect those feelings signifi-cant in her own life. The link between emo-tions and play activity is what brings play alivewith understanding. Concentration and in-volvement characterize play activity. The over-all hedonic tone may vary from positivefeelings, expressing pleasure, to negative feel-ings, associated with conflict.8 When distressis too threatening to the child, this will eventu-ate in play disruption.8 The child’s capacity toregulate expression of feelings will affectand/or reflect the organization of play.11 Thegreater capacity for smooth transitions andregulation of affect reflects an integration ofthe child’s subjective world, and it is a key tothe capacity to play at the highest levels of crea-tivity. If the child is able to gain expression ofintense feelings through play, she has madegiant steps toward coping and mastery. Thecapacity to play symbolically implies the ca-pacity for regulation of emotions. Indeed,scenarios portrayed with intensity and a widerange of emotions can be assumed to be ofgreat significance to the child.

Cognitive Components of Play Activity. Thismodified scale was based on the work of IngeBretherton6 on symbolic play. The structure ofthe social representational world is a crucialdimension of the child’s play. From a cognitiveperspective, it indicates the degree to which achild is capable of creating narrative structuresto represent different affect-laden relation-ships. Beginning role-play is the child pretend-ing he is another person, or animating a toy oranother’s behavior. In its most complex form,role-play becomes directorial play or narratorplay, with several interacting roles, enlivenedby the child with a variety of emotional themes.

Younger children are capable of only sim-ple representations; older children may drawfrom a varied repertoire. The level of role rep-resentation also indicates progression and re-gression in the child’s level of functioning. If a

child is unable to achieve a given complexityof role-play, this may reflect a lack of differen-tiation between self and others, an incapacityfor empathy with and investment in others, orcognitive limitations due to stage of develop-ment or other causes.9,12 Further, Piaget13 refersto failure to view reality from different perspec-tives as a failure in decentering. The child isunrelated to the other person and remains cen-tered on herself in an egocentric fashion. Al-ternatively, others (including the therapist ortoys) may be animated only as recipients orextensions of the child’s activities. From thisinitial point, the child proceeds to playing withtherapist and toys as passive recipients and be-gins to comprehend the give and take of recip-rocal roles and their reactions.

A major advance occurs when the child iscapable of expressing independent intention-ality for a toy or a person. At this importantjuncture the child has become capable of as-suming a different role, other than her own,without experiencing the threat that she herselfmight disappear. An example of this type ofcognitive anxiety occurs on Halloween, whensome young children, 3 to 4 years old, exhibitfear of being in disguise. The costume suggeststo the young child that she could disappear.However, at a later age a child can toleratedonning a disguise and playing another’s role;she has gained self-constancy.

Dynamic Components of Play Activity. Thetopic of play reveals important emotionalthemes to the child. A child who repetitivelyengages in play about particular topics is com-municating about the types of conflicts he isdealing with at the time: fear of death, sexualthemes, competitiveness. The theme indicatesthe narrative of the play enacted by particularcharacters. It is important to keep in mind whattopics and themes might be expected for agiven developmental perspective and what mi-nor discrepancies might represent divergencefrom this expected pattern. The divergencemay be significant in conveying a specific con-cern of the child.

The level of relationship portrayed withinthe play activity specifies the pattern of inter-

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actions between play characters. The level ofdyadic, triadic, and oedipal configurationsplaces the child at different points of personal-ity organization, from severely disturbed per-sonalities to neurotic or normal ones.

The Quality of Relationship Within thePlay Activity segment is an adaptation of theUrist Scale,9 as written for children by Tuber,14

and the scale of Diamond et al.15 It assesses,through the dynamics of the narrative, the na-ture of the child’s emotional conflicts and theextent of expression of aggressiondirect,attenuated, neutralized, or sublimatedthathe exercises over his subjective world, i.e.,autonomous, dependent, and destructive in-teraction among play characters.

Developmental Components of Play Activity.This dimension compares the child’s activitywith play of other children of the same age,gender, and level of emotional and social de-velopment. This analysis implies an underly-ing epigenetic sequence to the unfolding of achild’s capacity to play. It is a relative judgmentand depends on cultural and social standardsand values. Because play unfolds in a sociallyshared context, group norms are appropriateto evaluate the child’s play. Ideally, play activ-ity is consistent across developmental dimen-sions.

Several different sources supplied informa-tion for the compilation of these last categories.Gender identity assessment was influencedby the writing of Erikson,8,10,16 Coates,17 andZucker;18 psychosexual phases were based onthe writings of Anna Freud19 and Peller;20 sepa-ration-individuation phases were based on thewritings of Mahler;21 and the social level of playincludes Winnicott’s concept of the capacity toplay alone.22

Adaptive Analysis: The adaptive analysis as-sesses the overall purpose of the play activityfor the playing child. The child’s observableplay behaviors are classified as manifestingspecific coping/defensive strategies groupedinto four clusters: 1) Normal, 2) Neurotic, 3)Borderline, and 4) Psychotic. These clustersmay be placed in sequence in order of their

appearance. The concept of a spectrum ofclusters of coping and defensive strategies wasbased on the writings of Vaillant,23 Perry etal.,24 and P. Kernberg.25

A final subscale measures the child’sawareness that he is engaged in play activity.This subscale condenses several cognitive andaffective variables that determine how capablethe child is of observing himself at play, or,alternatively, the extent to which he and hissurroundings have been completely absorbedinto the play.

As outlined above, each of the CPTI scales(Descriptive, Structural, and Adaptive) con-sists of several subscales (see Table 1). Depend-ing on the interests of the examiner, he or shemay use the CPTI in its entirety or may selectonly certain scales or combinations of sub-scales.

Level Three:Patterns Over Time

This level of analysis refers to patterns ofthe child’s activity over time and seeks to assesschanges in treatment. The patterns of segmen-tation are expected to change over time. Forexample, the sequence and length of thedifferent segments of the child’s activityPre-play, Play Activity, Non-play, and Interrup-tionchange in the course of treatmentdepending on the child’s diagnosis and type oftreatment. However, this level of analysis willnot be addressed in this article.

P R E L I M I N A R Y

R E L I A B I L I T Y S T U D Y

Construction of the instrument requiredmultiple observations of videotaped play ther-apy sessions. The associated discussions in-volved 10 experienced clinicians over a spanof 3 years. The authors of the scale gleanedmaterial from these discussions to write a man-ual defining the primary dimensions of theCPTI and formulating operational definitionsfor each scale and subscale, with clinical illus-trations.

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Methods and Results

A preliminary reliability study wasplanned using three members of the group asraters. A videotape montage consisting of eightclinical vignettes was composed by an inde-pendent clinician trained to identify the differ-ent categories of child activity. The mainselection criterion was to find segments thatcontained at least one segment of play activityand any of the other three child activities (Pre-Play, Non-Play, and Interruption). Table 2 de-scribes the sample.

Level One (Segmentation): The three raters(one psychiatrist, two psychologists) werechild therapists, each with more than 10 yearsof clinical experience. They rated the eightvignettes independently, with subsequent dis-cussions of the ratings to improve on the clar-ity of the segmentation in the manual.

Agreement on the segmentation of thechild’s activity into four categories (Pre-Play,Non-Play, Play, and Interruption) as measuredby the weighted kappa coefficient was 0.69.26

This level of agreement between the judges onsegmentation is considered to be good.*

Level Two (Dimensional Analysis): Two raters(one psychiatrist, one psychologist) completedratings for level two. Analysis of the play ac-tivity segments was done by using intraclasscorrelation coefficient (ICC)28 for ordinal cate-gories of the CPTI and kappa for the nominalones. The most consistent subscale scoreswere obtained on the Descriptive dimensionof the CPTI. For example, Category of PlayActivity, ICC = 0.68; Script Description, ICC= 0.70; Sphere of Play Activity, ICC = 0.88.**

Among the Structural and Adaptivescales, good to excellent scores were obtainedfor all the subscales on these dimensions.

These scores ranged from ICC 0.50 to 0.79.For example, Affects Expressed in Play, ICC= 0.77; Stability of Role Representation, ICC= 0.79; Developmental Level of Play, ICC =0.50; Social Level of Play, ICC = 0.56. Lowscores were obtained on Role Representation,ICC = 0.29; Use of Play Object, ICC = 0.33;and Use of Language, ICC = 0.32. The Adap-tive dimension produced the lowest results,ICC = 0.09.

Despite acceptable levels of agreement be-tween raters on many of the subscales, therewere disparities on some subscales, which wereattributed primarily to the lack of sufficientspecificity in definition of categories in themanual. A decision was made to revise thescoring manual and refine the definitions.

To establish a consensual rating to be usedas a standard for new independent raters, theraters of the preliminary study performed anitem-by-item analysis of the ratings of the eightvignettes.

R E L I A B I L I T Y S T U D Y :I N D E P E N D E N T R A T E R S

A N D C O M P A R I S O N W I T H

C O N S E N S U S

Methods

Three independent raters, recruited fromdifferent institutions, rated the same eightvideotaped vignettes used in the preliminaryreliability study. The raters were all child psy-chologists, ranging in experience from 1 to 12years in child therapy. They received 15 hoursof training from one of the authors (a psycholo-gist). The training consisted of group discus-sions based on definitions and descriptions ofthe CPTI scales found in the manual.

Eight vignettes were selected from a set of19 videotaped play therapy sessions by anindependent clinician who was trained to

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*Landis and Koch27 furnished criteria to assess the level of agreement between judges as calculatedfrom the kappa: 0.00 to 0.39 poor; 0.40 to 0.74 acceptable to good; 0.75 to 1.00 excellent.

**Jones et al.29 suggested 0.70 agreement as an acceptable level when complex coding schemes areused; Gelfand and Hartmann30 recommend 0.60.

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identify the different Level One categories ofChild’s Activity, namely Pre-Play, Play, Non-Play, and Interruption. The main selection cri-terion was to find segments that contained atleast one Play Activity, defined as a narrativewith a beginning and an end, and any of theother three Child Activities. Also, the vignetteswere chosen to provide a varied array of childdiagnoses, levels of therapist experience, andphases of treatment. The duration of thevignettes ranged from 4 minutes, 6 seconds, to11 minutes, 34 seconds, with a mean of 7 min-utes, 47 seconds, and a standard deviation of2 minutes, 37 seconds (see Table 2).

To maintain each rater’s accuracy, ratingssessions were split into two parts, as suggestedby Hartmann,31 each part consisting of theCPTI-based rating of four vignettes followedby a discussion with the trainer.

After the submission of the whole ratings,discussion and comparison with the authors’consensus ratings were conducted. Reliabilityestimates were obtained for the degree ofagreement of each individual rater with theconsensus. The raters contributed to the clari-fication of the manual categories and to theirtraining by the exchange of opinions and clini-cal examples from their own experience.

Three types of reliability estimates werederived from data, according to the differenttypes of scales constituting the CPTI and thenumber of raters used in the experiment.

Reliability of the categorical data obtainedfrom the segmentation of the eight vignettes(Level One) was appraised by using a weightedkappa.26 Disagreements between differentcategories have different clinical implications.For example, it is more serious to rate equallyPlay and Non-Play than Pre-Play and Play.Therefore, the relative importance of differenttypes of disagreement among the four catego-ries of the Child Activity (Pre-Play, Play, Non-Play and Interruption) was established in orderto perform the data analysis. A disagreementbetween Play, Non-Play, or Pre-Play and In-terruption gets a weight of 1.00; a disagreementbetween Play and Non-Play gets a weight of0.75; a disagreement between Pre-Play andNon-Play gets a weight of 0.50; and a disagree-ment between Play and Pre-Play gets a weightof 0.25. However, weighted kappa is restrictedto cases where the number of raters is twoand the same two raters rate each subject(vignette).28 In this study, we will present amean weighted kappa derived from each pairof raters.

TABLE 2. Description of the eight vignettes

Phase of Therapist Patient Diagnosis Therapy Duration

1. 1st-year child resident 5–6-year-old boy Adjustment reaction disorder Middle–advanced 6′25″Grief reaction

2. Resident psychology intern 5-year-old girl Stress disorder Middle–advanced 6′54″Physical child abuseFailure to thrive

3. Senior therapist >15 years 5–7-year-old boy Gender identity disorder Early–middle 8′36″Posttraumatic stress disorder

4. Therapist 5 years 9-year-old boy Oppositional defiant disorder Late 11′34″ 5. 2nd-year child resident 7-year-old girl Separation anxiety disorder Middle–advanced 8′02″

Avoidant disorder6. Psychology intern 5-year-old girl Posttraumatic stress disorder Middle–advanced 5′06″

Physical child abuseFailure to thrive

7. Senior therapist > 15 years 91⁄2-year-old boy Pervasive developmental disorder Beginning 4′06″Autism

8. Senior therapist > 20 years 10-year-old boy Conduct disorder Middle 9′02″

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For reliability of the categorical scalesfrom Level Two of the CPTI, namely Categoryof Play Activity, subscales of Child and AdultScript Description, Topic, Theme, and GenderIdentity, a multiple-rater kappa is estimated,32,33

in which the average pairwise kappas are ad-justed for covariation among pairwise kappasand chance agreements.

For appraising reliability of the remainingquantitative scales of the CPTI (ordinal scaleranging from 1 to 5), an intraclass correlationcoefficient is calculated, using a two-way analy-sis of variance, where the three raters are con-sidered random effects. Thus, differences at thebetween-raters level are included as error fromthe analysis. The choice of this statistic is basedon the wish of the authors to generalize theestimated results to raters who have at least1 year of clinical experience and as much as12 years of experience, so that the CPTI couldbe reliably used by a variety of clinicians.34,35

Results

Level One: Segmentation: Agreement amongthree raters on the segmentation of a child’sactivity into four categories (Pre-Play, PlayActivity, Interruption, and Non-Play) as mea-sured by the weighted kappa coefficient was0.72.

Level Two: Dimensional Analysis: Interrater re-liabilities measured by the kappa coefficientfor the twelve categorical subscales of theCPTI indicate an average coefficient of 0.65,with range 0.42 to 1.00 (Table 3). The singleexception was 0.12, Initiation of Play by Adult.

The kappa statistic is extremely sensitiveto an unbalanced distribution of categories(presence versus absence), and this sensitivityaccounted for some of the variability in ourresults.

The intraclass correlation coefficientsfor the 25 main ordinal subscales of theCPTIspecifically the global scores for ScriptDescription, Affective, Cognitive, Develop-mental, and Dynamic components; Adaptivefunctions; and Awarenessshow a mean

tendency of 0.71, with a range from acceptableto excellent (ICC 0.52–0.89). However, thereare two subscales at unacceptable levels of re-liability, namely Separation-IndividuationPhases Represented in the Play (ICC = 0.43),an increment over earlier findings but still be-low acceptable levels, and Borderline cop-ing/defensive mechanisms (ICC = 0.45),lower than the acceptable levels obtained forother coping/defensive mechanisms.

Generally, the new raters did almost aswell as the authors of the scale and in severalinstances were able to obtain higher levels ofinterrater reliability. Significant improvementswere seen in Style of Role Representation: PlayObject (ICC = 0.83, compared with 0.38);Separation-Individuation Phase Representedin the Play (ICC = 0.43, compared with 0.21).

Individual Rater Agreement With the Consensus:Each rater’s performance was compared withthe standard provided by the consensus of theauthors of the scale. Results indicate that, over-all, satisfactory to excellent agreement with thestandard was obtained by all three judges. Forexample, the intraclass correlation coefficientsfor seven main subscales of the CPTIspecif-ically the global scores for Script Description,Affective, Cognitive, Developmental, and Dy-namic components; Adaptive functions; andAwarenessshow a mean of ICC = 0.81 (range0.61–0.94) for Rater A; a mean of ICC = 0.84(range 0.69–0.92) for Rater B; and a mean ofICC = 0.84 (range 0.71–0.96) for Rater C.

Further comparisons were performed foreach individual vignette and revealed a similarpattern of results on the main structural cate-gories of the CPTI. Raters A, B, and C reachedgood to excellent agreement with the standard.The intraclass correlation coefficients for thefour main structural categories of the CPTI,specifically the global scores for Affective,Cognitive, Developmental, and Dynamiccomponents, show a mean of ICC = 0.62(range 0.58–0.85) for Rater A; a mean of ICC= 0.73 (range 0.59–0.81) for Rater B; and amean of ICC = 0.69 (range 0.63–0.75) forRater C.

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TABLE 3. Interrater reliability among three raters as measured by kappa and intraclass correlationcoefficients (ICC)

Variable Kappa % Agreementa ICC

Category of the Play Activity Segment 0.50 81.0 NA

Script Description of the Play Activity Segment (Global) NA 0.89 Script Description (Child) NA 0.86 Initiation of Play 1.00 100.0 NA Facilitation of Play 1.00 100.0 NA Inhibition of Play 0.47 87.2 NA Ending of Play 0.52 80.0 NA Script Description (Adult) NA 0.87 Initiation of Play 0.12 44.4 NA Facilitation of Play 1.00 100.0 NA Inhibition of Play 0.42 86.1 NA Ending of Play 1.00 100.0 NA Contribution of Participants (Child) NA 0.89 Contribution of Participants (Adult) NA 0.57

Sphere of the Play Activity NA 0.92

Affective Components of the Play Activity Segment (Global) NA 0.84 Child’s Affects Modulation NA 0.70 Affects Expressed by the Child while in the Play NA 0.73 Therapist’s Affective Tone NA 0.66

Cognitive Components (Global) NA 0.80 Role Representation NA 0.72 Stability of Representation (People) NA 0.83 Stability of Representation (Play Object) NA 0.84 Use of Play Object NA 0.88 Style of Role Representation (People) NA 0.64 Style of Role Representation (Play Object) NA 0.83

Dynamic Components of the Play Activity Segment (Global) 0.63 92.3 0.68 Topic of the Play Activity Segment 0.66 94.1 NA Theme of the Play Activity Segment 0.60 90.7 NA Level of Relationship Portrayed within the Play Activity Segment NA 0.82 Quality of Relationship within the Play Activity Segment NA 0.70 Use of Language by the Child NA 0.68 Use of Language by the Therapist NA 0.57

Developmental Components of the Play Activity (Global) NA 0.62 Estimated Developmental Level of Play NA 0.90 Gender Identity of Play 0.90 NA Psychosexual Phase Represented in the Play NA 0.72 Separation-Individuation Phase Represented in the Play NA 0.43 Social Level of Play: Interaction with the Therapist NA 0.63

Adaptive Analysis of the Play Activity (Global) NA 0.65 Cluster I NA 0.81 Cluster II NA 0.64 Cluster III NA 0.45 Cluster IV NA 0.60

Awareness NA 0.52

2 aPercentage agreement among the three judges.

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These comparisons were derived from theconsensual mean and standard deviationscores obtained for each vignette (Table 4).One should note that vignettes that are associ-ated with high mean scores and small standarddeviation scores are mainly associated with themiddle–advanced and late phases of treat-ment, whereas low mean scores and largestandard deviation scores are associated withvignettes from the beginning or middle phasesof treatment.

D I S C U S S I O N

These preliminary studies demonstrate the fea-sibility of using the CPTI to measure a child’sactivity in psychotherapy. The CPTI providesa means to identify play activity within a psy-chotherapy session. The play activity is thenmeasured from three different perspectives:descriptive, structural, and adaptive. Each ofthese dimensions consists of individual sub-scales that are operationally defined. Thequantification of these subscales provides boththe flexibility to derive individual profiles ofplay activity in psychotherapy and a method-ology to identify relevant dimensions of achild’s play activity.

Training procedures established the credi-bility of these measures in assessing play activ-ity. The independent raters, with varying levelsof experience, required 15 hours of training toreach satisfactory levels of agreement. This re-sult is preliminary evidence to suggest CPTImay be a usable tool for researchers and clini-

cians who receive a minimum of 15 hours ofintensive training.

Despite the small number of vignettesused to establish the reliability of the instru-ment, it must be stated that the vignettes em-brace the whole spectrum of the differentordinal scales. The vignettes that showedhigher mean scores with smaller standarddeviations were associated with the middle–advanced and late phases of treatment; lowermean scores with larger SDs were associatedwith vignettes from the beginning or middlephases of treatment. Likewise, the raters wereconsistently able to make these sensitive dis-tinctions. However, in some subscales usingthe kappa, reliabilities were lowered by a pre-ponderant representation of one of the catego-ries over the other; for example, (Adult)Initiation of Play (κ = 0.12) and Functionalanalysis: Cluster II (κ = 0.41). This dispropor-tionate pattern was likely to lower the reliabil-ity coefficient each time a disagreement on theless represented category was encountered.

The Separation-Individuation category ofthe Developmental scale gave results below ac-ceptable standards. A closer examination ofraters’ individual ratings showed a wide dis-crepancy among raters. This scale clearly re-quired further definition, particularly as itpertains to higher-functioning children. Fur-ther work on clarifying the phases of separa-tion-individuation represented in the child’splay resulted in a revision of the definitions ofthese categories in the manual. Specifically,new examples illustrating these phenomena in

TABLE 4. Means and standard deviations of the average rating for the main structural categories ofeach vignette

Vignette Number and Phase of Treatment 1 2 3 4 5 6 7 8

Variable M-A M-A M-E L M-A M-A B M

Affective (Global) 3.2 ± 1.1 4.2 ± 0.8 2.8 ± 1.7 3.7 ± 0.9 3.5 ± 1.1 4.1 ± 0.6 1.7 ± 2.3 2.7 ± 2.1

Cognitive (Global) 3.7 ± 1.2 3.9 ± 0.5 2.9 ± 2.1 2.9 ± 0.5 3.5 ± 1.2 4.3 ± 1.2 1.5 ± 1.6 3.4 ± 1.3

Dynamic (Global) 4.2 ± 0.6 2.7 ± 1.4 2.7 ± 2.4 3.3 ± 1.1 2.7 ± 1.5 3.5 ± 0.6 1.7 ± 2.1 2.9 ± 1.9

Developmental (Global) 3.0 ± 0.9 3.1 ± 0.7 2.8 ± 1.5 3.3 ± 0.9 2.9 ± 0.8 3.1 ± 0.9 1.4 ± 2.2 2.7 ± 1.8

2Note: Phases of treatment: M-A = middle–advanced; M-E = middle–early; L = late; B = beginning; M = middle.

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children with mild emotional disorders wereadded in the training. In the prior reliabilitystudies, raters had experienced difficulty mak-ing meaningful reference to these categories,except in cases of severe disturbance (psychosisand autism). After a 2-month hiatus, the Sepa-ration-Individuation subscale was readminis-tered to the group of three trained raters, andthe results obtained were good: ICC = 0.63.

Looking toward the future, a larger data-base is required, to include both clinical andnonclinical children, to establish definitive re-liability and to validate the sensitivity andspecificity of the CPTI as a diagnostic tool thatdiscriminates distinctive psychopathologicalprofiles and is sensitive to changes occurringin the course of treatment.

S U M M A R Y

We described the development of a new andcomprehensive measure of a child’s play ac-tivity in psychotherapy, the CPTI, and pre-sented reliability studies. Using the instrument

and accompanying manual, raters weretrained to obtain satisfactory to excellent levelsof agreement on the segmentation and dimen-sions of a child’s play activity occurring withina psychotherapy session. In addition, each ofthese trained raters obtained good to excellentagreement with the consensus standard for thescale reached by the authors of the scale. Futureplanned studies include obtaining reliabilityon a larger new sample of play sessions andevaluating sequences of play sessions overtime. In addition, future validity studies areplanned to investigate the concurrence of playprofiles with diagnostic categories, attachmentbehaviors, and outcome variables. These pre-liminary findings indicate that the CPTI holdspromise to become a diagnostic instrumentand outcome measure of a child’s play activityin psychotherapy.

The authors acknowledge with appreciation theparticipation of Elsa Blum, Ph.D., Pauline Jordan,Ph.D., Judith Moskowitz, Ph.D., and Risa Ryger,Ph.D.

R E F E R E N C E S

1. Kernberg PF: Las formas del juego: una comunicaciónpreliminar [The forms of play: a preliminary commu-nication]. Revista Latinoamericana de Psicoanálisis1996; 1:197–201

2. Kernberg PF, Chazan SL, Normandin L: The CornellPlay Therapy Instrument. Poster presented at the an-nual meeting of the Society for Psychotherapy Re-search, York, England, June 1994

3. Greenspan SI, Lieberman AF: Representationalelaboration and differentiation: a clinical-quantitativeapproach to the clinical assessment of 2–4 year olds,in Children at Play, edited by Slade A, Wolf DP. NewYork, Oxford University Press, 1994, pp 3–32

4. Lindner TW: Transdisciplinary Play-based Assess-ment. Baltimore, Paul H. Brookes, 1990

5. Schaefer CE, Gitlin K, Sandgrund A: Play Diagnosisand Assessment. New York, Wiley, 1991

6. Bretherton I: Representing the social world in sym-bolic play, in Symbolic Play, edited by Bretherton I.New York, Academic Press, 1984, pp 3–41

7. Emde RN, Sorce JE: The rewards of infancy: emo-tional availability and maternal referencing, in Fron-tiers of Infant Psychiatry, vol 2, edited by Call JD,Galenson E, Tyson R. New York, Basic Books, 1983,pp 17–30

8. Erikson EH: Studies in the interpretation of play. Ge-netic Psychology Monographs 1940; 22:557–671

9. Urist J: The Rorschach test and the assessment of ob-ject relations. J Pers Assess 1977; 41:3–9

10. Erikson EH: Further explorations in play construc-tions. Psychol Bull 1941; 38:748–756

11. Sorce JE, Emde RN: Mother’s presence is not enough:effect of emotional availability on infant exploration.Dev Psychol 1981; 17:737–745

12. Stern D: The Interpersonal World of the Infant. NewYork, Basic Books, 1985

13. Piaget J: The Construction of Reality in the Child. NewYork, Basic Books, 1954

14. Tuber S: Assessment of children’s object repre-sentations with Rorschach. Bull Menninger Clin 1989;53:432–441

15. Diamond D, Kaslow N, Coonerty S, et al: Changes inseparation-individuation and intersubjectivity in longterm treatment. Psychoanalytic Psychology 1990;7:363–397

16. Erikson EH: Childhood and Society, 2nd edition. NewYork, Norton, 1963

17. Coates S, Tuber SB: The representation of object re-lations in the Rorschachs of extremely feminine boys,in Primitive Mental States and the Rorschach, edited

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by Lerner H, Lerner P. Madison, CT, InternationalUniversities Press, 1988, pp 647–664

18. Zucker KJ, Bradley SJ: Gender Identity Disorder andPsychosexual Problems in Children and Adolescents.New York, Guilford, 1992

19. Freud A: The concept of developmental lines. Psycho-anal Study Child 1963; 18:245–265

20. Peller LE: Libidinal phases, ego development andplay. Psychoanal Study Child 1954; 9:178–198

21. Mahler M, Pino F, Bergman A: The PsychologicalBirth of the Human Infant. New York, Basic Books,1975

22. Winnicott D: Playing and Reality. New York, BasicBooks, 1971

23. Vaillant GE, Bond M, Vaillant CO: An empiricallyvalidated hierarchy of defense mechanisms. Arch GenPsychiatry 1986; 43:786–794

24. Perry CJ, Kardos ME, Pagano CJ: The study of de-fenses in psychotherapy using the Defense MechanismRating Scale (DMRS), in The Concept of DefenseMechanisms in Contemporary Psychology: Theoreti-cal, Research, and Clinical Perspectives, edited byHentschel U, Ehlers W. New York, Springer, 1993, pp122–132

25. Kernberg PF: Current perspectives in defense mecha-nisms. Bull Menninger Clin 1994 58:55–87

26. Cohen J: Weighed kappa: nominal scale agreement

with provision for scaled disagreement or partialcredit. Psychol Bull 1968; 70:213–220

27. Landis JR, Koch CG: The measurement of observeragreement for categorical data. Biometrics 1977;33:159–174

28. Bartko JJ: On various intraclass correlation coeffi-cients. Psychol Bull 1976; 83:762–763

29. Jones RR, Reid JB, Patterson GR: Naturalistic obser-vation in clinical observation, in Advances in Psycho-logical Assessment, vol 3, edited by McReynolds P.San Francisco, CA, Jossey-Bass, 1973, pp 42–95

30. Gelfand DM, Hartmann DP: Child Behavior Analysisand Therapy. New York, Pergamon, 1975

31. Hartmann DP: Assessing the dependability of obser-vational data, in Using Observers to Study Behavior,edited by Hartmann DP. San Francisco, CA, Jossey-Bass 1982, pp 51–65

32. Conger AJ: Integration and generalization of kappasfor multiple raters. Psychol Bull 1980; 88:322–328

33. Hubert L: Kappa revisited. Psychol Bull 1977; 84:289–297

34. Shrout PE, Fleiss JL: Intraclass correlations: uses inassessing rater reliability. Psychol Bull 1979; 86:420–428

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Stone WN: Affect and therapeutic process in groups forchronically ill persons. J Psychother Pract Res 1998;7(3):____–____Group Psychotherapy; Psychotherapy and Medical Ill-ness; Schizophrenia

Affect and Therapeutic Process in Groups for Chronically Mentally Ill Persons

W A L T E R N . S T O N E , M . D .

A dynamic group treatment model forchronically ill persons allowing them todetermine the frequency of attendanceempowers the members and potentiates groupdevelopment. This format respects patients’needs for space as represented by missedmeetings. In this context, absences areformulated as self-protective andself-stabilizing acts rather than as resistance.In an accepting, supportive environment,members can be helped to explore affects andgain insight into their behaviors. A clinicalexample illustrates patients’ examination ofthe meaning of missing and attendingsessions, with particular focus on intensity ofinvolvement, autonomy, and control. In theprocess of testing the therapist and group,members show capacity to gain insight intorecent in-group and extra-group behaviors.

(The Journal of Psychotherapy Practiceand Research 1998; 7:208–216)

The ravaging effects of schizophrenic andbipolar illness on thought and affect re-

main a therapeutic challenge. The multiplebiological, social, and emotional needs that arethe basis and consequence of severe and per-sistent mental illness defy simplistic solutions.Medication may alleviate some of the chaosbut fails to reverse or halt impairment in es-sential areas of human functioningrelationswith the self and with others from which comea sense of wellness and comfortable regard.

For many patients, the illness may havebegun in childhood, even before overt clinicalfeatures were present or were of sufficient in-tensity to justify a clinical diagnosis. Many first-person reports attest to patients’ recollectionsof feeling different, estranged, or isolated frompeer groups. Before the onset of a diagnosableillness, impairments may be expressed in thesocial domain as diminished interpersonal re-sponsiveness, poor eye contact, and failures inexpression of positive affect. Subtle motorsymptoms add to these individuals’ relationalawkwardness.1 After the onset of clinical ill-ness, the personal and societal costs escalate.

Innovative psychosocial treatment ap-proaches have been partially effective in alle-viating patients’ disabilities. Case managementand assertive community treatment have fo-cused on providing services to severely im-

Received November 30, 1997; revised January 6, 1998;accepted January 16, 1998. From the Department ofPsychiatry, University of Cincinnati College of Medicine,4239 Elland Avenue, Cincinnati, Ohio 45229. Send cor-respondence to Dr. Stone at the above address.

Copyright © 1998 American Psychiatric Press, Inc.

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paired individuals who require assistance ineveryday living. Social skills training and vo-cational rehabilitation address aspects of socialimpairment. Psychoeducational programs,including family management, are valuableadditions to the overall treatment armamen-tarium. Amidst this plethora of interventions,the place of psychotherapy, and in particularlong-term group psychotherapy aimed at as-sisting patients in their efforts to improve theirpsychosocial functioning, has been relegatedto lesser overall importance.

Research findings for psychotherapy ofschizophrenia have not been robust, and as aresult research efforts in this area have nearlyvanished. This has occurred in part because ofthe hypothesized lack of effectiveness of psy-chotherapy when compared with medicationsand in part because of problems inherent infunding and conducting psychotherapy re-search. The difficulties are magnified when itcomes to research on group treatment.

Reviews of psychotherapy for schizophre-nia suggest that outpatient group treatmentmay help patients improve social function-ing.2,3 The treatment process is described asoccurring in a two-step sequence: 1) a stabili-zation phase, which focuses on reducing andstabilizing positive symptoms and maintainingpatients in the community; and 2) a rehabili-tation phase, in which emphasis is on socialadjustment relationships, interpersonal rela-tions, and vocational possibilities.4

In the stabilization phase, treatment em-phasizes patients continuing their medicationsand becoming more informed about their ill-ness through supportive and educationalstrategies. This approach is particularly salientwith the current practice of brief periods ofhospitalization.

In the rehabilitation phase, the emphasisshifts to exploration of patients’ capacities toform and sustain social relations and to deter-mination of vocational capacities. Change inthese latter sectors takes place much moreslowly and is more difficult to assess. Yet it isin this rehabilitation phase that long-term psy-chotherapy, including group therapy, can have

a significant impact on interpersonal and in-trapsychic functioning. In this process patientscan slowly gain greater control over their af-fects and develop insights into aspects of theirrelationships with others and with self.

The salience of addressing the social andinterpersonal sectors of functioning in chronicmental illness was reported in a survey byCoursey et al.5 Chronically ill patients in reha-bilitation settings were asked to rate the impor-tance of 40 therapeutic topics. The highestrated items clustered in a category describedas “illness-intensified life issues” and encom-passed independence, developing self-esteem,relationships, and feelings. Other categories,rated important at least two-thirds of the time,included adverse secondary consequences ofthe illness, self-management of the disorder,and coming to terms with the disability. Thesefindings bring into focus patients’ awareness ofa continuity in their life and an appreciationthat their condition has added a particularlydevastating dimension to difficulties that mayhave been present prior to the onset of theirclinical illness.

In the context of a history of social disap-pointments and emotional injury or rejection,it would be unrealistic to expect patients en-gaging in treatment to rapidly reveal their in-ner experiences and risk being retraumatizedwithout thoroughly testing their environment.They will test and retest the therapist and thegroup to assess the safety of the situation. Theclinician who “sticks with it” despite the per-sonal difficultieswhich may include bothcountertransferences and the real aspects ofthe relationshipswill find opportunities togain understanding of patients’ efforts to cope,protect themselves, and work toward makingpositive changes in their lives.

T H E C H A N G I N G F A C E O F

P S Y C H O T H E R A P Y

The quality of the relationship between patientand therapist is recognized as the foundationon which the therapist can assist the patient ingaining self-awareness and psychological

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growth. Among the many theoretical advancesthere are two important strands: the consistentuse of an empathic stance6–8 and increasing at-tention to the therapist’s affect.9–11

Self psychology has enabled clinicians togain greater understanding of the patient’s“use” of the therapist as a selfobject to fulfillmissing or incompletely formed psychologicalfunctions, including containment of affects.Therapists can experience considerable dys-phoria when they feel depersonalized andtreated as a function. Recognizing this phe-nomenon as an archaic selfobject transferencehelps clinicians maintain their emotional equi-librium. In turn, therapists, by maintainingtheir balance, can more effectively help pa-tients understand themselves.

A second valuable theoretical contribu-tion, the “higher mental functioning” hypo-thesis described by Weiss and Sampson,explicates patients’ interactions as consciousand unconscious testing in the therapeutic en-counter. The tests are “designed” to determineif pathogenic beliefs in childhood should besustained.12–14 Skolnick,15 working with psy-chotic and borderline individuals, writes, “Nomatter how withdrawn or bizarre these indi-viduals may seem, or how much they try todestroy links with others, often there remaindisguised pleas for help and attempts to com-municate about the agonies of becoming andrelating” (p. 243). Apprehending the confusingand disturbing affects evoked in the clinicianin response to the “test” provides informationabout the patient’s therapeutic hopes.

These and other theoretical advanceshave contributed to changes in therapeutictechnique. Writing primarily within a self psy-chological framework, Lichtenberg et al.16 notethat they emphasize emotions as a guide for“appreciating self-experience and the desires,wishes, goals, aims, and values that come to beelaborated in symbolic forms” (p. 9). In psy-chotherapy of psychosis, affect “serves as the‘handle’ that the psychotherapist ‘grabs’ in theeffort to help the patient tolerate unbearablefeelings and subsequently to reorganize his orher behavior in interpersonally productive

ways” (p. 12).9 The clinician’s capacity to ex-amine his or her affects stirred in the treatmenttransactions and then to use these responses toadvantage becomes a central element in theconduct of treatment.

The focus on affects contributes to therapybecoming a more collaborative venture inwhich clinicians no longer make interpreta-tions as the “truth,” but instead offer inter-ventions that encourage patients to makenecessary “corrections.” This stance recog-nizes that the patient’s self experience is cen-tral, and that each participant has importantemotions that can mutually enhance under-standing. Thus, a patient’s rejection or incom-plete acceptance of a therapist’s interpretationis not considered solely as resistance, but as apotential message regarding the impact on thepatient of the therapist’s interventions.

In group psychotherapy the complexity ofcommunication is multiplied manifold. Inter-actions take place in relation to authority, topeers, or to the group as a whole. Particularlysalient for individuals with chronic mental ill-ness are fears of being unable to maintain asense of themselves in a potentially threateningsituation, with the possibility that they willexperience further psychic disruption. Thesource of these potential injuries arises notonly from the clinician, but from member-to-member interactions, or from member-to-subgroup or group-as-a-whole interactions.

In the process of emotionally joining agroup, members may experience intense andpotentially disorganizing affect stimulationthat occurs in relation to others and withinthemselves. The group can come to repre-sent or simulate life experiences, before orafter the onset of the illness or in or outsidethe family. Old defensive and adaptive pat-terns will emerge, primarily as resistances oras tests to determine if the individual will betraumatized in the present as in the past.Thus the obvious cautious engagement andsense of mistrust displayed by most patientsis understandable. Even with an optimal em-pathic response, change, if it is to occur, willtake place slowly.

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The model of the flexibly bound group isdesigned to collaboratively empower mem-bers and potentiate respect for each person’scapacity to engage in treatment. The centralelement of the model is a group structure inwhich patients, after attending four sessions,choose the frequency with which they wish toattend meetings. This agreement, which re-flects patient behavior but diminishes the po-tential for patients to feel pressure to attendeach session as well as lessening the clinician’sconcerns about attendance, results in a groupformation of core and peripheral subgroups.Group development is delayed, but over timethe group becomes cohesive, and memberscan begin to address their intragroup relation-ships. In this context, it becomes possible toexplore absences and for individuals to exam-ine the reasons they give for their absences andgain insight into their failures to attend in ac-cord with their agreement.

The following illustration examines theimpact of a treatment structure that builds inflexibility of attendance, but without preclud-ing discussion of absences in members learn-ing about themselves and their affect states inrelation to others.

I L L U S T R A T I O N

The group, which has been in existence forover a decade, has achieved considerable sta-bility, with a current census of 8 members. Nopersons have been added in the past 2 years.With the exception of Greg, who is diagnosedwith mild mental retardation and a dependentpersonality disorder, all members have a diag-nosis of schizophrenia, schizoaffective disor-der, or bipolar disorder. The group structurehas evolved with a core subgroup of 5 personswho attend more than 75% of the meetings; 2members who attend intermittently; and 1who appears at widely spaced intervals. Mem-bers had engaged sufficiently to interact withone another and were no longer turning almostexclusively to the therapist.

The vignette illustrates patients’ capacityto work with affects related to group absences

and to gain insight into aspects of their behav-ior. Following a small meeting, with 2 or 3 per-sons present, i t is possible to exploreexperiential aspects of group membership byfocusing on subgroups (those who were pres-ent and those who were absent), thereby notisolating any single individual.

Sessions are 45 minutes long. All arevideotaped, with the camera operator in theroom and in view of the members. Thevignette presented below was transcribed fromthe videotape and then edited for ease of pres-entation.

The session was particularly striking inmembers’ movement of chairs. The seats hadbeen set up in a horseshoe shape for videotap-ing but were pulled back by the patients in amanner that lessened the sense that they weresitting in a semicircle. However, within the first12 minutes of the meeting, there were 5 in-stances of patients moving their seats morefully into their original position. At a point inthe meeting at which the most distant member,Carl, seemed more engaged, the therapist in-vited him to bring his chair closer, a requestwith which he complied.

The meeting took place in mid-December.Three weeks previously, the group had not metbecause of the Thanksgiving holiday. Addi-tionally, members had been informed therewould not be a meeting between Christmasand the New Year holiday. These circum-stances created a sense of discontinuity, and inthe session prior to that illustrated in thevignette only Rita and Greg had been present.The focus of that session had been Greg’s fearsthat he would be separated from his mother,whose deteriorating health made hospi-talization appear imminent.

The following session began with 6 of the8 members present. The therapist was 3 min-utes late. After the therapist’s entry into theroom there was an initial subdued silence.

THERAPIST: What’s been happening?LORNA: You could say that we are all so sedated.

[laughs]RITA: Well, it’s the first time in a couple of weeks

that everybody has been here, I think. [pulls in

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her chair] It seems like the last couple of times alot of people weren’t here. Last week it was justGreg and me.

JACK: I had a bad cold last week. I could havecome, but I didn’t want to spread my germs. ButI didn’t feel good either.

RITA: I wouldn’t, either. That would have madeyou crabby.

JACK: I’m crabby enough as it is.GREG: There was only Rita and I here.RITA: We got a lot accomplished, though.

Following a brief interchange in which itis acknowledged that there have been priormeetings with only one or two members pres-ent, the interaction continues.

JACK: [moves his chair into the circle] So who did allthe talking? Greg?

RITA: He had some problems at home he neededto talk about.

JACK: It was good that he had a chance to talkabout them.

This comment seems to invite closure, butRita (while moving her chair in more) contin-ues the discussion of the previous week’s topic,and Greg relates that his mother has improvedand remains at home. Rick has wondered ifprayer had helped her, and Greg responds thatindeed they had prayed. When this discussionhas run its course, the therapist intervenes.

THERAPIST: We were talking about one side of it:what it’s like for Greg and Rita to be here. Whatabout the others? What’s it like to miss?

JACK: I needed to miss because I was sick, but thereason, I mean, I’m here practically every week.I could say I’m here every week. I just want toget away from it for a while. Not that I didn’t getaway Thanksgiving, but there was no groupThanksgiving. I wanted to be away when therewas a group once. So I was glad to get away fora while.

RITA: I think it’s good.JACK: Once in a great while.RICK: I was away for two or three weeks. I wanted

to be here.GREG: You didn’t want to be here?RICK: I did want to be here. I was having depres-

sion and stuff.RITA: That’s the worst part of it. When you want

to be here and your depression keeps you away.RICK: Yeah, well I wasn’t doing anything else, either.

THERAPIST: What happens here? The two of you[Rita and Jack] are saying the same kind of thing.Though I would expect in part that others feelthe same, can you say what it is about the groupthat you want to get away from, or is it somethinginside you or something about yourself?

JACK: Well, it’s kind of equivalent to being on thejob every day for a year and just the pressureevery day. Every day and the routine, not aboring routine; the routine of it all and it’s justlike . . . I didn’t go anywhere on vacation, but itfelt like I was on vacation from the group, and Ido feel better after I did that, and I do. [Greg pullshis chair closer into the group.]

LORNA: It’s kinda like working on something.Each one of us has a different story.

THERAPIST: [to Lorna] Can you say more? Does itfeel better to work on it at times alone or in thegroup? Can you identify when you might wantto get away? What’s happening inside you?

LORNA: Well, I never really want to get away, butI am asleep until 10:00 or 10:30 in the morning,which I have been doing lately. That kindahappens. It is good to get away at times. It isintense. All these . . . you know, everybody is sodifferent.

THERAPIST: To feel others’ problems at times feelsintense.

LORNA: Yeah, I don’t know exactly; it would bedepression.

This theme related to missing meetingscontinues. Initially, Carl echoes the view thathe “sort of likes missing,” and he has so manythings he is doing, but then he acknowledgesthat it is a relief not to have to listen to others.Rick indicates that the day he comes to thegroup is the only day he does anything, thatotherwise his week is empty. Jack’s ambiva-lence emerges, but he indicates that he wouldbenefit from being away one time.

THERAPIST: It is different if one makes that decision[to be away] rather than the group not meeting.That is when you miss a week when you decide,rather than when there isn’t a group scheduled.

JACK: It might be a week that there is no groupscheduled, and you might really need one. Andwhen you choose your own, maybe it’s for agood reason. Maybe you are running away fromsomething, but at least you are in control. [moveshis chair further into the circle]

THERAPIST: [to Rita] Where does this fit for you?

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RITA: I might handle what they do the same way.I might not come once in a while. Also I mighthandle it another way in the group. You used tosay I talked too much. Maybe I talked too muchbecause . . . what other people say upset me, andI . . . then it won’t upset me so much.

JACK: So you didn’t have to listen to somebodyelse.

RITA: I might. I’m saying that it could be.RICK: You don’t talk too much any more.RITA: Maybe I’m getting better. [pause] I felt bad

because nobody was coming because [referring toa prior meeting] me and Rick were talking all ofthe time.

CARL: It’s so hot in here. I’m getting hot.RITA: You’re not getting sick, are you?

Not hearing the metaphor, the therapistrefocuses back to feelings about regularly at-tending the meetings. Jack begins to expressthe idea that he wishes attendance were man-datory. He elaborates that he feels tensionwhile in the group and that he is “forced tothink harder in here than anyplace else.” Thetherapist again intervenes, suggesting that eachindividual has his or her own “internal moni-tor” that helps regulate attendance, and asksagain for descriptions of the inner feelings.Carl, who acknowledges that being busy is anexcuse, says that the group is the place wherehe talks to people the most, except when he ison the phone. At this point, the therapist invitesCarl to move his chair into the group, and hecomplies. These interactions took place withinthe initial 15 minutes of the meeting.

D I S C U S S I O N

This vignette illustrates the capacity of somechronically ill persons to engage in a discussionof the intensity of their feelings stimulated byparticipating in group psychotherapy, and togain insight into aspects of their self-protectivebehaviors. Participating in group therapy pro-vides opportunities for patients to becomemore flexible in managing affects. A group alsorepresents a threat, since patients fear that theywill be unable to maintain their personalboundaries and will be flooded with their ownand others’ affects. The result is a tendency to

miss sessions or terminate treatment.17 How-ever, absences can be understood not only asa defense, but as a test as well. The test mightbe formulated, “If I assert my independenceand decide not to come to a meeting, will I becriticized, punished, neglected, or ignored al-together?” If this and similar tests are passed,patients may increase their trust in others andbegin to tolerate and integrate their affects.

Rita begins with the bland statement thatpeople have not been present for severalweeks. The affective meaning of this is not in-itially apparent but emerges in the ensuing pro-cess. Jack indicates that his absence was due tohis cold, but his gratuitous comment, “I didn’twant to spread my germs,” may be understoodas a metaphor for fears that he would emotion-ally infect others. The interchange focuses onbeing “crabby” as the uncomfortable emotion.

The emotionally salient central theme ofseparations and losses is illustrated by Rita’scontinued discussion with Greg of his mother’sillness and the possibility of her requiring hos-pital care. The dyadic form of this discussion,as if only Rita and Greg were present, reen-acted the prior week’s session. The therapist’sinquiry framed members’ enactment as be-longing to one of two subgroups: those presentand those absent the preceding week. The in-terpretation emerged from the therapist’s lis-tening “and not bother[ing] about keepinganything in mind.”18 Such interventions havebeen labeled “disciplined spontaneous en-gagements” and represent the therapist’s “gen-erative intent” emerging from knowledge ofthe patients.16 Contributing to the interventionwas the therapist’s experience with group treat-ment and his appreciation that patients weremore willing to share feelings and engage inthe group if they were part of a subgroup.19

The model of the flexibly bound groupdoes not preclude discussion of absences. Overtime a rhythm of attendance becomes estab-lished, and members know, and respond,when others do not attend in accordance withtheir usual agreement. In this session, mem-bers’ responses ranged from describing meet-ings as boring to describing them as intense.

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This latter feeling is addressed by Jack and byCarl, who indicates that it is a relief not to haveto listen to others.

After the therapist differentiates betweenmissing due to canceled sessions and missingthrough a patient’s personal decision, Jack isable to summarize the central theme as a con-flict that “you have control even if you are run-ning away.” Lotterman20 (p. 115) reflects on theimportance of control in the psychotherapy ofpatients diagnosed with schizophrenia:

Schizophrenic patients are enormouslysensitive to intrusion and what to themfeels like coercion. If they feel invaded orviolated, they will flee. . . . [They] cantravel far down the path of self-destructionwith little concern, and can quickly bringthemselves and their treatments to thebrink of collapse. . . . The therapist iscaught between the Scylla of overactivityand intrusiveness, and the Charybdis ofbeing lulled by the patient’s bland denialuntil suddenly the treatment is destroyed.

The flexibly bound group model enables thetherapist to comfortably permit missing, whichthereby allows patients to maintain a degreeof sanction-free control.

A paradox is involved in discussing pa-tients’ fears of being overwhelmed and accept-ing, if not encouraging, their choosing todistance themselves. The therapist, by verbal-izing patients’ needs to have control, acceptstheir needs to create personal space and dis-tance. Members are then prepared to explorefears of losing control and being unable tomanage personal boundaries. Out of this thera-peutic stance emerges the patients’ wish forinvolvement, which had been partially ob-scured. The members’ wish for greater engage-ment is enacted in behavior as they draw theirchairs into the group circle.

Coursey et al.5 reported that 84% of thesurveyed schizophrenic patients preferredshorter, less frequent individual sessions (lessthan 30 minutes, less than once a month). Withthis treatment dosage, 3⁄4 of respondents indi-cated that therapy had brought positive or very

positive changes to their lives. Thus it is notsurprising that attendance in a more complexsocial setting of a group will be linked to ab-sences. Over time, absences may decrease andgreater engagement take place. Moving one’schair outside the circle represents a mini-dis-tancing. When patients have a sense of controland acceptance, they are freer to diminish thatdistance. Jack’s comment equating runningaway with control was directly linked to hismoving his chair into the circle.

The therapist, not consciously recallingRita’s history of monopolizing meetings,turned to her to ask where this fit in for her.Rita said that she used a different behavior(talking) to achieve the similar goal of creatingspace. In this process, Rita’s self-reflectiondemonstrated the paradox and represented astep in addressing a more difficult issue, heranxious fantasy that her excessive talking hadbeen the cause of others’ recent absences.

I would suggest that the integrative act (in-sight) of linking talking with control enhancedRita’s self-esteem. An experience of discoveryand a concomitant experience of self-efficacyhad taken place. In that context, Rita revealedher thought that she was the cause of the ab-sences. This process reverses the more typicalsequence in which insight in the present leadsto insight into the past. The past and presentare intertwined, and integration of the two doesnot follow a set formula.

For Carl, who had positioned himself on thegroup periphery, this sequence turned up the“heat” of involvement, and he complained. Hisposition is echoed by Jack, who states how he isforced to think harder in the group than any-where else. After the therapist frames the situ-ation in terms of an “internal monitor,” therebydiminishing the risk of group-wide criticism, Carlexposes his behavior as an excuse. At this pointCarl is able to accept the therapist’s invitation tomove his chair more into the group circle.

C O M M E N T

Schizophrenic patients are not prone to be in-trospective. Most individuals are content to

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seal over their psychotic experience, and onlya small proportion are motivated to integratethe experience as part of their lives.21 An im-portant contribution to patients’ difficulties inengaging in treatment is their lack of insightinto their illness behaviors. Deficits in insightexist even in stable outpatients and contributesubstantially to their limited participation insocial activities and interpersonal communica-tion.22 By achieving insight into their illness,patients may lower barriers to engagement. In-volvement in the group process may induce apositive, reinforcing spiral of insight and anincreasingly emotionally satisfying engage-ment both in and out of the group setting.

Acknowledging that others are importantand meaningful is a risky business. Many ex-periences preceding the onset of the illnesshave been perceived as emotionally toxic.With the establishment of a chronic course, pa-tients are subjected to further trauma as aspectsof their illness further alienate them and dis-rupt social relationships. The lack of insight isoften manifested as denial of need for others.Thus, the process of testing to determine thenature of others’ responses is an expectable in-terpersonal process.

Additional major components of theschizophrenic illness are the negative symp-toms of apathy, low motivation, and disen-gagement, which may be an amalgam ofbiological and emotional elements. As demon-strated in studies of expressed emotion, theseaffective experiences, which often becomeparticular targets for family hostility, may over-ride the therapeutic benefit of medication.23,24

Patients’ vulnerability to injury represents asignificant therapeutic challenge as they placebarriers to forming potentially therapeutic re-lationships, and they are particularly alert toany transaction that criticizes their distancingand self-protective mechanisms.

Clinicians face a formidable task of help-ing shape a group milieu in which patients willabandon their preferences for sealing over andfor brief, widely spaced sessions and move toa position in which they will risk reflecting andsearching for meaning in their interactions. A

central element in achieving these goals isemotional affirmation that will sustain patientsthrough the inevitable affective stimulation in-trinsic to group interactions.

Bacal25 asserts that patients are seeking“optimal responsiveness,” not optimal frustra-tion. Similarly, Teicholz26 notes that “frustra-tion becomes not a positive developmentalprinciple in its own right, but an inevitable con-comitant of the human condition, to which spe-cific environmental response is required inorder to help the developing child or the pa-tient master otherwise overwhelming affectiveexperience” (p. 148). The intensity of an indi-vidual’s response to a “hurtful” interaction (asexperienced by the individual, even if the in-teraction is considered “appropriate” by theobserver) is a product of the person’s biologicalheritage, his or her developmental influences,and the current environment. Experiences ofoptimal responsiveness, particularly to affec-tively significant transactions, affirm the valueof the injured person, a process that stabilizesthe individual and encourages growth.

The clinical example illustrates a thera-pist’s interventions that are based on valuingthe establishment of a positive therapeutic cli-mate and appreciating patients’ communica-tive efforts as transmitted by missing sessions.These behaviors are understood not merely asresistances, but as self-protective and self-sta-bilizing responses, particularly in the sector ofmanaging affect. Within the framework of thetherapist’s recognizing the behaviors as tests,members may feel appreciated and empow-ered, and they may be able to explore affectsthat were previously walled off and achieveinsight into aspects of their interactions.

We have incomplete knowledge of thepathophysiology of schizophrenia. Currenttreatment models are sufficiently broad to takeinto account biological vulnerability and psy-chosocial stress. Inevitably, there will be fluc-tuations in patients’ clinical state as theyexperience stress arising from intrapsychic orinterpersonal conflicts. With their presumedbiological deficits, patients with schizophreniaappear to need extended periods of treatment,

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requiring therapeutic persistence, patience,tolerance of ambiguity and strong affects, anda willingness to stick with the patient.27 Onesession in which patients exhibit self-reflectionand insight into their behavior represents onlya small step on their road to improved func-tioning. Many fluctuations will occur in the

treatment process, and therapeutic persistenceis essential. The rewards for both therapist andpatient, however, are substantial.

The author thanks Edward B. Klein, Ph.D., MarvinSkolnick, M.D., and Esther Stone, MSSW, for theirthoughtful comments on this manuscript.

R E F E R E N C E S

1. Walker E, Lewine RJ: Prediction of adult-onset schizo-phrenia from childhood home movies of the patients.Am J Psychiatry 1990; 147:1052–1056

2. Mosher LR, Keith SJ: Psychosocial treatment: individ-ual, group, family, and community support ap-proaches. Schizophr Bull 1980; 6:10–41

3. Schooler NR, Keith SJ: The clinical research base forthe treatment of schizophrenia, in Health Care Reformfor Americans With Severe Mental Illnesses: Reportof the National Advisory Mental Health Council (USDept of Health and Human Services). Washington,DC, US Government Printing Office, 1993, pp 22–30

4. Breier A, Strauss JS: The role of social relationships inthe recovery from psychotic disorders. Am J Psychia-try 1984; 141:949–955

5. Coursey RD, Keller AB, Farrell EW: Individual psy-chotherapy and persons with serious mental illness:the clients’ perspective. Schizophr Bull 1993; 21:283–301

6. Bacal HA: The essence of Kohut’s work and the prog-ress of self psychology. Psychoanalytic Dialogues1995; 5:353–366

7. Kohut H: The Restoration of the Self. New York, In-ternational Universities Press, 1977

8. Kohut H: How Does Analysis Cure? Chicago, Univer-sity of Chicago Press, 1984

9. Garfield DAS: Unbearable Affect: A Guide to the Psy-chotherapy of Psychosis. New York, Wiley, 1993

10. Semrad E, Van Buskirk D: Teaching Psychotherapyof Psychotic Patients. New York, Grune and Stratton,1969

11. Stone WN: On affects in group psychotherapy, in TheDifficult Patient in Group, edited by Roth BE, StoneWN, Kibel HD. Madison, CT, International Univer-sities Press, 1990, pp 191–208

12. Weiss J, Sampson H, and the Mount Zion Psychother-apy Research Group: The Psychoanalytic Process:Observations and Empirical Research. New York,Guilford, 1986

13. Weiss J: How Psychotherapy Works: Process andTechnique. New York, Guilford, 1993

14. Stone WN: Group Psychotherapy for People withChronic Mental Illness. New York, Guilford, 1996

15. Skolnick MR: Intensive group and social systems treat-ment of psychotic and borderline patients, in Ring ofFire: Primitive Affects and Object Relations in Group

Psychotherapy, edited by Schermer VL, Pines M. Lon-don, Routledge, 1994, pp 240–274

16. Lichtenberg JD, Lachmann FM, Fosshage JI: The Clini-cal Exchange: Techniques Derived from Self and Moti-vational Systems. Hillsdale, NJ, Analytic Press, 1996

17. Yalom ID: The Theory and Practice of Group Psycho-therapy, 4th edition. New York, Basic Books, 1985

18. Freud S: Recommendations to physicians practicingpsycho-analysis (1912), in The Standard Edition of theComplete Psychological Works of Sigmund Freud, vol12, translated and edited by Strachey J. London,Hogarth Press, 1958, pp 109–120

19. Agazarian Y: Systems theory and small groups, inComprehensive Group Psychotherapy, 3rd edition,edited by Kaplan HI, Sadock BJ. Baltimore, Williamsand Wilkins, 1993, pp 32–44

20. Lotterman A: Specific Techniques for the Psychother-apy of Schizophrenic Patients. Madison, CT, Interna-tional Universities Press, 1996

21. McGlashan TH, Levy ST, Carpenter WT: Integrationand sealing over: clinically distinct recovery stylesfrom schizophrenia. Arch Gen Psychiatry 1975;32:269–272

22. Dickerson FB, Boronow JJ, Ringel N, et al: Lack ofinsight among outpatients with schizophrenia. Psychi-atric Services 1997; 48:195–199

23. Kuipers L: Expressed emotion: a review. British Jour-nal of Social and Clinical Psychology 1979; 18:237–243

24. Runions J, Prudo R: Problem behaviors encounteredby families living with a schizophrenic member. CanJ Psychiatry 1983; 28:382–386

25. Bacal HA: Recent theoretical developments: contri-butions from self psychology theory, in Handbook ofContemporary Group Psychotherapy, edited by KleinRH, Bernard HS, Singer DL. Madison, CT, Interna-tional Universities Press, 1992, pp 55–85

26. Teicholz JG: Optimal responsiveness: its role in psy-chic growth and change, in Understanding Therapeu-tic Action: Psychodynamic Concept of Cure, editedby Lifson LE. Hillsdale, NJ, Analytic Press, 1996, pp139–161

27. Fenton WS, Cole SA: Psychosocial therapies of schizo-phrenia: individual, group, and family, in Synopsis ofTreatments of Psychiatric Disorders, 2nd edition, ed-ited by Gabbard GO, Atkinson SD. Washington, DC,American Psychiatric Press, 1996, pp 425–438

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Bridges NA: Teaching psychiatric trainees to respond tosexual and loving feelings: the supervisory challenge. JPsychother Pract Res 1998; 7(3):____–____Psychotherapy Training and Supervision; Transferenceand Countertransference

Teaching Psychiatric Trainees toRespond to Sexual and Loving FeelingsThe Supervisory Challenge

N A N C Y A . B R I D G E S , L I C S W , B C D

The intimate nature of the psychodynamicpsychotherapy process requires that trainees beeducated to deal competently with sexual andloving feelings that arise duringpsychotherapy. The absence of substantiveteaching on these complex treatment issuesplaces a responsibility on the psychotherapysupervisor to educate trainees about the eroticaspects of transference/countertransference. Amodel of supervision addressing sexualfeelings in treatment relationships is proposedand discussed with reference to clinicalvignettes.

(The Journal of Psychotherapy Practiceand Research 1998; 7:217–226)

Although trainees often encounter sexualand loving feelings in therapeutic rela-

tionships, specialized curriculum addressingsexual dilemmas and boundary issues is oftenabsent from graduate coursework and clinicaltraining programs for mental health profes-sionals.1–8 With inadequate preparation, train-ees run the risk of engaging in destructivebehavioral enactments or developing re-stricted practice styles that stunt the psycho-therapeutic process.1–3,5–8 Unfortunately, thissame lack of formal curriculum leaves manysupervisors inadequately prepared to deal withsexual feelings and the resultant complex clini-cal issues in supervision.5,7,9–13

In this article, I propose a model of indi-vidual psychodynamic clinical supervisionthat addresses sexual feelings in trainees andin their treatment relationships. The psycho-therapy supervisor is in a unique position tofoster in the trainee more confidence and com-petence in his or her ability to manage thesecomplex treatment situations in an ethical andtherapeutically sound manner. This model ofindividual supervision increases trainees’comfort, confidence, and ability to respond tosexual and loving feelings in the treatment

Received August 7, 1997; revised November 21, 1997;accepted November 26, 1997. From the Cambridge Hos-pital, Cambridge; Harvard Medical School, Boston; andSmith College School for Social Work, Northampton,Massachusetts. Address correspondence to Ms. Bridges,135 School Street, Belmont, MA 02178.

Copyright © 1998 American Psychiatric Press, Inc.

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relationship with a formulation that advancesthe treatment process. It aims to provide train-ees with a psychodynamic framework for ana-lyzing and managing erotic and lovingfeelings. Examples of how the supervisor intro-duces and manages the emergence of sexualfeelings, and of the use of the supervisor’s selfas a model, are provided and discussed.

Of course, in psychotherapy supervision,one attends to all intense feelings in therapeuticrelationships, including among others rage,disgust, and grief. For the purposes of this ar-ticle, the exclusive focus is on sexual feelingsand longings.

R O L E O F T H E

S U P E R V I S O R

The intimate nature of the psychotherapy pro-cess requires that trainees be educated to dealcompetently with erotic feelings and longingsthat naturally arise during phases of psycho-therapy. Presently, many trainees’ concernsabout the technical handling of erotic and lov-ing aspects of treatment go unanswered, andothers are frightened by the much-talked-ofslippery slope of misconduct.1,3,5,6,10 The preva-lence of sexual misconduct by psychothera-pists of all disciplines suggests that increasedtraining and education about the erotic aspectsof clinical work is indicated.1–5

The issue of how much, if at all, super-vision should focus on the student’s intrapsy-chic issues and person is a long-standingdebate.12–15 Many supervisors and traineeshave made a clear and conscious effort to re-strict discussion to the patient’s data as a wayto protect the trainee from any risk of boundaryconfusion between supervision and personaltherapy. This approach neglects crucial areasof psychotherapeutic discourse and instruc-tion, namely, the discussion and sorting out ofprojective identifications and mutual enact-ments by therapists and patients. Thus, formany supervisory dyads, personal feelings andissues and their effect on the psychotherapeuticrelationship and process become a part of thedialogue of supervision only when a serious

problem or a boundary violation occurs.Clearly, this is too late.

Trainees may feel dangerously isolatedand inadequately prepared for the intense andintimate nature of the psychotherapy process.Supervision may, in fact, be the only arenawhere models for understanding and psy-chodynamically managing erotic and lovingfeelings are discussed. The shame, phobicdread, and self-consciousness associated withthese feelings in clinical practice require thatthe supervisor initiate the discussion of theseissues and feelings.

The supervisor may establish a milieu ofsafety and openness where learning can occurby offering the following frame for the super-visory relationship and for work around theseissues. Consider the following comments to asupervisee:

Clinical work often evokes strong feelingsincluding attraction and sexual arousal, inour patients and ourselves. It is to beexpected. Often, these feelings signal im-portant information about our patients’development and relational difficulties,and about ourselves, and the therapeuticwork to be done. Supervision is a place tosort out the nature and meaning of thesefeelings when they arise to guide yourclinical work. I trust as these issues presentthemselves to you in your clinical work,you will bring them to supervision. I willbe happy to share with you my own ex-perience struggling with these issues as wefeel it’s useful. I neither want to pry nordo I want to leave you to struggle alonewith these complicated feelings.

A matter-of-fact introduction to sexual feelingsand longings diminishes the embarrassmentand shame trainees may fear around the dis-cussion of such feelings, and in my experienceit increases the possibility of meaningful dia-logue as they raise such issues and feelings.

Supervision for the purpose of under-standing and managing erotic transference/countertransference focuses attention on thestudent’s personal feelings and self. Addition-

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ally, the supervisor assumes a self-revelatorystance in supervision with regard to these clini-cal issues and consciously uses herself as ademonstration model for the trainee. Theprobability of a parallel process between thetrainee’s supervisory experience and the pa-tient’s psychotherapy experience has beennoted.3,7,12–15

G U I D E L I N E S F O R

S U P E R V I S I O N

Suggested Teaching Strategies

1. Combating Taboo and Silence: The legacy ofsilence, stigma, and shame surrounding thesefeelings and issues needs to be addressed insupervision. The supervisor directly and sim-ply addresses feelings of self-consciousnessand dread by normalizing these feelings.Trainees long for mentors in regard to theseissues and are deeply appreciative of super-visors who share ways in which they haveunderstood and managed erotic feeling statesin their own practices. Personal disclosures bysupervisors of erotic feelings, useful interven-tions, and dilemmas with patients are invalu-able when judiciously shared. Supervisorswho model the process of not knowing, ofdeveloping hypotheses, of bearing intense af-fect, and of muddling through to a usefulunderstanding and intervention are particu-larly valued.1,3,5,12–15

Many trainees express the wish for super-visors of a specific gender. In my experience,some trainees may find it is more possible forthem to raise these issues with a supervisor ofone gender and overwhelmingly difficult withsomeone of the other gender.

2. Introducing Phases of the Process of Mastery:The literature suggests that for trainees, theprocess of mastering this clinical material hasidentifiable stages.1,3,5,7 The process of attain-ing comfort with sexual material involves shift-ing from concrete to symbolic understandings,from a focus on external factors to attention tointrapsychic and interpersonal issues, and

from a simple one-sided analysis to more com-plex formulations.3 For the supervisor, a thor-ough understanding of the normativedevelopmental sequence of mastering theseissues is useful. The most important points forsupervisors to bear in mind and to communi-cate to trainees are discussed below.

Erotic and loving feelings, when unex-pected or unprepared for, are frightening andoverwhelming.1,3,6 The power of these feelingsto startle and disorient trainees needs to berecognized. The sense of anxiety and power-lessness may be so intense that trainees tem-porarily lose the distinction between erotic andloving feelings on the one hand and behaviorson the other.1,3 Commonly, at first, trainees re-act and respond to sexual feelings, fantasies,and erotic dreams as if the feelings were un-ethical or a manifestation of misconduct.1–3

This sense of anxiety and danger is infectious.Sometimes supervisors respond as if these feel-ings were dangerous or “inappropriate” aswell. Consultations from a trusted colleaguemay be of benefit to the supervisor as she at-tempts to assess degree of risk and to sort outthe meaning of these feelings to the patient, thetrainee, and the treatment process.

In the process of mastering the feelings ofpowerlessness associated with intense erotic orloving states, trainees may first focus on bound-ary issues and treatment contracts. Harsh as-sessments of themselves and their patientsoften mark the early phases of engagementwith these intense states and complex treat-ment situations.1,3,5,12 Trainees worry that theywill humiliate or harm a patient with an un-helpful intervention. Supervisors need to reas-sure trainees, support the distinction betweenfeelings and behaviors, and give permissionfor the trainee to experience and explore thesefeeling states.1–8,11–13 Supervisors who commu-nicate to trainees an abiding faith in their learn-ing process and convey information about thenormative developmental phases of masteringthese aspects of psychotherapy are valued.

3. Teaching Trainees to Listen to Physical Sensa-tions: Supervisors guide the trainee to listen to

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her body and physical sensations. Often, thefirst signs of sexual tension in a therapeuticrelationship are experienced in shifting physi-cal sensations, a sense of emotional stirring orarousal and of interpersonal heat in thetrainee’s body.1,3,16–21 These may be accompa-nied by sexual longings, fantasies, and night orday dreams accompanied by feelings of in-tense pleasure that are coupled with dread,guilt, or shame. Often, these conflicting im-ages, sensations, and affects are confusing anddeeply unsettling to the trainee. With super-visorial support and instruction, trainees learnto rely on these physical sensations to informand guide them through exploration of themultiple layers of meaning so that they canreach a clearer understanding of the possibletransference/countertransference enactmentsand useful therapeutic interventions.2,3,6,16–24

4. Offering Models of Therapeutic Action: Traineescan be offered a developmental and a rela-tional model of therapeutic action. A relationalmodel views psychotherapy as a two-personmodel and relies on the integration of interper-sonal, object relations, and self psychologytheories.17–24 A developmental model focuseson strivings and deficits in self-consolida-tion.17–19,25–27 Deficits or delays in self-consoli-dation and strivings for affect mastery compelthe patient to rely on others for support of afragile sense of self and troublesome affects.The patient delivers into the therapeutic rela-tionship the earlier developmental needs forself-growth and consolidation and reenactspredetermined relational paradigms that are asource of conflict. The therapist is cast in vari-ous roles by the patient in order to recreate thepatient’s well-established relational matrixwith the hope of a different outcome.

Erotic states in therapeutic relationshipsare best understood as a mixture of needs, un-resolved longings, repetition of earlier objectrelations, and the real relationship for bothtrainee and patient.3,7,16,21,28,31 Arriving at a use-ful understanding often requires analysis ofboth parties’ contribution. Employing thesemodels, the supervisor instructs the trainee and

models the exploration of erotic feelings fromboth the trainee’s and patient’s perspectivewith the understanding that these feelings sig-nal information about developmental issuesand relational experiences.

Questions the supervisor may pose to as-sist a trainee in the exploration of these issuesfrom the patient’s experience include:

• Do these feelings inform you about devel-opmental deficits, developmental gains,boosting of self-esteem, wishes for admi-ration? What developmental issues andattendant affects are being longed for, re-peated, or defended against with thesefeelings?

• Do these feelings defend against moreintolerable affectsfor example, disap-pointment, hate, grief, expression of rage,sadism, terror around others, or denial ofvulnerability/dependency?

• Do these feelings represent an uncon-scious effort to maintain positive feelings,a wish to be loved, to be cherished, or tolove another?

• Do these feelings signal a reenactment ofan earlier traumatic relationship or expe-rience of exploitation with a trusted other?

With experience and practice, traineeswill develop and integrate a model of concep-tualization that fits their personal and clinicalstyle. Models of therapeutic action offered bysupervisors assist trainees with this develop-mental task.

Consider the following vignette:

A female trainee troubled by sexual feelings for amale patient who has been in treatment with herfor 2 years presents the case in supervision. Thepatient, a 40-year-old, physically attractive manemployed as the CEO of a well-known majorcompany, presents for treatment of interpersonaldifficulties. From the trainee’s perspective, the pa-tient has a glamorous life filled with extensive in-ternational travel to exotic destinations,enormous interpersonal and financial power, andsuccess. The trainee finds this patient to be irre-sistibly attractive and enormously appealing.

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During sessions, the trainee catches herself star-ing at this man’s body and being filled with eroticfantasies. The trainee wonders how to makesense of these feelings.

The supervisor begins with, “It’s good thatyou let yourself feel and know about these feel-ings. Often, these feelings are unsettling for thera-pists. Usually these sensations and feelings alertus to important information about our patient,the phase of the psychotherapy, and ourselves.Let’s begin by assuming there is some projectiveidentification process operating here. What mightthese feelings be telling us about your patient?For example, if we look at these feelings as sym-bolic communications about your patient’swishes, needs, and reenactments, what’s your un-derstanding of the possible meaning? We don’tneed to have the ‘right answer.’ What’s helpful isto generate possible hypotheses and try themout.”

The supervisor begins by giving thetrainee support in several ways. The supervisornormalizes the trainee’s experience and pro-tects her self-esteem while explaining how toproceed by offering a cognitive instructive ap-proach.12–15,22 By normalizing the trainee’s ex-perience and providing a cognitive frame ofreference, the supervisor supports the traineein efforts to manage the experience of beingoverwhelmed, of not knowing, and of feelinghelpless, with the accompanying feelings ofshame. Support also takes the form of praiseor admiration for the trainee’s courage and ef-forts.

5. Increasing Capacity to Tolerate and AnalyzeIntense Sexual States: Supervision aims to in-crease the trainee’s capacity to endure intensesexual feeling states. The supervisor assists thetrainee in the development of tolerance andunderstanding of her own and her patients’affective experiences. Often, the best super-visory approach is to begin with a patient-focused discussion detailing the subjective ex-perience of the patient and the relationship tothe trainee.3,7,13 A supervisory focus on thepatient’s inner experience and developmentalissues is recommended for the inexperiencedtrainee or for those who are particularly fearful

of affect. With the development of tolerancefor and familiarity with their own affectiveresponses, trainees can turn their attention toanalyzing erotic sensations and feelings, withthe following understandings.

Erotic transference/countertransferencerepresents a complex interaction and processbetween trainee and patient, involving amixture of the real relationship and past objectrelationships for both parties. These intensestates represent transferences from both thepatient and trainee and are best understoodas a joint creation between trainee and pa-tient.1–3,16,17,20,21,25,27,31,33 Trainees’ and patients’sexual feelings and declarations of love havemultiple and varied meanings, representingwishes, fears, conflicts, unacknowledged anddefended-against affects, and developmentaldelays and gains. For the trainee, under-standing and responding therapeutically re-quires a self-reflective stance where the traineeallows herself to freely fantasize and follow herown associations and feelings. If one followsphysical sensations, affect, and fantasies, thenit is possible to explore the origins of these sym-bols, and their meanings to the trainee and thepatient in the treatment process, and arrive ata therapeutically useful stance. The traineeneeds adequate support and instruction to as-sist her in bearing the intense and disorientingaffect involved and exploring the questions,“Is this me or is this you?”; “Is this now or isthis then?” (P. L. Russell, personal communi-cation, 1982); and “What is the meaning ofthese feelings/fantasies to this patient, thistherapist, and at this juncture in the treat-ment?”

The supervisor recognizes that this ap-proach holds the potential for embarrassmentand heightened anxiety in the trainee. Super-visors must remain alert to the trainee’s senseof emotional privacy and make allowance forindividual differences in affect tolerance andmastery.13–15,22,23 Some trainees may or may notchoose to explore these issues personally insupervision and may remain more patient-fo-cused. Equipped with a model for conceptu-alization, these trainees may choose to

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examine privately the affects and issues in-volved. Other trainees may choose appropri-ately to take these feelings to personal therapy.Supervision is not intended to explore or workthrough the trainees’ conflicts around sexualfeelings and issues. Rather, the ultimate edu-cational goal is to assist the trainee with theidentification and management of intense af-fect and the development of a psychodynamicformulation with regard to erotic transfer-ence/countertransference. Containment andsymbolic understanding of these feeling statesis crucial in order to decide how best to usethis information therapeutically.

Consider the following vignette:

In supervision, a trainee in her late twenties dis-cusses a male patient whom she feels is attractedto her. Her patient’s feelings of attraction makeher uncomfortable. Through her body languageand descriptions of the patient it becomes clear tothe supervisor that the feelings of attraction andperhaps arousal are mutual between the patientand the trainee. After exploring and attending toher questions and concerns about her patient’sfeelings and developing a patient-based formula-tion, the supervisor inquires about the trainee’sfeelings toward this patient. The trainee is awareof a special fondness for her patient and describesthe qualities of person she finds admirable andeven attractive. With further discussion, thetrainee reports paying closer attention to her per-sonal appearance and dressing attractively on thedays she meets with him, and she anxiously re-counts an erotic dream. In the dream, the traineeis making love to her patient and discusses withthe patient concerns about being lovable.

The supervisor comments: “Thank you forsharing your feelings and the dream. This is use-ful information. I wonder if this patient has be-come very special to you, in a personal way. It isimportant that you figure out what this patientand your relationship with him mean to you. Youdo not have to discuss this with me, although Iwould be happy to help you if you wish. What’simportant is that you understand why this patienthas become so significant in your inner life. If itwould be useful, I can share with you a personalexperience with similar feelings toward a patientand how I made sense of it for myself.”

In the supervisory dialogue, the supervisorpraises the trainee for acknowledging her feelings

and revealing the dream, but also pushes her todeepen and expand her understanding of themeaning of these feelings in herself and to her pa-tient. The trainee begins by accepting the super-visor’s offer to share a personal experience. Thesupervisor responds with:

This reminds me of a patient I treatedwhom I felt overwhelmingly attracted to,and I, like you, dreamt of a sexual encoun-ter with this patient. This treatment oc-curred during a time in my life when I waswithout a significant other. My personallongings contributed to my special attach-ment and sexual feelings toward my pa-tient. It helped me to know this aboutmyself.

Sharing a clinical vignette exposes more ofthe supervisor’s professional self and her own ex-perience with these issues. The sharing of the per-sonal professional experience takes the focus offthe trainee and her feelings for a moment andplaces the focus on the supervisor.2,15 By exam-ple, the supervisor’s self-revelation declares thatidentifying and processing these feelings and di-lemmas is a normative aspect of professional de-velopment. Following the supervisor’s comments,the trainee accepts the invitation to approach herexploration of the therapeutic relationship in amore anxiety-provoking and personally intenseway. She deepens her exploration of attractionand erotic fantasies about this patient with the fol-lowing insights.

On reflection in supervision, the traineecame to view her sexual feelings and fantasies asprimarily a reflection of her intense attachment tothis patient as a longed-for love object, and as aresponse to her patient’s gratifying idealization ofher. The trainee shared that her intimate partnerhad relocated recently to a distant city. The inten-sity of her affective response to this patient sig-naled to her the depth of her own sense ofloneliness, and perhaps grief over the relocationof her lover. As she became more compassionateand in touch with her own personal vulnerabili-ties, needs, and longings, she observed moreclearly the ways in which her patient was flirta-tious and beckoned her closer. The trainee nowclearly understood how her erotic dream was con-nected to her own wishes and needs as well asher patient’s.

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Supervision aims to increase trainees’comfort with their inner experience and theircapacity to examine it compassionately. It alsohelps trainees accept the inevitability of enact-ments by therapists and patients. The norma-tive process of attaining comfort and masteryof erotic feelings for trainees involves shiftingfrom concrete concerns to symbolic under-standings.1,3,7,13 In my experience, in the begin-ning phases of engagement with these issuestrainees’ thinking is concrete, and they seemto lose their capacity for abstract and symbolicthinking. It is as if sex is sex, although evenbeginning clinicians know that psychotherapyis characterized by images, multiple and variedmetaphors, and shifting symbols.2 The super-visor may be of particular help here as she as-sists the trainee in managing anxiety, whichoften allows for the shift to symbolic under-standing.1–3,13–15 Gabbard and Lester’s33 consid-eration of the “thickness” and “thinness” ofboth the therapist’s internal boundaries (accessto unconscious processes) and her externalboundaries (within and between the therapistand patient) is relevant here. While acknowl-edging variations in innate individual capaci-ties with regard to permeability of innerboundaries, supervision ideally assists thetrainee in developing as fully as individuallypossible the capacity to fantasize and produc-tively employ fantasy for mastering intensecountertransference states.2,7,17 The super-visory challenge and task is to initiate and con-duct the discussion in a respectful and boundedmanner that in fact proves useful to the trainee,the patient, and the therapeutic process.

Consider the following supervisoryvignette:

A male trainee in great subjective distress pre-sents a 3-month treatment relationship for super-vision. The patient, a young woman, presentswith severe depression, social phobia, intermit-tent drug abuse, and a childhood history of abuseand abandonment. Beginning in the third session,the patient presents with an erotic transference asrevealed in requests to be hugged and to sit in hislap, comments on his clothing and body, and in-vitations to meet for a drink. The trainee feels

overwhelmed with anxiety, confusion, and un-certainty about where to set the therapeuticboundary.

The supervisor assists the trainee in concep-tualizing the patient’s issues and presentationfrom a dynamic, developmental perspective andarrives at an understanding of what might be clini-cally useful. After this discussion, it becomesclear that the trainee is still experiencing great dis-tress. The supervisor comments, “You look up-set.” The trainee responds, “I am, please give mea minute.” The supervisor continues, “Would yoube comfortable talking about your feelings here?Perhaps it has something to do with this treat-ment?” The trainee responds, “I don’t know ex-actly why I’m so upset. It’s about this patient. I’mnot sure it will be OK with you to discuss per-sonal feelings here.” The supervisor reassures thetrainee that continuing the discussion of his feel-ings is appropriate and fine. However, the super-visor suggests that they also pay attention to thetrainee’s level of comfort and privacy.

The supervisor begins with, “What’s yourunderstanding of why you’re so upset?” Thetrainee comments, “My feelings of wanting tophysically comfort this patient are much toostrong, confusing, and overwhelming at mo-ments. I don’t think I can work with this patient.It’s too difficult for me.” The supervisor asks,“How do you make sense of your wish to comfortthis patient?” The trainee then shares that this pa-tient’s history resembles that of his own familyand that this patient reminds him of a troubledyounger sibling whom he had been very in-volved with as a surrogate parent. As a child, hefelt compelled to honor his sibling’s requests fornurturance even at personal cost to himself. He’snot sure he can separate his feelings about his sib-ling from this patient and is concerned about hiscapacity to manage his affect and maintain thera-peutic boundaries. The trainee and supervisor dis-cuss ways for the trainee to modulate his affect,remain patient-focused, and take the next step inthe treatment.

The supervisor suggests the trainee take upthese intense feelings and issues in his personaltherapy. The supervisor wishes to support andpreserve the trainee’s self-esteem during his strug-gle to manage raw and overwhelming feelings,commenting, “It’s brave of you to be so self-revealing in here. Clinical work may be deeplyemotionally stirring. I know it has been in myprofessional work. I admire your willingness to

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be attuned to your inner experience and how it af-fects your work. When we are open to ourselvesand our patients, we become reacquainted withour unfinished business. It happens to all thera-pists. If it would be helpful, I can share an experi-ence of mine struggling with overwhelmingfeelings for a patient.” Finally, the supervisorasks, “Has this discussion felt OK for you?”

6. Considering Countertransference Use and Mis-use: Internal and intersubjective explorationof the meaning of these feelings presents thetrainee with a broad array of choices abouthow best to use this information to advancetherapeutic aims. After thoughtful decision-making and a considered response, traineesmay decide to use this information directlythrough interpretations, clarifications, or com-ments to patients.

All direct comments to patients abouterotic feelings require skill and sensitivity. Di-rect use of countertransference data, althougha delicate process, works best if all commentsare compassionate, self-enhancing, and in-structive.

Direct disclosure of therapists’ sexual feel-ings to a patient is likely to frighten the patient,particularly in light of the incidence of profes-sional sexual misconduct, and it is not recom-mended.7,18–20,29,30 Davies27 describes a case inwhich she directly disclosed sexual feelings toa patient with what she feels were ultimatelysuccessful results. However, the patient in-itially felt intruded upon, even assaulted, byhis analyst’s unsolicited disclosure.

Ehrenberg21 wisely warns us to be alert tothe possibility that any effort to attend to oneset of transference/countertransference issuesmay be a form of resistance with respect toother issues. Therapists and trainees do well toexercise restraint with regard to direct disclo-sure of sexual feelings to patients even if theycan justify them based on a belief in the cen-trality of the countertransference experience.Although a minority propose such disclosures,as yet there are not enough data to supportsuch proposals, and we must be aware of thereal possibility of burdening or traumatizing

our patients and unnecessarily derailing a psy-chotherapy. Research and more published ac-counts of therapists’ experiences, both positiveand negative, with direct disclosures areneeded. Thoughtful discussion of the useful-ness and danger of such disclosures continues.

Unhelpful Supervisory Responses

Unhelpful supervisory responses mayemerge if there is difficulty in establishingsafety in the supervisory relationship or if thesupervisor lacks the clinical skill to managethese treatment dilemmas. The supervisorneeds to be alert to several areas of potentialdifficulty with regard to establishment of a psy-chologically safe interpersonal educational mi-lieu. Although a supervisor will be aware oftrainees’ vulnerabilities and issues, intrusivepersonal comments or interpretations arenever useful or appropriate.13–15 Pressure or de-mands for a trainee’s self-disclosure, even inthe context of helping her work more effec-tively with patients, may be harmful to thetrainee, the supervisory relationship, and theopen exploration of clinical material.

Supervisors who reflexively or universallyview these treatment dilemmas as indicative ofcharacter issues or boundary maintenanceproblems confuse the educational context withthe treatment context. Supervisors who denyor ignore these feelings or alternatively be-come overly concerned about these feelingsare likely to be of little help to trainees. Traineesin these types of supervisory relationships areunlikely to allow themselves to be vulnerableor to present anxiety-provoking clinical mate-rial in supervision.

Causes for Concern

Gabbard and Lester33 outline several fac-tors they view as red flag indicators of concernabout a trainee’s performance. A trainee whodemonstrates a marked, repetitive pattern ofboundary crossings with the absence of self-observing capacity about the treatment rela-tionship and the therapeutic process warrants

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careful attention. Practitioners who engage ina pattern of boundary crossings without self-reflection and critical examination may, in-deed, harm patients.

The capacity of trainees to discuss andstudy the inevitable transference/counter-transference enactments is critical to the devel-opment of a non-exploitative therapeuticrelationship. In particular, trainees who con-sciously or unconsciously misrepresent theirconduct in the treatment process signal to thesupervisor serious personal difficulties. Self-observation and revelation by trainees insupervision is at times crucial and contributesto the therapy of the patient and the educationof the therapist.3,6,7,12,13,15 Trainees who are un-willing or unable to consider alternate perspec-tives and new data about themselves and theirpatients are of concern.

C O N C L U S I O N S

All trainees will at some point be faced withsexual and loving feelings in their psychothera-peutic work. The incidence of professional sex-ual misconduct by all disciplines indicates thecontinued need for training on the erotic as-pects of clinical practice.3–8,30,33 While we nowhave much clinical data and sophisticated in-formation about how to understand and man-age these feelings in therapeutic relationships,this information has not yet been integratedinto core curriculum. Presently, the psychody-namic psychotherapy supervisor, who may or

may not feel adequately prepared, is the pri-mary clinical teacher around these complexclinical situations.

Matter-of-fact integration of the under-standing and management of sexual feelingsinto supervision is indicated. Addressing train-ees’ dread and self-consciousness concerningidentification and discussion of these feelingsand issues opens up the possibility of dialogueand is helpful. Clear articulation of models oftherapeutic action is valued by trainees andpromotes feelings of competence.

Employing a developmental model for af-fective mastery around sexual feelings is use-ful. Supervisors who share experiences abouttheir own development of mastery strugglingwith these issues become important models fortrainees’ professional development. A safe,shame-free, trustworthy supervisory relation-ship provides the arena for open dialogue, self-revelation, and deep clinical curiosity aboutthese issues for both the trainee and patient.

If the supervisor creates an atmosphere ofmutual exploration with a heightened aware-ness of the possibility for shame and humili-ation and remains sensitive to the trainees’subjective experience, these issues may beopenly, honestly, and fruitfully discussed. Em-phasis and empathic attunement to the train-ees’ development of the sense of professionalself is critical. Supervision becomes an arenato promote mastery and demystify compli-cated erotic treatments and transference/coun-tertransference enactments.

R E F E R E N C E S

1. Adrian C: Therapist sexual feelings in hypnotherapy:managing therapeutic boundaries in hypnotic work.Int J Clin Exp Hypn 1996; 1:20–32

2. Bridges N: Managing erotic and loving feelings intherapeutic relationships: a model course. J Psycho-ther Pract Res 1995; 4:329–339

3. Bridges N: Meaning and management of attraction:neglected aspects of psychotherapy training and prac-tice. J Psychother 1994; 31:424–433

4. Roman B, Kay J: Residency education on the preven-tion of physician–patient sexual misconduct. Aca-demic Psychiatry 1997; 21:26–34

5. Gorton GE, Samuel SE: A national survey of training

directors about education for prevention of psychia-trist–patient sexual exploitation. Academic Psychiatry1996; 20:92–97

6. Gorton GE, Samuel SE, Zebrowski SM: A pilot courseon sexual feelings and boundary maintenance in treat-ment. Academic Psychiatry 1996; 20:43–55

7. Steres LM: Therapist/patient sexual abuse and sexualattraction in therapy: a professional training interven-tion. Doctoral Dissertation, California School of Pro-fessional Psychology, Los Angeles, CA, 1992

8. Lakin M: Coping With Ethical Dilemmas in Psycho-therapy. New York, Pergamon, 1991

9. Rodolfa ER, Kitzow M, Vohra S, et al: Training interns

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to respond to sexual dilemmas. Professional Psychol-ogy Research and Practice 1990; 21:313–315

10. Strasburger LH, Jorgenson LM, Sutherland P: Theprevention of psychotherapist sexual misconduct:avoiding the slippery slope. Am J Psychother 1992;46:544–555

11. Pope KS, Sonne JL, Holroyd J: Sexual Feelings inTherapy: Explorations for Therapists in Training.Washington, DC, American Psychological Associa-tion, 1993

12. Pope KS, Tabachnick BG: Therapist’s anger, hate, fearand sexual feelings: national survey of therapists re-sponses, client characteristics, critical events, formalcomplaints, and training. Professional Psychology Re-search and Practice 1993; 24:142–152

13. Pope KS, Bouhoutsos JC: Sexual Intimacy BetweenTherapists and Patients. Westport, CT, Praeger, 1986

14. Alonso A: The Quiet Profession: Supervisors of Psy-chotherapy. New York, Macmillan, 1985

15. Jacobs D, David P, Meyer DJ: The Supervisory En-counter. New Haven, CT, Yale University Press, 1995

16. Gabbard GO: Sexual excitement and countertransfer-ence love in the analyst. J Am Psychoanal Assoc 1994;42:1083–1135

17. Tansey MJ: Sexual attraction and phobic dread in thecountertransference. Psychoanalytic Dialogues 1994;4:139–152

18. Tansey TJ, Burke WF: Countertransference disclosureand models of therapeutic action. Contemporary Psy-choanalysis 1992; 27:351–383

19. Benayah C, Stern M: Transference–countertransfer-ence: realizing a love by not actualizing it. Isr J Psy-chiatry Relat Sci 1994; 31:94–105

20. Maroda KJ: The Power of Countertransference: Inno-vations in Analytic Technique. New York, Wiley, 1991

21. Ehrenberg DB: The Intimate Edge. New York, WW

Norton, 199222. Allen G, Szollos S, Williams B: Doctoral students’ com-

parative evaluations of best and worst psychotherapysupervision. Professional Psychology Research andPractice 1986; 17:91–99

23. Hoffman L: Old Scapes, New Maps. Cambridge, MA,Milusik Press, 1990

24. Hutt C, Scott J, King M: A phenomenological studyof supervises’ positive and negative experiences insupervision. Psychotherapy: Theory, Research andPractice 1983; 20:118–122

25 Gorkin M: Varieties of sexualized countertransfer-ence. Psychoanal Rev 1985; 72:421–440

26. Gorkin M: The Uses of Countertransference.Northvale, NJ, Jason Aronson, 1987

27. Davies JM: Love in the afternoon: a relational recon-sideration of desire and dread in the countertransfer-ence. Psychoanalytic Dialogues 1994; 4:153–170

28. Winnicott DW: Hate in the counter-transference. IntJ Psychoanal 1949; 30:69–75; rpt J Psychother PractRes 1994; 3:348–356

29. Gabbard GO (ed): Sexual Exploitation in ProfessionalRelationships. Washington, DC, American Psychia-tric Press, 1989

30. Gabbard GO: Psychotherapists who transgress sexualboundaries with patients. Bull Menninger Clin 1994;58:124–135

31. Kernberg OF: Love in the analytic setting. J Am Psy-choanal Assoc 1994; 42:1137–1157

32. Gartrell N, Herman J, Olarte S, et al: Psychiatrist–patient sexual contact: results of a national survey,II: prevalence. Am J Psychiatry 1986; 143:1126–1131

33. Gabbard GO, Lester EP: Boundaries and BoundaryViolations in Psychoanalysis. New York, Basic Books,1995

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Levy MS: A helpful way to conceptualize and understandreenactments. J Psychother Pract Res 1998; 7(3):___–____Reenactment; Repetition; Psychological Trauma

A Helpful Way to Conceptualize andUnderstand Reenactments

M I C H A E L S . L E V Y , P H . D .

Attempts to understand the purpose and theetiology of reenactments can lead to confusionbecause reenactments can occur for a varietyof reasons. At times, individuals activelyreenact past traumas as a way to masterthem. However, in other cases, reenactmentsoccur inadvertently and result from thepsychological vulnerabilities and defensivestrategies characteristic of trauma survivors.This article offers a means to conceptualizeand understand the many ways in whichreenactments can occur. Psychotherapeuticstrategies are offered to help individualsintegrate past traumas and decrease theirchances of becoming involved in destructivereenactments.

(The Journal of Psychotherapy Practiceand Research 1998; 7:227–235)

Victims of trauma often experience a widerange of psychiatric symptoms, including

intrusive recollections of the trauma, numbingand avoidance of stimuli associated with it,anxiety, hypervigilance, and other symptomsindicative of increased arousal.1–3 Many indi-viduals re-create and repetitively relive thetrauma in their present lives.1–6 These phenom-ena have been called reenactments.5 For exam-ple, it has been found that women who weresexually abused as children are more likely tobe sexually or physically abused in their mar-riages.7 It has been noted that traumatized in-dividuals seem to have an addiction to trauma.8

A number of researchers have observed thatretraumatization and revictimization of peoplewho have experienced trauma, especiallytrauma in childhood, are all too common phe-nomena.7,9,10

Several ideas have been suggested to ex-plain the phenomenon of reenactments. Someconceive reenactments as spontaneous behav-ioral repetitions of past traumatic events thathave never been verbalized or even remem-bered.11,12 Patients may express their internalstates through physical action rather than withwords.13,14 Freud15 noted that individuals whodo not remember past traumatic events are“obliged to repeat the repressed material as acontemporary experience, instead of . . . re-membering it as something belonging to thepast” (p. 12). He further hypothesized that the

Received November 13, 1996; revised December 2, 1997;accepted December 4, 1997. From CAB Health andRecovery Services, Salem, and the Zinberg Center forAddiction Studies, Harvard Medical School, Boston,Massachusetts. Address correspondence to Dr. Levy, 7Island Way, Andover, MA 01810.

Copyright © 1998 American Psychiatric Press, Inc.

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obligatory repetition of painful situations fromone’s past may result from the death instinctor “an urge inherent in organic life to restorean earlier state of things” (p. 30). Indeed, it hasbeen noted that the compulsion to repeat mayhave an almost biological urgency.11 Otherssuggest that reenactments result from the psy-chological vulnerabilities characteristic oftrauma survivors.5,7,14,16 As a result of a rangeof ego deficits and poor coping strategies,trauma survivors can become easy prey for vic-timizers. Other writers understand reen-actments as a means of achieving mastery: atraumatized individual reenacts a trauma in or-der to remember, assimilate, integrate, andheal from the traumatic experience.1,12,17,18

A definitive understanding of reenact-ments and the function they serve remainselusive. Herman5 has written that there issomething uncanny about reenactments.While they often appear to be consciously cho-sen, they have a quality of involuntariness. Inaddition, although it has been theorized thatreenacting a past trauma is a way an individualattempts to master it, lifelong reenactmentsand reexposure to trauma rarely result in reso-lution and mastery.8,17 Understanding and ad-dressing the fact that traumatized peopletypically lead traumatizing lives remains agreat challenge.6

Reenactments can arise from very differ-ent underlying dynamics and can result invastly different outcomes. Thus, an under-standing of the purpose of reenactments mustbe multidimensional. A conceptualization andunderstanding of the many different ways inwhich reenactments can occur will also helpto shed light on why traumatized individualsoften do not achieve mastery and will help toorganize and focus clinical intervention.

In this article I have broken down reen-actments into four general categories. In thefirst, reenacting as an attempt to achieve mas-tery, individuals more actively reenact a trau-matic situation from their past. Some of theseefforts are adaptive resolutions of earlier trau-mas; others, however, are reflective of a mal-adaptive process and can lead to continued

revictimization and difficulties. In the otherthree types of reenactments, I suggest thatreenactments occur in inadvertent and unin-tentional ways. In reenactments caused byrigidified defenses, defenses lead to reen-actments and to the problems that the originaldefenses sought to avoid. With reenactmentscaused by affective dysregulation and cogni-tive reactions, intense affective and cognitivereactions produce others that can lead to areenactment. And finally, with reenactmentscaused by ego deficits, trauma survivors’ psy-chological vulnerabilities can often lead toreenactments and revictimization. This classi-fication admittedly is somewhat artificial, sinceelements from several categories often play arole in the manifestation of a particular reen-actment. The categories are not all-inclusive,and there are other ways to conceptualize reen-actments. However, this breakdown serves toillustrate the various ways that reenactmentscan evolve.

R E E N A C T M E N T S A S A N

A T T E M P T T O A C H I E V E

M A S T E R Y

Individuals may actively reenact elements ofa past traumatic experience as a way to copewith and master it. At times, the attempt is anadaptive process that facilitates the successfulresolution and working through of the earliertrauma. In other cases, however, the effort tomaster the trauma is a maladaptive mechanismand the strategy results in continued distressand difficulties for the individual.

The distinction between adaptation andmaladaptation can be difficult to make, sinceall coping mechanisms are inward struggles toadapt to life and to master its challenges.19 Inaddition, because trauma can affect manyspheres of functioning, the individual mayhave adaptively mastered certain aspects of thetrauma, but in other areas the resolution maybe less than adequate. For example, Peck20 de-scribed an individual who was violently beatenas a child and who adaptively mastered thistrauma by becoming a homicide detective and

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having a driven search for crime. However,despite his effective mastery in the vocationalrealm, his intimate relationships were markedby competitiveness, detachment, and underly-ing terror.

Notwithstanding this difficulty, adaptationcan be distinguished from maladaptation inthat adaptive responses are characterized by amore flexible coping style, they are motivatedmore by the present and future than by thepast, and they make use of secondary processthinking.19,21 In addition, with adaptation,emotions stemming from the past are less over-whelming and destabilizing, and overgeneral-ized negative schemas about self and othershave been altered.22,23 As Pine24 has noted,these adaptive changes enable the person “torespond to the present free of the categories ofexperiencing laid down in the past” (p. 175).

Reenacting Indicative ofAdaptation

It has been suggested that actively reen-acting a past trauma can provide an opportu-nity for an individual to integrate and workthrough the terror, helplessness, and other feel-ings and beliefs surrounding the originaltrauma.1,12,17,18 Freud posited that mastery couldbe achieved by actively repeating a past un-controllable and unpleasurable experience.15

Control can slowly be reestablished by repeat-edly experiencing what once had to be en-dured.21,25 For example, a woman who wassexually abused as a child and who, as a result,was terrified of physical contact involved her-self in massage therapy training. Placing her-self in a situation reminiscent of her pasttrauma and exploring her massage therapy ex-periences in psychotherapy enabled her towork through her overwhelming affect relatedto her past sexual abuse and diminished herfear of physical contact. We can also see thisprocess in normal grief work: reexperiencingthe feelings of grief, telling stories about a lostloved one, and repeatedly confronting everyelement of the loss until the intensity of thedistress has remitted can enable the individual

to assimilate the event and to work through thefeelings surrounding the trauma.26

Psychotherapy can also help individualsto more fully work through and effectivelymaster a previous trauma. With the adjunct oftherapy and the benefit of insight, the detectivementioned earlier20 who adaptively copedwith past physical abuse by becoming a detec-tive and taking on highly risky situations beganto exercise better judgment and no longer feltas strongly compelled to take on situations in-volving physical risk.

Reenacting Indicative ofMaladaptation

In many cases, actively reenacting a pasttrauma can be more reflective of a maladaptivedefensive posture than an adaptive process.For example, many childhood victims of sex-ual abuse become abusers of others.27,28 Inthese cases, reenacting past abuse by becomingan active abuser is a defensive stance that en-sures that the terror and helplessness relatedto the old traumatic situation or relationshipdo not get reexperienced. In addition, the abu-sive act allows the individual to express anddirect rage at others. This way of being in theworld is an attempt to master the previoustrauma, but it is a maladaptive one because itdoes not result in a reworking and integrationof the individual’s traumatic past and it victim-izes others in the process.

Childhood sexual abuse has also beenlinked to prostitution in adulthood.29,30 Chu17

describes a woman who explained her prosti-tution as a way to control men through sex andas an attempt to have active control of a pre-viously passively experienced victimization.Although this has explanatory value, it is a mal-adaptive resolution of the earlier sexual abuse.The woman is now controlling rather than be-ing controlled, but the old drama of past objectrelations is still being played out in the present.An adaptive mastery of the earlier conflict hasnot been achieved; men are still feared, theystill need to be controlled, and revictimizationoften continues to occur.

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An individual may also seek out a personwho is like a past abuser and reenact a pasttraumatic relationship out of a need to changethe other person in order to feel better aboutherself. For example, a woman who wasabused by her father and who blamed herselffor this found herself in a relationship with anabusive man. The woman’s unconscious at-traction to this person was rooted in a desireto get him to treat her well, which, if successful,would have ameliorated her feelings of self-blame and badness. She never succeeded,however, and a reenactment occurred. Al-though her effort was an attempt to master anearlier conflict, it was a maladaptive one: shecontinued to be involved in a destructive rela-tionship where her needs were never met.

Trauma survivors may also be drawn toestablish relationships that are similar to pastsignificant relationships because there is com-fort in familiarity. For example, a man who wasemotionally abused by his aloof, distantmother ends up in a relationship with a womanwith similar traits. Another woman who wassexually abused by her father and brothers actsin sexually provocative ways with others. It hasbeen found that when animals are hyper-aroused, they tend to avoid novelty andperseverate in familiar behavior regardless ofthe outcome. However, in states of low arousalthey seek novelty and are curious.31 For manyvictims of childhood abuse, dealing with otherpeople on an intimate basis is a high-arousalstate because past relationships have beenmarked by terror, anxiety, and fear. As a result,when establishing relationships, they avoidnovelty and form relationships that, even if de-structive, are similar to past ones. Maladaptivereenactments can also occur because a personseeks out and “chooses” a powerful, caretaking(and sometimes abusive) figure to solidify ashaky self-concept and a fragile sense ofself.5,16,23 In addition, survivors of childhoodabuse who suffer from self-hatred, an internalsense of badness, and a sense that they deservemistreatment may gravitate to others who reso-nate with this negative self-concept, and pastexperience can then be recapitulated.17

R E E N A C T M E N T S C A U S E D

B Y R I G I D D E F E N S E S

As suggested above, individuals for variousreasons often actively reenact elements ofpast traumatic relationships. However, evenwhen there is no active reenactment of a pasttrauma, a person’s defensive armor and rigidway of defending against the reexperiencingof traumatic affect can inadvertently lead toa reenactment. As Krystal32 has noted,“Among the direct effects of severe child-hood trauma in adults is a lifelong dread ofthe return of the traumatic state and the ex-pectation of it” (p. 147). People learn how toavoid their ultimate dread through rigidcharacterological changes,14 which are themental “fingerprints” of who they are. Un-fortunately, inflexible and rigid defenses canlead to the very problems that the originaldefenses attempted to avoid.

As an example, a man who was constantlypreoccupied with abandonment because hismother abandoned him and his family whenhe was a young boy continued to be plaguedby unresolved dependency concerns. To en-sure that he was never again abandoned, hedeveloped extremely possessive and clingingrelationships with women. Since the man wasso suffocating, women typically left him, andhe reexperienced the pain of abandonmentagain and again. Through his own behavior,which was designed to prevent loss, abandon-ment, and terror, he inadvertently caused areenactment to occur. Another woman whohad a rejecting relationship with her fathercoped with her fear of again being rejected byestablishing relationships with “losers” she didnot really love. Although these “losers” did notmeet her emotional needs, which was a reen-actment of her past relationship with her fa-ther, she avoided her greatest fear, namelyrejection by someone whom she truly loved.In these cases, reenactments occurred in para-doxical ways: through efforts to avoid an over-whelming, disintegrating state of trauma, theseindividuals made decisions and choices thatbackfired and led, after all, to reenactments.

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R E E N A C T M E N T S

C A U S E D B Y A F F E C T I V E

D Y S R E G U L A T I O N A N D

C O G N I T I V E R E A C T I O N S

Trauma survivors who have not integrated pastfeelings surrounding the trauma can becomeflooded and overwhelmed by them.33 Intenseanger, disappointment, and fear can be trig-gered in interpersonal relationships, and thepresent situation can be perceived and re-sponded to in the same way as the oldtrauma.5,14 For example, a man who had notworked through his parents’ neglect of him be-came flooded with rage, hurt, and disappoint-ment when a friend failed to return a phonecall. The man understood this omission asproof that he was not cared about, which wasa reenactment of his earlier relationship withhis parents. The man then withdrew from hisfriend, which further re-created his isolationand loneliness.

Reenactments may also occur when an in-dividual reexperiences and expresses intensefeelings from the past that are then reacted toby another. For example, a woman who wasphysically abused by her father when she wasa child continued to feel rage and anger. Herfather also used to criticize her, which madeher feel worthless. As well as having a fragileself-esteem and extreme sensitivity to criti-cism, this woman often perceived harsh criti-cism even when it had not been expressed. Inher current relationships with men, when shereceived any criticism she overreacted andreexperienced her rage, which she expressedin vicious and hostile ways. Not only did thisfrequently cause her relationships to end infights, but often the verbal fights would turnphysical and the woman would again beabused.

Individuals can also reexperience andsubsequently become overwhelmed by fearthat has never been integrated. When they en-counter a threatening situation, trauma survi-vors may reexperience their old, unresolvedfeelings of terror and helplessness. These feel-ings will then overwhelm their psyches and

prevent them from taking appropriate action,thus leading to a reenactment and revictimiza-tion.5,17

Understanding reenactments in this fash-ion should not be construed as imposing blameon trauma survivors for their victimization.There can be no justification for the abuse ofothers, and victimizers must always take re-sponsibility for their actions. These examplesare offered to demonstrate that in select situ-ations, depending on who is encountered andwhat defenses are put into use, a reenactmentcan develop when unresolved feelings and be-liefs resulting from past traumatization arereexperienced in the present.

R E E N A C T M E N T S

C A U S E D B Y G E N E R A L

E G O D E F I C I T S

Although methodological and research prob-lems arise in attempting to ascertain the long-term effects of childhood abuse, there appearto be many associated long-term psychologicaleffects. These long-term effects typically in-clude depression and low self-esteem, drugand alcohol abuse, self-abusive behavior, anxi-ety, learning difficulties, impaired interper-sonal relationships including an inability totrust others, identity disturbances, and help-lessness.10,34 Again without blame to thetrauma survivor, early childhood abuse canlead to ego deficits that render an individualsusceptible to both reenactments and repeatedrevictimization. For example, a woman whodeveloped poor self-esteem and identity dis-turbances as a result of having been raised inan abusive childhood environment found her-self unable to leave an abusive relationship.On many levels, she lacked the internal re-sources to separate herself from her abusivepartner. The difficulty she had in trusting oth-ers also prevented her from turning to othersto obtain the help she so badly required. Thelearned helplessness model also played a rolein her tolerance for the abuse, since she be-lieved that nothing could be done about it any-way. Another trauma survivor’s alcohol and

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drug use resulted in a reenactment and revic-timization when, under the influence of alco-hol or drugs, she was victimized due toimpaired judgment and loss of consciousness.

Deep-seated disturbances in identity, self-concept, and security in the world can also ren-der individuals vulnerable to being enticed byothers who resonate with and counter theseego deficits. Because of early trauma, a personcan feel helpless, fragile, and out of control. Inturn, the person may be extremely susceptibleto anyone who can take control, who can grat-ify dependency needs, and who can elegantlycounter the individual’s extreme sense of pow-erlessness, insecurity, and vulnerability.5 Inthis regard, Kluft16 has discussed incest survi-vors who became sexually victimized by theirtherapists.

Another factor that can contribute to thefrequent reenactments of trauma survivors isthe use of dissociative defenses.5,16 Trauma sur-vivors often tolerate mistreatment and abusebecause of their habitual use of this defensivestyle. Whether it is physical abuse, abusive re-marks, emotional neglect, or a partner’s drink-ing or drug use, individuals with a history oftrauma seem to minimize, block out, not see,and tolerate such abuse. Although this mayhave an adaptive value since it allows the per-son to tolerate the situation, simultaneously itwill inhibit appropriate action, and past abusemay be reenacted.

I M P L I C A T I O N S F O R

T R E A T M E N T

Ongoing reenactments are a reflection that apatient is continuing to act in stuck and rigidi-fied ways. In addition, reenactments often leadto revictimization and related feelings ofshame, helplessness, and hopelessness. Conse-quently, an important goal of treatment is fa-cilitating an understanding and control ofreenactments. Reenactments are caused inpart by powerful unconscious forces that musteventually be verbalized and understood.Thus, in order to address reenactments and tobreak their repetitiveness, the therapist should

help the individual to understand why they oc-cur. However, before proceeding into thisphase of treatment and exploring past trau-matic relationships and experiences, the thera-pist must first have achieved a strong and solidtherapeutic alliance with the patient.35 In ad-dition, the patient’s safety must be firmly es-tablished, and any acute problem areas, suchas chemical abuse problems or ongoing self-destructive behavior, need to be stabilized.5

Once these issues have been resolved, explora-tory therapy may begin.

As the patient becomes aware that a pat-tern of dysfunction is evident, the therapist cansuggest that it might be useful to try to under-stand this. Using as a framework the categoriesof reenactments that have just been discussed,the therapist can explore which of them couldbe playing a role in a particular patient’s reen-actment. It will generally be more helpful tointimate that a pattern of destructive inter-action appears to be occurring and to then ex-plore how this takes place than to suggest thatthe patient is reenacting a trauma. Further-more, even if the reenactment is due to a moreactive process, the patient is not truly reenact-ing a past trauma, but rather a traumatic rela-tionship. Consequently, in such cases it will bemore productive to suggest this latter process,which is closer to the patient’s subjective ex-perience.

Once both the patient and the therapistunderstand what the patient is doing that con-tributes to the reenactment, the next task is toexplore why the patient feels and acts in suchways. Inevitably, this will lead back historicallyto the traumatization that triggered and con-tinues to cause the resulting feelings and be-havior. Considerable time must be devoted todiscovering how life was experienced for thepatient as a child, because it must be ascer-tained how it influenced the individual, howthe patient learned to cope, and what feelingswere experienced.5,23 The overwhelming fear,terror, and related beliefs that the patient origi-nally experienced in childhood must first bevalidated and acknowledged by both therapistand patient. In turn, in order to break the

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pattern, the patient must process and workthrough the entire traumatic experiencethroughout the course of therapy with the sup-port of the therapist.

An example is the therapy of a man whocame for treatment because he had been feel-ing uncontrollably angry. He reported that hehad been raised by an extremely physicallyabusive mother and a distant, removed father.He had been in therapy previously and felt thathe had worked through many of his past issues,which indeed he had. As therapy progressed,it became evident that much of his rage wasdue to mistreatment and emotional abuse byhis lover, which appeared to be a reenactmentof his past relationship with his mother. Whenhe recounted interactions when his lover hadtreated him “like dirt,” he displayed little affectand often shrugged it off even when his friendsmade comments to him about his lover’s mis-treatment of him. As his nonchalance and histendency to block off emotion were pointedout to him, he was able to see how he tendedto brush off his feelings, and he recognized howhe had learned to do this at an early age totolerate his mother’s abusive behavior towardhim. This led to an exploration of his earlychildhood environment, and over time he be-came significantly more aware of his feelings.He learned to attend to them and to use hisfeelings as a guide for action. He eventuallyleft his lover because he no longer wanted tobe the recipient of the lover’s abuse.

Patients will eventually come to see thatwhereas their feelings, beliefs, and ways todefend against overwhelming terror wereappropriate and justified in the past, suchintense feelings and defensive operationsmay no longer be as necessary. Through apainstakingly close examination of the indi-vidual’s past and a process of allowing thepatient to experience the intensity of the oldtraumatic feelings within the safety of thetherapeutic relationship, the patient is giventhe opportunity to integrate the entire trau-matic experience.36

Wolf37 has articulated this process in thefollowing way: “A patient’s self is strengthened

by re-experiencing the archaic trauma, with itsassociated affects, in the here-and-now of atherapeutic situation that allows an integratingand self-enhancing restructuring of the self”(p. 103). Once the trauma has been integrated,the patient’s feelings will be less intense andmore manageable, and the person will be ableto exercise better judgment as well as use lessrigid defenses.

Although some patients may not have theego strength or desire to explore early trauma-tization, therapy can still be of considerablebenefit. Even without a full reworking of theindividual’s past traumatization, reenactmentscan be stopped by helping the patient to re-spond differently in the world through behav-ioral and cognitive change.

Throughout the course of therapy, thetherapist’s own countertransferential feelingsshould be examined and used to help under-stand patients’ problems with reenactments.Boredom, anger, rage, or sexual feelings expe-rienced throughout the course of therapy canbe useful in understanding what patients en-gender in others that may play a role in thereenactments they experience. Without blam-ing patients for their reenactments, therapistscan help them to better understand their vul-nerabilities and how they may contribute totheir own exploitation.

For example, a 32-year-old female patientwith a long history of childhood sexual abusenoted to her therapist that she had been abusedin many of her past relationships. In the earlycourse of therapy, the therapist began to ex-plore with her how it was that others took ad-vantage of her, which did not prove to beparticularly productive. As the therapy prog-ressed, however, the therapist became awareof his own wish to take control of the patient’slife, to rescue her, and to tell her what to do.When he examined these feelings, he becamemore cognizant of how timid and frail the pa-tient’s presentation was, and he decided that itwould helpful to explore this. He began by in-quiring how the patient imagined othersviewed her. With specific questions aboutwhether she thought others viewed her as

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powerful or powerless, the patient eventuallybegan to better understand how she presentedto others, which, in turn, played a role in hervictimization. The therapist’s awareness of hisown feelings when working with the patientwas the catalyst for this line of questioning thatenabled the therapy to progress.

Whatever tools are used, the healing thatneeds to occur is not a short-term process. Suc-cessful clinical work can take years because thegoals are to help patients work through over-whelming affect, modify their internal objectrelationships and cognitive structures, andchange their basic ways of being in the world.Such work is necessary, however, if we are go-ing to diminish their vulnerabilities and de-crease their chances of getting involved indestructive reenactments.

S U M M A R Y

In this article I have proposed a useful way tocodify and conceptualize reenactments andoffered strategies for addressing them in thetherapeutic process. Although trauma survi-vors may actively reenact elements of pasttraumas, reenactments can also occur in inad-vertent ways that result from psychologicalvulnerabilities and defensive strategies. In ad-dition, although an active reenacting of a pasttraumatic situation may reflect an adaptiveprocess, in other cases it may be a maladaptivedefensive strategy that can cause the individualrepeated difficulties. Understanding the manydifferent ways in which reenactments can arisewill help to focus and sharpen clinical inter-vention.

R E F E R E N C E S

1. Horowitz MJ: Stress Response Syndrome. Northvale,NJ, Jason Aronson, 1976

2. Kardiner A: The Traumatic Neuroses of War. NewYork, P Hoeber, 1941

3. Krystal H: Trauma and affects. Psychoanal StudyChild 1978; 33:81–116

4. Sharfman MA, Clark DW: Delinquent adolescentgirls: residential treatment in a municipal hospital set-ting. Arch Gen Psychiatry 1967; 17:441–447

5. Herman JL: Trauma and Recovery. New York, BasicBooks, 1992

6. van der Kolk BA, McFarlane AC: The black hole oftrauma, in Traumatic Stress: The Effects of Over-whelming Experience on Mind, Body, and Society,edited by van der Kolk BA, McFarlane AC, WeisaethL. New York, Guilford, 1996, pp 3–23

7. Russell DEH: The Secret Trauma: Incest in the Livesof Girls and Women. New York, Basic Books, 1986

8. van der Kolk BA, Greenberg MS: The psychobiologyof the trauma response: hyperarousal, constriction,and addiction to traumatic reexposure, in Psychologi-cal Trauma, edited by van der Kolk BA. Washington,DC, American Psychiatric Press, 1987, pp 63–87

9. Browne A, Finkelhor D: Impact of child sexual abuse:a review of the literature. Psychol Bull 1986; 99:66–77

10. Briere J, Runtz M: Post sexual abuse trauma, in LastingEffects of Child Sexual Abuse, edited by Wyatt GE,Powell GJ. Newbury Park, CA, Sage, 1988, pp 85–100

11. Chu JA: The repetition compulsion revisited: relivingdissociated trauma. Psychotherapy 1991; 28:327–332

12. Miller A: Thou Shalt Not Be Aware, translated by Han-num HH. New York, Meridian, 1984

13. van der Kolk BA: The complexity of adaptation totrauma: Self-regulation, stimulus discrimination, andcharacterological development, in Traumatic Stress:The Effects of Overwhelming Experience on Mind,Body, and Society, edited by van der Kolk BA,McFarlane AC, Weisaeth L. New York, Guilford,1996, pp 182–213

14. Terr L: Too Scared To Cry. New York, Harper andRow, 1990

15. Freud S: Beyond the Pleasure Principle (1920), trans-lated and edited by Strachey J. New York, WW Nor-ton, 1961

16. Kluft RP: Incest and subsequent revictimization: thecase of therapist–patient exploitation, with a descrip-tion of the sitting duck syndrome, in Incest-RelatedSyndromes of Adult Psychopathology, edited by KluftRP. Washington, DC, American Psychiatric Press,1990, pp 263–287

17. Chu JA: The revictimization of adult women with his-tories of childhood abuse. J Psychother Pract Res 1992;1:259–269

18. Janet P: Psychological Healing, vol 1 (1919), translatedand edited by Paul E, Paul C. New York, Macmillan,1925

19. Vaillant GE: Adaptation to Life. Boston, Little, Brown,1977

20. Peck EC: The traits of true invulnerability and post-traumatic stress in psychoanalyzed men of action, inThe Invulnerable Child, edited by Anthony EJ. NewYork, Guilford, 1987, pp 315–360

21. Anthony EJ: Risk, vulnerability, and resilience: anoverview, in The Invulnerable Child, edited by An-

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thony EJ. New York, Guilford, 1987, pp 3–4822. van der Kolk BA, McFarlane AC, der Hart O: A gen-

eral approach to treatment of posttraumatic stressdisorder, in Traumatic Stress: The Effects of Over-whelming Experience on Mind, Body, and Society,edited by van der Kolk BA, McFarlane AC, WeisaethL. New York, Guilford, 1996, pp 417–440

23. McCann IL, Pearlman LA: Psychological Trauma andthe Adult Survivor. New York, Brunner/Mazel, 1990

24. Pine F: Developmental Theory and Clinical Process.New Haven, CT, and London, Yale University Press,1985

25. Fenichel O: The Psychoanalytic Theory of Neurosis.New York, WW Norton, 1945

26. Parkes CM, Weiss RS: Recovery from Bereavement.New York, Basic Books, 1983

27. Goodwin J, McCarthy T, DiVasto P: Physical and sex-ual abuse of the children of adult incest victims, inSexual Abuse: Incest Victims and Their Families, ed-ited by Goodwin J. Boston, Wright/PSG, 1982, pp139–153

28. Kaufman J, Zigler E: The intergenerational transmis-sion of child abuse, in Child Maltreatment: Theoryand Research on the Causes and Consequences ofChild Abuse and Neglect, edited by Cicchetti D,Carlson V. Cambridge, UK, and New York, Cam-

bridge University Press, 1989, pp 129–15029. James J, Myerding J: Early sexual experience and pros-

titution. Am J Psychiatry 1977; 134:1381–138530. Silbert M, Pines A: Sexual abuse as an antecedent to

prostitution. Child Abuse Negl 1981; 5:407–41131. Mitchell D, Osborne EW, O’Boyle MW: Habituation

under stress: shocked mice show nonassociative learn-ing in a T-maze. Behav Neural Biol 1985; 43:212–217

32. Krystal H: Integration and Self-Healing. Hillsdale, NJ,Analytic Press, 1988

33. van der Kolk BA: The psychological consequences ofoverwhelming life experiences, in PsychologicalTrauma, edited by van der Kolk BA. Washington, DC,American Psychiatric Press, 1987, pp 1–30

34. Courtois CA: Healing the Incest Wound. New York,WW Norton, 1988

35. Lindy JD: Psychoanalytic psychotherapy of posttrau-matic stress disorder: the nature of the therapeutic re-lationship, in Traumatic Stress: The Effects ofOverwhelming Experience on Mind, Body, and Soci-ety, edited by van der Kolk BA, McFarlane AC,Weisaeth L. New York, Guilford, 1996, pp 525–536

36. Rozynko V, Dondershine HE: Trauma focus grouptherapy for Vietnam veterans with PTSD. Psychother-apy 1991; 28:157–161

37. Wolf ES: Treating the Self. New York, Guilford, 1988

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Joyce AS, Piper WE: Expectancy, the therapeutic alliance,and treatment outcome in short-term individual psycho-therapy. J Psychother Pract Res 1998; 7(3):____–____Psychotherapy, Brief and Short-Term; Therapeutic Alli-ance; Therapy Outcome

Expectancy, the TherapeuticAlliance, and Treatment Outcome inShort-Term Individual Psychotherapy

A N T H O N Y S . J O Y C E , P H . D .W I L L I A M E . P I P E R , P H . D .

Patient and therapist expectancies regardingthe “typical session” were measured during acontrolled trial of short-term, time-limitedindividual psychotherapy. Relationshipsbetween expectancy ratings and measures ofthe therapeutic alliance and treatmentoutcome were examined. Significantrelationships were tested in the presence of acompeting predictor variable, eitherpre-therapy disturbance (depression) or thepatient’s quality of object relations (QOR).Expectancies were associated strongly withthe alliance but only moderately withtreatment outcome. In most instances,expectancy and QOR combined in anadditive fashion to account for variation inalliance or outcome. The patient’s capacityfor mature relationships and expectancies fortherapy appear to be important determinantsof treatment process and outcome. Theclinical value of establishing accurate,moderate expectancies prior to therapy isconsidered.

(The Journal of Psychotherapy Practiceand Research 1998; 7:236–248)

Expectancies about psychotherapy includebeliefs about the duration of treatment, the

process of therapy, and the outcome of treat-ment. In 1959 Frank1 suggested that the beliefsor attitudes a patient brings to therapy have animportant influence on the process and out-come of treatment. Expectancy variables havesince occupied an awkward place in psycho-therapy research: while continuing to holdpromise as significant components of thechange process, they have received only in-consistent empirical support.2

The most reliable finding in the literatureis the direct relationship between the expectedand actual duration of treatment.3 Confirmingany significant effects of expectancy on ther-apy outcome has been difficult because ofdiscrepant findings across studies. Methodo-logical differences may help explain the incon-sistency of results.2 For therapists’ ratings ofoutcome, the effects of outcome expectancyappear negligible.4 Stronger findings haveemerged when the patient’s ratings are consid-ered, with expectancy accounting for 8% to12% of the variation in therapy outcome. Re-views of research on individual5 and grouptherapy6 conclude that expectancy variablesdo have some promise as predictor variables

Received June 30, 1997; revised November 18, 1997;accepted November 26, 1997. From the Edmonton Psy-chotherapy Research Centre, Department of Psychiatry,University of Alberta, Edmonton, Alberta, Canada. Ad-dress correspondence to Dr. Joyce, Department of Psy-chiatry, University of Alberta, 8440 112 Street,Edmonton, Alberta, T6G 2B7, Canada.

Copyright © 1998 American Psychiatric Press, Inc.

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and should be considered more systematicallyby clinicians and researchers.

To deal with certain methodological diffi-culties, Perotti and Hopewell7 suggest the ef-fects of expectancy should be differentiatedaccording to the stage of therapy. Initial out-come expectancies are subject to revision astreatment progresses and thus may lose theirpredictive power. In contrast, initial expectan-cies regarding the therapy relationship may bemore important because they represent the pa-tient’s preparedness for early engagement in,and presumably benefit from, the treatmentprocess. We adopted this rationale for an ex-amination of initial expectancy ratings col-lected during a controlled trial of short-termindividual (STI) psychotherapy conducted inEdmonton.8 We predicted that our measuresof expectancy would be strongly and directlyassociated with ratings of the therapeutic alli-ance, but only weakly if at all related to mea-sures of therapy outcome.

We previously reported that the time-lim-ited interpretive therapy evaluated in the con-trolled trial was effective on both statistical andclinical grounds.8 We also found direct rela-tionships between patient and therapist ratingsof the therapeutic alliance and treatment out-come.9 Similar direct relationships have beenhighlighted in reviews.10,11 Our present exami-nation of the relationships of patient and thera-pist expectancies to alliance and outcome hadfour objectives:

1. To assess the simple relationships betweeninitial patient and therapist expectanciesregarding the “typical session” and mea-sures of the therapeutic alliance.

2. To assess relationships between expec-tancy and therapy outcome.

3. To assess predictive relationships involv-ing measures of the degree of confirmationor disconfirmation of initial expectanciesby subsequent session evaluations col-lected during the course of treatment.Frank1 and his colleagues12 argued that theconfirmation of expectancy should be di-rectly related to therapy benefit.

4. To evaluate the simple relationships be-tween expectancy and alliance or out-come against the prediction provided bytwo competing variables. One competingpredictor variable was a quantitative mea-sure of the patient’s developmental levelof interpersonal relations. Our clinicaltrial of STI therapy provided evidence thatthe patient personality variable quality ofobject relations (QOR) was directly re-lated to the therapeutic alliance and treat-ment outcome.9 We used the patient’sinitial level of depressive symptoms, basedon pre-therapy scores from the Beck De-pression Inventory,13 as the second com-peting predictor variable.

M E T H O D S

The reader is directed to the original reportof the controlled trial8 for methodological de-tails.

Setting and Procedures

The setting for the clinical trial was thePsychiatric Walk-In Clinic, Department of Psy-chiatry, University of Alberta Hospitals Site inEdmonton. Patients were matched in pairs onQOR, age, and gender, and then randomlyassigned to immediate or delayed therapy andto one of eight project therapists. During a3-year period, 86 of 105 patients who begantherapy completed the protocol. Sixty-four ofthese were chosen to form a sample that wasbalanced for QOR, treatment condition (im-mediate vs. delayed), and therapist.

Patients and Therapists

Diagnoses were made by the assessingtherapist according to DSM-III14 after an in-itial assessment and consultation with a staffpsychiatrist. For the sample of 64 patients, 72%received Axis I diagnoses, the most frequentbeing affective (27%), impulse control (7.8%),or anxiety (6.3%) disorder. An Axis II diagno-sis was assigned for 27% of the sample, the most

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frequent being dependent (14%) or avoidant(5%) disorder. The average age of the patientswas 32 years (SD = 8, range = 21–53 years),and 62% were female. Three psychiatrists, onepsychologist, and four social workers served astherapists in the study. Their average age was40 years, and they had practiced individualtherapy for an average of 11.5 years.

Therapy

The time-limited therapy was dynami-cally oriented and followed a technical manualthat drew on the approaches of Malan15 andStrupp and Binder.16 Interpretation and clari-fication were emphasized relative to supportand direction. Twenty weekly sessions of 50minutes’ duration were planned; the averagenumber of sessions attended was 18.8. Thetechnical nature of the therapy was verified bya content analysis of therapist interventions foreight sessions (numbers 4, 7, 9, 11, 14, 16, 18,and 20), using the Therapist Intervention Rat-ing System.17 On average, there were 44 inter-ventions, 11 interpretations, and 5 transferenceinterpretations per session, confirming that thetherapists had been active, interpretive, andtransference-oriented.

Predictor Variables

Expectancy Variables: Patients completed a se-ries of expectancy ratings as part of the initialoutcome assessment. The first two sessions ofSTI therapy were commonly used for history-taking and development of rapport. Therapistscompleted expectancy ratings after the secondtherapy session. Expectancy ratings regardingthe “typical session” were based on a modifiedversion of Stiles’s Session Evaluation Ques-tionnaire (SEQ).18 As commonly used, theSEQ involves the rating of 12 semantic differ-ential items (e.g., good–bad, easy–difficult) inresponse to the sentence stem, “This sessionwas . . . .” Two scores, based on the underlyingfactor structure of the SEQ reported byStiles,18 are obtained: Depth-Value representsthe perceived usefulness of the session, and

Smoothness-Ease represents the perceivedcomfort of the session. Scores range from aminimum of 1 to a maximum of 7. To representexpectancies at pre-therapy and early therapy,respectively, the patient and therapist rated theSEQ items in response to the sentence stem,“The typical therapy session will be . . . .” Thisapproach allowed us to derive scores for ex-pected session usefulness (Depth-Value) andexpected session comfort (Smoothness-Ease).

Patients and therapists completed theusual form of the SEQ after each session. Thetwo session evaluation scores were aggregatedacross all sessions for each participant. The dif-ference (evaluation minus expectancy) was cal-culated for each measure for both patient andtherapist, and represented the discrepancyfrom expected usefulness (Depth-Value) andcomfort (Smoothness-Ease). Positive discrep-ancy scores indicated that the overall sessionevaluations exceeded initial expectancies(confirmation); negative scores indicated thatthe overall session evaluations failed to meetinitial expectancies (disconfirmation).

Quality of Object Relations: A personality vari-able, QOR is defined as a person’s internal,enduring tendency to establish certain types ofrelationships with others.19 The dimensionranges across five levels of object relations(primitive, searching, controlling, triangular,and mature). In the clinical trial, the assess-ment of QOR comprised two 1-hour clinicalinterviews.

During the assessment, the lifelong patternof relationships is examined. The interviewerconsiders the overall pattern of relationshipsin terms of behavioral manifestations, regula-tion of affect, regulation of self-esteem, and his-torical antecedents for each of the five levels.The interviewer then distributes 100 pointsamong the five levels and derives a singleglobal score ranging from 1 to 9.

At the primitive or low end of the 9-pointscale, relations are characterized by inordinatedependence, extreme reactions to real or imag-ined loss, and destructiveness. At the matureend, relations are characterized by equity and

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the expression of love, tenderness, and con-cern. It is common for two overall scores ofequal value to represent different patterns ofobject relatedness.

Since we conducted the STI therapy trial,the QOR assessment has been streamlined toa single hour of interview time, and reliabilityhas been improved. In the clinical trial, thereliability between the interviewer and an in-dependent rater using an audiotape was as-sessed for a sample of 50 cases. A stringentindex of reliability, the intraclass correlationcoefficient for the individual rater [ICC(1,1)],was used. A reliability coefficient of 0.50 wasobtained.

For the current investigation, the overallQOR score (a continuous measure) was usedas a predictor variable.

Initial Disturbance: The pre-therapy score onthe Beck Depression Inventory13 was used torepresent initial disturbance, measured as se-verity of depressive symptoms prior to ther-apy. The BDI is a commonly used outcomemeasure with established psychometric prop-erties.

Dependent Measures

Therapeutic Alliance: The alliance was definedas the nature of the working relationship be-tween patient and therapist. The two partici-pants independently rated six 7-point items.Four “immediate” items were rated after eachtherapy session, and two “reflective” itemswere rated after each one-third of the therapy(at sessions 7, 14, and 20). Three immediateitems addressed whether the patient hadtalked about private, important material,had felt understood by the therapist, and wasable to understand and work with the thera-pist’s interventions. The remaining immediateitem concerned the overall usefulness of thesession. The two reflective items addressedLuborsky’s concept of the helping alliance(collaboration and helpfulness).20 Each set ofsix item ratings was aggregated across sessionsor thirds; aggregate ratings were then sub-

jected to a principal components analysis. Onepatient-rated alliance factor and two therapist-rated alliance factors (immediate, reflective)were derived.

Therapy Outcome: The STI therapy outcomebattery included several well-established self-report and interview measures of the patient’spsychiatric symptomatology, interpersonalfunctioning, and personality functioning. Thepatient’s individual target objectives were de-veloped with the assistance of an independentassessor. Patient, therapist, and assessor ratingsof target objective distress were included in theoutcome battery. A total of 23 outcome vari-ables were available; 19 were measured bothbefore and after therapy (residual gain scores),and the remaining 4 were measured at post-therapy only (rated benefit scores). Seven vari-ables were eliminated because of redundancyor a low response rate.

TABLE 1. Clinical trial of STI (short-termindividual) therapy: outcome factorsand variables

VariableOutcome Factors and Variables Loadings

General Symptoms and Dysfunction (39% of variance) Emotional reliance21 0.82 Self-esteem22 0.78 Depression13 0.76 Present interpersonal functioning23 0.74 Anxiety24 0.74 Symptomatic distress25 0.73 Life satisfaction 0.60Individualized Objectives (10% of variance) Overall usefulness as rated by patient 0.76 Target objective severity as rated by patient 0.70 Overall usefulness as rated by therapist 0.68 Target objective severity as rated by assessor 0.66 Work role functioning26 0.48Social-Sexual Adjustment (8% of variance) Sexual role functioning26 0.83 Social role functioning26 0.52Target Severity and Family Role Disturbance (7% of variance) Target objective severity as rated by therapist 0.73 Family role functioning26 0.46

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The results of a principal componentsanalysis of 16 post-therapy outcome variablesare presented in Table 1. The analysis identi-fied four factors. The first three factors wereretained to represent change due to treatment.Measures of improvement at post-therapywere the following: I, General Symptoms andDysfunction (patient self-report); II, Individu-alized Objectives (patient, therapist, and inde-pendent assessor); and III, Social-SexualAdjustment (assessor).

Approach to Analysis

The relationships among the predictorvariables (expectancy, discrepancy, QOR,BDI), and between the predictor and depen-dent variables (alliance, outcome), were exam-ined by using Pearson product-momentcorrelation coefficients. Expectancy and dis-crepancy variables having significant simplerelationships with alliance or outcome werethen considered in a series of hierarchical mul-tiple regression analyses. The regression analy-

ses assessed the strength of the relationshipagainst the prediction provided by competingvariables.

The regression analysis for each simplerelationship (expectancy or discrepancy withalliance or outcome) followed the same se-quence. On the first step, a competing predic-tor (QOR or BDI) entered the equation. Theexpectancy or discrepancy variable was en-tered on the second step. The interaction vari-able (product of the two predictors) wasentered on a third step. The regression wasthen repeated with the order of entry of thetwo (main effect) predictors reversed. All pre-dictor variables were centered (the samplemean subtracted from each patient’s score) tocontrol for a form of error variance, nonessen-tial ill-conditioning,27 which is defined asshared variance that is not due to a real asso-ciation in the population. Specifically, predic-tor and dependent variables with similarmeasurement scales would contribute to non-essential ill-conditioning and raise the likeli-hood of type I error.

TABLE 2. Descriptive statistics for predictor and dependent variables

Variable Name Mean ± SD

Predictor variables Session expectancy Patient Depth-Value PTDV 5.06 ± 0.90 Patient Smoothness-Ease PTSE 3.81 ± 0.76 Therapist Depth-Value THDV 4.56 ± 0.50 Therapist Smoothness-Ease THSE 4.07 ± 0.52 Session discrepancy Patient Depth-Value PTDVD 0.26 ± 0.58 Patient Smoothness-Ease PTSED 0.14 ± 0.33 Therapist Depth-Value THDVD 0.04 ± 0.20 Therapist Smoothness-Ease THSED 0.03 ± 0.14 Quality of object relations QOR 4.69 ± 1.17 Beck Depression Inventory BDI 14.13 ± 10.40

Dependent variables Therapeutic alliance Patient impression TAP 5.89 ± 0.73 Therapist immediate impression PET 5.03 ± 0.58 Therapist reflective impression HAT 4.27 ± 0.72

2Note: The n for the variables ranged between 61 and 64. Outcome factor scores had a mean of 0 and SD of 1.PT = patient; TH = therapist; DV = depth-value expectancy; SE = smoothness-ease expectancy; DVD =depth-value discrepancy; SED = smoothness-ease discrepancy.

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R E S U L T S

The noncentered means and standard deviationsfor the therapeutic alliance, expectancy, QOR,and initial disturbance are presented in Table2. Overall, patients expected that sessionswould be significantly more useful (t = 3.91, df= 61, P < 0.0001) but significantly less comfort-able (t = –2.21, df = 62, P < 0.03) than theirtherapists did. The mean discrepancy betweensession evaluations and expectancies was sig-nificantly larger (indicating greater confirma-tion) for patients than for therapists, both forusefulness (t = 2.97, df = 61, P < 0.005) and forcomfort (t = 3.17, df = 62, P < 0.002). In gen-eral, most patients reported that the experienceof therapy sessions met or exceeded their in-itial expectations.

Correlations BetweenPredictor Variables

Table 3 presents the intercorrelationsamong the 10 predictor variables. Except forthe two therapist expectancy ratings (THDV,THSE), which were independent, each re-maining pair of variables (e.g., the two patientexpectancy, two patient discrepancy, and twotherapist discrepancy variables) were signifi-cantly correlated. Overall, expectancy ratingswere significantly and inversely related to the

respective discrepancy scores. These relation-ships indicated that the higher the initial ex-pectancy, the greater the likelihood ofdisconfirmation; that is, of a failure of sessionevaluations to meet expectations.

Two additional patterns of intercorrelationwere identified. First, confirmation of the pa-tient’s expectancy of session comfort was asso-ciated with confirmation of the therapist’sexpectancies of both session comfort andusefulness. Second, confirmation of thetherapist’s expectancy of session comfortwas directly associated both with lower pa-tient expectancies of usefulness and confirma-tion of patient-expected usefulness. Theserelationships indicated a degree of patient–therapist interdependence in the evaluation ofwhether initial expectancies were confirmedby the actual experience of therapy sessions.

QOR was independent of the expectancyand discrepancy variables and was inverselyrelated to initial disturbance. Patient expectan-cies were inversely related to initial distur-bance: the greater the patient’s depressivesymptoms at pre-therapy, the lower the expec-tancies of session usefulness and comfort.

Simple Predictions

Table 4 presents the simple relationshipsamong the 10 predictor variables (QOR, initial

TABLE 3. Intercorrelations of predictor variables

Variables PTSE THDV THSE PTDVD PTSED THDVD THSED QOR BDI

Session expectancy Patient Depth-Value 0.37** 0.09 0.12 –0.70*** –0.40** –0.08 –0.27* 0.08 –0.40** Patient Smoothness-Ease 1.0 0.01 0.02 –0.42** –0.42** –0.12 –0.17 –0.10 –0.34** Therapist Depth-Value 1.0 0.00 –0.25 –0.22 –0.56** –0.44** 0.07 –0.06 Therapist Smoothness-Ease 1.0 –0.06 0.02 –0.26* –0.26* 0.14 0.05

Session discrepancy Patient Depth-Value 1.0 0.55** 0.16 0.31* 0.15 0.22 Patient Smoothness-Ease 1.0 0.36** 0.43** 0.04 0.07 Therapist Depth-Value 1.0 0.77*** –0.04 –0.03 Therapist Smoothness-Ease 1.0 –0.15 0.07

Quality of object relations 1.0 –0.32*

2Note: Range of n’s for the correlations was 62–64. Abbreviations of variables are defined in Table 2.*P < 0.05; **P < 0.01; ***P < 0.001.

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disturbance, 4 expectancy, 4 discrepancy) andthe 6 dependent variables (3 therapeutic alli-ance, 3 post-therapy outcome).

From previous work,9 we knew that QORwas directly associated with the patient-ratedalliance, the therapist-rated reflective alliance,and improvement on two of the three outcomefactors (I and II). The BDI score was inverselyassociated with the patient-rated alliance.

Expectancy and Alliance: Three expectancy–alliance relationships were identified, each in-volving a distinct pair of expectancy andalliance variables associated with the samerating source. First, the patient’s expectancy ofusefulness was directly associated with the pa-tient-rated alliance. Second, the therapist’s ex-pectancy of usefulness was directly associatedwith the therapist-rated immediate alliance.Third, the therapist’s expectancy of sessioncomfort was directly associated with the thera-pist-rated reflective alliance. These correla-tions indicated that expectancy accounted for18% to 40% of the variation in alliance ratings.

Expectancy and Outcome: Expectancies regard-ing session comfort were directly associated

with improvement at post-therapy. Three sig-nificant relationships were identified, each in-volving one of the three outcome factors. Thepatient’s expectancy of session comfort wasdirectly associated with benefit on GeneralSymptoms and Dysfunction (I) and Social-Sex-ual Adjustment (III). The therapist’s expec-tancy of session comfort was directlyassociated with benefit on Individualized Ob-jectives (II). These correlations indicated thatexpectancy accounted for 7% to 10% of thevariation in outcome scores. This was consid-erably less than the variation of alliance ac-counted for by expectancy.

Discrepancy and Alliance/Outcome: Confirmationof each of the patient’s initial expectancies(usefulness, comfort) was directly associatedwith the therapist’s rating of the reflective alli-ance. Discrepancy scores were not signifi-cantly associated with therapy outcome.

Multivariate Relationships

Expectancy–Alliance: Three relationships weretested: patient-expected usefulness and patientalliance; therapist-expected usefulness and

TABLE 4. Simple relationships between predictor and dependent variables

Dependent VariablesAlliance Outcome

Predictor Variables TAP PET HAT I II III

Quality of object relations 0.29* 0.05 0.28* –0.25* –0.35** –0.07

Beck Depression Inventory –0.27* –0.17 –0.04 0.10 0.14 0.14

Session expectancy Patient Depth-Value 0.46*** 0.18 0.00 –0.06 –0.15 –0.03 Patient Smoothness-Ease 0.09 0.00 –0.23 –0.26* –0.02 –0.31* Therapist Depth-Value –0.07 0.63*** 0.15 –0.06 –0.24 –0.19 Therapist Smoothness-Ease 0.13 0.14 0.42*** –0.19 –0.31* 0.03

Session discrepancy Patient Depth-Value 0.02 –0.08 0.26* –0.14 –0.14 0.03 Patient Smoothness-Ease 0.04 –0.05 0.26* –0.03 –0.06 0.08 Therapist Depth-Value –0.02 –0.17 0.06 0.01 0.02 0.23 Therapist Smoothness-Ease –0.15 –0.18 –0.03 0.23 0.17 0.18

2Note: Range of n’s of the correlations was 62–64. TAP = patient-rated impression; PET = therapist-ratedimmediate impression; HAT = therapist-rated reflective impression of the therapeutic alliance. I = GeneralSymptoms and Dysfunction; II = Individualized Objectives; III = Social-Sexual Adjustment.*P < 0.05. **P < 0.01. ***P < 0.001.

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therapist immediate alliance; and therapist-expected comfort and therapist reflective alli-ance. For the first relationship, initialdisturbance (depression) was considered asthe first competing predictor variable. Initialdisturbance was predictive of the patient-ratedalliance, as described above. However, in thepresence of the expectancy variable (patientusefulness), this contribution did not attainsignificance. In all of the remaining analyses,the pre-therapy BDI score was found not toaccount for significant proportions of criterionvariance. As a competing predictor variable,initial disturbance will not be addressed fur-ther.

Remaining with the patient-expected use-fulness–patient alliance relationship, our nextstep in the analysis was to consider QOR as acompeting predictor variable. Table 5 presentsthe regression analysis. Both predictors (QOR,expectancy) were significant, but the inter-action was not. Proportions of alliance vari-ance accounted for were averaged across thepair of regression analyses conducted to testeach expectancy–alliance relationship. QORaccounted for 7%, and the expectancy variablefor an additional 26%, of the variation in thepatient-rated therapeutic alliance.

Therapist-expected usefulness emerged asthe only significant predictor of the therapist-rated immediate alliance. For the relationshipbetween therapist-expected comfort and thetherapist-rated reflective alliance, a similar pat-tern of findings was evident: both predictors(expectancy and QOR) were significant, and

the interaction was not. QOR accounted for7%, and the expectancy variable for an addi-tional 16%, of the variation in the therapist-rated reflective alliance.

Expectancy–Outcome: Three relationships weretested: patient-expected comfort and GeneralSymptoms and Dysfunction (I); patient-ex-pected comfort and Social-Sexual Adjustment(III); and therapist-expected comfort and In-dividualized Objectives (II). Analyses withQOR as the competing predictor again re-sulted in important findings.

Table 6 presents the results of the regres-sion analysis for General Symptoms and Dys-function (I). QOR and patient-expectedcomfort both emerged as significant predic-tors, but the interaction did not. Each predictoraccounted for roughly 7% of the variance insymptomatic improvement. Patient-expectedcomfort emerged as the only significant pre-dictor of Social-Sexual Adjustment (III). ForIndividualized Objectives (II), both predictorsemerged as significant, and the interaction didnot. QOR accounted for approximately 11%of the variance in improvement, and therapist-expected comfort accounted for an additional8% of outcome variance.

Discrepancy–Alliance: The two patient discrep-ancy variables having significant relationshipswith the therapist’s reflective alliance werethemselves highly correlated (r = 0.55, df = 60,P < 0.0001). To maintain consistency with theother analyses, separate regression analyses

TABLE 5. Patient Depth-Value expectancy as a predictor of patient alliance (TAP)

Overall PartialStep and Variable R2 ∆ R2 F df P F df P

Competing predictor: QOR1. QOR 0.08 5.56 1,62 0.032. PTDV 0.33 0.25 14.85 2,61 0.0001 22.76 1,61 0.0001

Reverse order of main effects1. PTDV 0.27 22.48 1,62 0.00012. QOR 0.33 0.06 14.85 2,61 0.0001 5.46 1,61 0.033. Interaction 0.36 0.03 11.03 3,60 0.0001 2.82 1,60 0.11

2Note: QOR = quality of object relations; PTDV = patient-rated expectancy of session Depth-Value.

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were conducted to test the strength of eachdiscrepancy–alliance relationship on its own.

For the regression analysis involving dis-crepancy scores for patient-expected useful-ness, QOR and the discrepancy variable bothemerged as significant predictors of the alli-ance, but the interaction did not. For the analy-sis involving the discrepancy scores forpatient-expected comfort, there was evidencefor significant independent contributions byeach predictor and for the interactive effect.Table 7 presents the result of the regressionanalysis. QOR accounted for approximately8%, patient comfort accounted for approxi-mately 7%, and the interaction accounted foran additional 9% of the variance in the thera-pist-rated reflective alliance. The interactionindicated that the greater the confirmation ofthe patient’s expectancy (the more positive thediscrepancy between experienced and ex-pected comfort), the stronger the direct effectof the patient’s QOR on the therapist’s generalperception of the alliance.

Expectancy and Alliance asJoint Predictors of Outcome

We returned to the expectancy variablesat this point in the analysis. We were interestedin whether expectancies would still signifi-cantly account for outcome variance when theprediction afforded by the therapeutic alliancewas considered first. Three hierarchical regres-sion analyses were conducted. For outcome

factor I (General Symptoms and Dysfunction),the predictors were QOR, each of the alliancevariables in turn, and patient-expected com-fort. QOR accounted for 7% of outcome vari-ance, as above, but when alliance andexpectancy were in the equation the direct ef-fect of QOR was no longer significant. Allianceaccounted for 7% to 13% of outcome variance;each alliance variable provided for significantprediction in the regression. The patient ex-pectancy rating, when entered last, accountedfor an additional 6% to 14% of outcome vari-ance and was also a significant predictor ineach analysis. For outcome factor II (Individu-alized Objectives), the predictors were QOR,the alliance variables, and the therapist’s ex-pected comfort. QOR accounted for 12% andthe alliance for 19% to 22% of outcome vari-ance, but therapist expectancy did not providefor a significant additional contribution. Foroutcome factor III (Social-Sexual Adjustment),the predictors were the alliance variables andpatient-expected comfort. Only the expec-tancy variable accounted for significant out-come variance (9%–11%). These additionalanalyses indicated that patient expectancy, butnot therapist expectancy, provided for a sig-nificant prediction of outcome over and abovethe prediction afforded by the alliance.

D I S C U S S I O N

We studied patient and therapist expectancyratings as potential predictors of the therapeu-

TABLE 6. Patient Smoothness-Ease expectancy as a predictor of improvement on outcome factor I,General Symptoms and Dysfunction

Overall PartialStep and Variable R2 ∆ R2 F df P F df P

Competing predictor: QOR1. QOR 0.06 4.23 1,62 0.052. PTSE 0.15 0.09 5.18 2,61 0.008 6.46 1,61 0.02

Reverse order of main effects1. PTSE 0.07 4.48 1,62 0.042. QOR 0.15 0.08 5.18 2,61 0.008 5.74 1,61 0.033. Interaction 0.15 0.00 3.49 3,60 0.03 0.0 1,60 0.99

2Note: QOR = quality of object relations; PTSE = patient-rated expectancy of session Smoothness-Ease.

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tic alliance and treatment outcome. The analy-ses demonstrated that expectancies regardingthe experience of therapy sessions are stronglyand directly related to the quality of the thera-peutic alliance. Relationships between expec-tancy and outcome proved to be less strongbut still substantial. In the multivariate analy-ses, expectancy variables frequently combinedadditively with quality of object relations inaccounting for variation in alliance and out-come. In an analysis examining the joint pre-diction of outcome, QOR, the alliance, andpatient expectancy were found to inde-pendently contribute to therapy benefit. Wewill consider the results and their clinical im-plications in the sequence that was followed inthe preceding section.

The simple descriptive analyses (directcomparisons of patient and therapist ratings,correlations among the predictor variables)proved to be quite informative. High expec-tancies were clearly related to the experienceof disconfirmationthat is, disappointmentwith actual therapy sessions. In direct compari-sons of the expectancy ratings, patients ex-pected significantly more session usefulnessbut significantly less session comfort thantherapists. To put this another way, therapistshad moderate expectancies about therapysessions relative to patients. The two therapistexpectancy variables were found to be inde-pendent of one another, which also suggestedthat the therapists had a more differentiatedpicture of the therapy process. In effect, it islikely that therapists “know what to expect” as

therapy begins. This clinical understanding ofthe therapy process should be employed dur-ing the preparation phase to modify any pa-tient expectations that appear to be overlyoptimistic or idealized.

Correlations between patient and thera-pist discrepancy scores indicated that there isa clear dyadic interdependence when sessionexperiences are evaluated against expectan-cies. Patient discrepancy scores were signifi-cantly more positive than were therapistdiscrepancy scores. For the patients, the actualexperience of therapy was generally in linewith or exceeded their expectations, suggest-ing that for most of them, therapy was a rea-sonably positive experience.

Overly optimistic or idealized expecta-tions thus may not be a frequent occurrence,but they should definitely be addressed if theyare identified early in the treatment process.Ensuring that the patient has reasonable ex-pectancies about the treatment experience willmilitate against disappointment. Although thispoint was not addressed by our analyses, it isalso possible that reasonable expectancies thatare shared by the patient and therapist wouldbe even more strongly associated with thequality of the therapeutic collaboration.

Substantial expectancy–alliance relation-ships were identified. For patients and thera-pists, expectancies of session usefulness weredirectly associated with the strength of the re-spective alliance ratings. Beginning therapywith the expectation that individual sessionswill be productive may help ensure that the

TABLE 7. Patient Smoothness-Ease discrepancy as a predictor of therapist reflective alliance (HAT)

Overall PartialStep and Variable R2 ∆ R2 F df P F df P

Competing predictor: QOR1. QOR 0.08 5.44 1,62 0.032. PTSED 0.14 0.06 5.03 2,61 0.01 4.26 1,61 0.05

Reverse order of main effects1. PTSED 0.07 4.37 1,62 0.052. QOR 0.14 0.07 5.03 2,61 0.01 4.96 1,61 0.033. Interaction 0.23 0.09 6.02 3,60 0.001 7.01 1,60 0.01

2Note: QOR = quality of object relations; PTSED = patient-rated discrepancy of session Smoothness-Ease.

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therapy relationship is also productive, or atleast is perceived as productive. The therapist’sexpectancy of session comfort was directly as-sociated with his or her rating of the reflectivealliance. This relationship suggests that if thetherapist believes he or she will be comfortablein the therapy, again perhaps as a result of aproductive preparation, more general percep-tions of the treatment relationship will also turnout to be positive.

Expectancy–outcome relationships werenotably smaller in absolute value than expec-tancy–alliance relationships. This discrepancysupports the findings of Perotti and Hopewell,7

which suggest that expectancies may have moredirect effects on the establishment of the thera-peutic alliance than on the actual outcome oftreatment. Expectancies regarding sessioncomfort were nonetheless clearly associatedwith treatment benefit. For patients, who com-pleted these ratings prior to meeting the thera-pist, expectancies of session comfort may havereflected “preparedness” and a positive inten-tion to engage in meaningful self-examination.For therapists, who completed ratings after twosessions, expectancies regarding comfort mayhave reflected positive impressions of the pa-tient and of the potential for collaboration.

Patient expectancies of comfort were di-rectly associated with symptom improvementand overall adjustment in social activity andintimate relationships. Expecting sessions tobe relatively comfortable may indicate open-ness to the relationship with the therapist andthe process of therapy. A simple assessment ofthe patient’s expectancy of session comfortcould be used as an early indicator of potentialchange in symptomatic and interpersonal dis-tress. Therapist expectancies of comfort weredirectly associated with positive change on in-dividualized objectives for therapy. Therapistexpectancies of comfort may reflect an estima-tion of the potential for collaboration on thepatient’s problems, involving judgments aboutappropriateness and capacity for therapy, theusefulness of any preparation, and the thera-pist’s own experience with treatment for simi-lar problems.

Relative to expectancy ratings, the discrep-ancy scores were less fruitful as predictor vari-ables. Confirmation of the patient’s expectancieswas directly associated with the therapist’s reflec-tive alliance. If the patient finds that sessions meetor exceed expectations, the therapist’s generalperception of the therapeutic alliance is positive.A reasonable confirmation of the patient’s ex-pectancies may represent a therapist objectivefor the early stages of therapy.

Multivariate analyses aimed at testing therobustness of the simple relationships involv-ing the expectancy and discrepancy variables.The competing predictors included an indexof the patient’s capacity for healthy interper-sonal relationships (QOR) and an establishedmeasure of initial symptomatic distress (BDI).The first set of regression analyses consideredthe three expectancy–alliance relationships.Initial disturbance was eliminated as a signifi-cant predictor in one analysis, and it did nothave a significant relationship with the crite-rion in any subsequent analyses. QOR was sig-nificant as a competing predictor in two of threeanalyses, in each case accounting for roughly 7%of the variation in the quality of the therapeuticalliance. In sharp contrast, expectancy was a sig-nificant predictor in all three analyses and ac-counted for a large proportion (16%–40%) ofvariation in the alliance. The prediction providedby QOR and expectancy was additive.

This finding has implications for the selec-tion and preparation of patients for short-terminterpretive therapy. A capacity to establish agood working relationship (selection) and theexpectation that work will occur comfortablyand productively during therapy sessions(preparation) are strongly associated with apositive therapeutic alliance.

The second set of regression analysestested the three expectancy–outcome relation-ships. A similar pattern of findings emerged.QOR was predictive of improvement in twoof three analyses. In all three analyses, theexpectancy variable made a significant singleor additional contribution to the prediction.Expectancy accounted for roughly 8% of out-come variance in each instance.

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The third set of regression analyses con-sidered the relationships between confirma-tion of the two patient expectancies and thetherapist-rated reflective alliance. When thepatient discrepancy score for expected useful-ness was used as a predictor, the familiar pat-tern of findings emerged: both quality of objectrelations and the discrepancy variable ac-counted for significant proportions of alliancevariance, but the interaction did not. Thetherapist’s rating of the general quality of thetherapeutic alliance was elevated when the pa-tient presented with a good capacity for inter-personal relationships and a belief in theusefulness of the therapy process.

When the patient discrepancy score forexpected comfort was used as a predictor, allthree effects (QOR, patient discrepancy, andthe interaction) emerged as significant. Thus,confirmation of the expectancy that sessionswould be comfortable increased the likelihoodthat the patient’s capacity for satisfying rela-tionships would be put to use in the work oftherapy. Ensuring that the patient is comfort-able with the demands of the therapy processprior to and during sessions allows for the de-velopment of the best possible patient–thera-pist relationship. This multiplicative effectrepresented an important independent contri-bution to the prediction of the therapist-ratedreflective alliance.

The final set of regression analyses wasprompted by our interest in the joint predictionof outcome by three variables: the quality of ob-ject relations, the therapeutic alliance, and ex-pectancy. If expectancy accounted for outcomevariance over and above the contributions ofQOR and the alliance, this would underscorethe importance of the relationship. The resultsshowed that symptomatic improvement wasstrongly predicted by the alliance and the pa-tient’s expectancy of session comfort; QOR waseliminated as a predictor when these variableswere present in the regression equation. Changeon individualized objectives was predicted byQOR and the alliance, but not by therapistexpectancy. Change in broader overall adjust-ment was predicted solely by the patient’s

expectancy of session comfort.Taken together, the results of these addi-

tional analyses suggest two conclusions. First,patient expectancies are strong predictors oftherapy outcome, but therapist expectanciesare not. Second, the patient’s capacity for agood relationship, the patient’s expectancythat the therapy sessions will be comfortable,and the actual experience of a strong therapeu-tic alliance all represent consistently strong de-terminants of therapy benefit.

The strength of our findings with measuresof patient and therapist expectancy was some-what of a surprise, particularly given the sim-plicity of the expectancy rating. The findingsclearly argue for the preparation of patients forshort-term, time-limited individual psycho-therapy. Referring therapists, or the treatingtherapist at the time of a treatment contract,should seek to reinforce moderate patient ex-pectancies. Overly high expectancies are likelyto be painfully disconfirmed and perhaps in-crease the likelihood of a treatment dropout.Reasonable expectancies represent one goalfor the patient’s preparation for therapy. Interms of expectancies regarding session useful-ness, the patient should understand that eachsession contributes to overall benefit and byitself is unlikely to have dramatic effects on thepresenting problem.

In terms of expectancies regarding sessioncomfort, the patient should be clear that somedegree of session difficulty is associated withthe hard work of a successful psychotherapy.After therapy has actually started, one aspectof the therapist’s activity should be to engagethe patient in a “good” working process28 andreinforce the patient when this is achieved.

Confirming an early expectancy that ses-sions can be productive and comfortable maymake it more likely that the patient and thera-pist will be able to establish a good workingrelationship. This confirmation can also allowthe patient’s capacity for healthy relationshipsto come more fully to the fore in the therapyprocess. In turn, the patient’s actual experienceof a strong alliance can be the foundation fora successful treatment outcome.

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R E F E R E N C E S

1. Frank JD: The dynamics of the psychotherapeutic re-lationship. Psychiatry 1959; 22:17–39

2. Beutler LE, Machado PPP, Allstetter Neufeldt S:Therapist variables, in Handbook of Psychotherapyand Behavior Change, 4th edition, edited by GarfieldSL, Bergin AE. New York, Wiley, 1994, pp 229–269

3. Jenkins SJ, Fuqua DR, Blum CR: Factors related toduration of counseling in a university counseling cen-ter. Psychol Rep 1986; 58:467–472

4. Bonner BL, Everett FL: Influence of client preparationand problem severity on attitudes and expectations inchild psychotherapy. Professional Psychology: Re-search and Practice 1986; 17:223–229

5. Luborsky L, Crits-Christoph P, Mintz J, et al: WhoWill Benefit From Psychotherapy? Predicting Thera-peutic Outcomes. New York, Basic Books, 1988

6. Piper WE: Client variables, in Handbook of GroupPsychotherapy, edited by Fuhriman A, BurlingameGM. New York, Wiley, 1994, pp 83–113

7. Perotti LP, Hopewell CA: Expectancy effects in psy-chotherapy and systematic desensitization: a review.JSAS: Catalog of Selected Documents in Psychology1980; 10: Ms No 2052

8. Piper WE, Azim HFA, McCallum M, et al: Patientsuitability and outcome in short-term individual psy-chotherapy. J Consult Clin Psychol 1990; 58:475–481

9. Piper WE, Azim HFA, Joyce AS, et al: Quality of objectrelations vs. interpersonal functioning as predictors oftherapeutic alliance and psychotherapy outcome. JNerv Ment Dis 1991; 179:432–438

10. Henry WP, Strupp HH, Schacht TE, et al: Psychody-namic approaches, in Handbook of Psychotherapyand Behavior Change, 4th edition, edited by BerginAE, Garfield SL. New York, Wiley, 1994, pp 467–508

11. Horvath AO, Symonds BD: Relation between work-ing alliance and outcome in psychotherapy: a meta-analysis. Journal of Counseling Psychology 1991; 38:139–149

12. Frank JD, Gliedman LH, Imber SD, et al: Patients’expectancies and relearning as factors determining im-provement in psychotherapy. Am J Psychiatry 1959;115:961–968

13. Beck AT, Steer RA: Beck Depression Inventory Man-ual. New York, Harcourt Brace Jovanovich, 1987

14. American Psychiatric Association: Diagnostic and Sta-tistical Manual of Mental Disorders, 3rd edition.Washington, DC, American Psychiatric Association,1980

15. Malan DH: The Frontier of Brief Psychotherapy. NewYork, Plenum, 1976

16. Strupp HH, Binder JL: Psychotherapy in a New Key:A Guide to Time-Limited Dynamic Psychotherapy.New York, Basic Books, 1984

17. Piper WE, Debbane EG, de Carufel FL, et al: A systemfor differentiating therapist interpretations and otherinterventions. Bull Menninger Clin 1987; 51:532–550

18. Stiles WB: Measurement of the impact of psychother-apy sessions. J Consult Clin Psychol 1980; 48:176–185

19. Azim HFA, Piper WE, Segal PM, et al: The Qualityof Object Relations Scale. Bull Menninger Clin 1991;55:323–343

20. Luborsky L: Principles of Psychoanalytic Psychother-apy: A Manual for Supportive-Expressive Treatment.New York, Basic Books, 1984

21. Hirschfeld RMA, Klerman GL, Gough JG, et al: Ameasure of interpersonal dependency. J Pers Assess1977; 41:610–618

22. Rosenberg M: Conceiving the Self. New York, BasicBooks, 1979

23. Piper WE, Debbane EG, Garant J: An outcome studyof group psychotherapy. Arch Gen Psychiatry 1977;34:1027–1032

24. Spielberger CD: Manual for the State-Trait AnxietyInventory. Palo Alto, CA, Consulting PsychologistsPress, 1983

25. Derogatis LR: SCL-90-R Manual I. Baltimore, MD,Johns Hopkins University School of Medicine, Clini-cal Psychometrics Unit

26. Weissman MM, Paykel ES, Siegel R, et al: The socialrole performance of depressed women: a comparisonwith a normal sample. Am J Orthopsychiatry 1971;41:390–405

27. Aiken LS, West SG: Multiple Regression: Testing andInterpreting Interactions. Newbury Park, CA, Sage,1991

28. Hoyt M: Therapist and patient actions in “good” psy-chotherapy sessions. Arch Gen Psychiatry 1980;37:159–161

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2Most of the articles that have been published in this Grand Rounds section to datehave described psychotherapy case histories. The current piece from the PayneWhitney Clinic at The New York Hospital-Cornell Medical Center is different.Drs. Kalman and Goldstein present the results of a survey that provide empiricalsupport for the much discussed but little studied effects of managed care onpsychiatric practice. As might have been anticipated, psychiatrists involved inmanaged care organizations reported less financial reward and less emotionalsatisfaction in their private practices than did psychiatrists not involved inmanaged care. The ability to conduct psychotherapy, as opposed to relegation to astrictly psychopharmacological role, was an important component of psychiatrists’satisfaction with practice. Kalman and Goldstein thus raise a key issue confronting psychiatry today:how to preserve psychotherapy as an integral facet of psychiatric practice in an eraof managed care and cost containment. Many psychiatrists consider psychotherapy acore aspect of their professional identity and believe that there are advantages topsychiatrists’ conducting psychotherapy, at least with selected patient populations.For example, plausible arguments can be raised for having a single mental healthprofessionalthe psychiatrist provide psychotherapy and psychopharmacologyinterventions for patients who need combined treatment, and for psychiatrists tofunction as psychotherapists for patients with complex or severe Axis III disorders. There are almost no data, however, to corroborate or contradict theseassertions. (A recent report in Psychiatric Services found that psychiatrist-provided combined psychotherapy and pharmacotherapy cost less than split therapy,but this research did not examine treatment outcome [Goldman et al. 1998;49:477–482].) In the absence of proof that psychotherapy by psychiatrists issuperior to psychotherapy by other mental health professionals, cost-driven managedcare organizations have sought the latter, less expensive alternative. This isapparently endangering the psychiatrist-psychotherapist as a species in the managedcare jungle. Research to demonstrate the particular psychotherapeutic skills ofpsychiatrists, although complex to undertake, may be essential to sustain them.

—John C. Markowitz, M.D., Grand Rounds Editor

G R A N D R O U N D S

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Satisfaction of Manhattan PsychiatristsWith Private PracticeAssessing the Impact of Managed Care

T H O M A S P . K A L M A N , M . D .M A R T I N A . G O L D S T E I N , M . D .

O V E R V I E W O F T H E S T U D Y

This study surveyed a sample of Manhattan-based private psychiatrists regarding aspectsof their professional activities: general practicecharacteristics (size of practice, managed careparticipation), economic factors (yearly grossrevenues, fee schedules), attitudes towardmanaged care, patterns of psychotherapy de-livery, and career satisfaction. A questionnairewas sent to 100 randomly selected medicalschool voluntary faculty with a return enve-lope designed to ensure anonymity. Forty-three percent of those surveyed returnedcompleted questionnaires.

Gross revenues were nearly level for theyears 1993–1995; however, those psychiatristsengaged in managed care averaged approxi-mately 20% lower annual revenues than thosenot on a provider panel.

Managed care participants were signifi-cantly less satisfied with practice than werenonparticipants. Respondents reported di-minishing opportunities for the practice ofpsychotherapy, and the perception that psy-chiatry was becoming a more difficult profes-sion was widely held across groups.

The study data support anecdotal ac-counts of demoralization among private prac-tice psychiatrists, specifically documentinglower income and professional satisfaction rat-ings among managed care participants versusnonparticipants.

B A C K G R O U N D

Few developments in organized medicinehave progressed as rapidly as the emergenceof managed care in the United States in the1990s. Although not new, such managedsystems have newly dramatic prevalence.The common purpose of all managed careapproaches is the control of health care expen-ditures, theoretically without compromisingthe quality of care administered and the well-being of patients. As of 1995, more than 58million Americans were receiving medicalcare under the auspices of such organizedsystems.1 Even in New York City, where theestablishment of managed care organizations(MCOs) was long resisted and their growthlagged well behind levels in other parts of thecountry, their recent expansion has been ex-plosive. Between 1993 and 1995, managedcare penetration in New York State increased

Accepted March 18, 1998. From Cornell UniversityMedical College and The New York Hospital-CornellMedical Center, New York, New York. Address corre-spondence to Dr. Goldstein, Payne Whitney Clinic, De-partment of Psychiatry, New York Hospital-CornellMedical Center, Baker 16, 525 E. 68 Street, New York,NY 10021; e-mail: mgoldste%[email protected].

Copyright © 1998 American Psychiatric Press, Inc.The material in this Grand Rounds was adapted, withpermission, from an earlier version appearing in MedScapeMental Health 3(1)1997; copyright © 1997 MedScape Inc.,all rights reserved (http://www.medscape.com).

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from 23% to 31%, with a greater than 50%increase (from 18% to 29%) in New York Cityfor the same time period.2

Mental health care, long feared as an enor-mous cost item for insurance companies, hasbeen a featured target of managed care. In-itially, cost control efforts were directed to-ward reducing inpatient expenditures, sincehospitalization accounted for the bulk of costs.Later, MCOs targeted outpatient treatment aspatients were shifted from hospitalization tocommunity-based management.3,4 In fact,only psychiatry, among all medical fields, hasseen the emergence of superspecialized man-agement entities: organizations such as MeritBehavioral Care, American Psych Manage-ment, and dozens more, are routinely em-ployed by MCOs to manage the mental healthbenefits of enrollees.

American psychiatry has met the adventof managed care with combinations of tre-pidation, hysteria, ignorance, and, not unex-pectedly, demoralization. The AmericanPsychiatric Association has become polarizedby fierce critics and ardent supporters of be-havioral health care management within itsranks. The position of the former is well sum-marized by Inglehart: “The application ofmanaged-care principles to mental health andsubstance-abuse services has provoked un-precedented turmoil in the profession by erod-ing the autonomy of practitioners, squeezingtheir incomes, and forcing them into con-stricted new roles.”5 Conversely, proponentshold that managed care offers enhanced accessto care for more people, and they accept thepremise that constraints on open-ended careare necessary to prevent abuses. Other psychi-atrists support efforts at health care reform,hoping that control over escalating costs willbe followed by parity of insurance coveragefor treatment of mental disorders.6,7

With as many as 70% of insured Ameri-cans receiving mental health care throughmanaged care systems,8 practitioners will in-evitably be affected. Yet despite the obviousneed to assess the impact of managed care onpsychiatry, there is surprisingly little useful

information available about the impact ofmanaged care on private practice, which is stillthe predominant delivery mode of outpatientpsychiatric treatment in the United States. Theliterature currently consists of three types ofmaterial: 1) numerous highly subjective tab-loid-style articles, 2) a few large informal sur-veys, and 3) a small number of systematicsurveys of heterogeneous groups of mentalhealth professionals.

A large 1988–1989 overview of psychia-trists’ professional activities (N = 19,431)documented a decline in private practice anddramatic diversification of practice settings.9

The authors attributed these trends to eco-nomic pressures, principally the growth ofMCOs. The proportion of psychiatrists listingprivate practice as their primary work activitydeclined from 58%, a majority, in 1982 to 45%in 1988. The same study also documented theextensive prevalence of cost-shifting (in whichpsychiatrists charge higher fees to their pri-vate, non–managed care patients) across abroad range of services.10

A 1995 multidisciplinary survey of psy-chotherapists (N > 200, including psychia-trists, psychologists, social workers, andothers) documented a reduced psychotherapycaseload among 43% of respondents, in-creased use of time-limited techniques (a man-aged care hallmark) in 51%, and reducedincome among 61% of psychiatrists.11 Sixty-three percent of responding psychiatrists re-ported an increase in disallowed claims due tomanaged care.

Another study (N > 100) suggested thatpsychiatrists’ incomes decline as their man-aged care participation increases.12 Theauthors (the Medical Group Management As-sociation) noted that “psychiatrists are not ex-pected to do well under managed care becausethese organizations typically restrict psychia-trists’ use to medication management.”

Between these few data-based surveysand the subjective diatribes that pour forth(“Managed Care May Save the Profiteers butKill the Doctors;”13 “Earning a Living: A Blue-print for Psychiatrists;”14 “Reversing Managed

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Denial;”15 etc.), there exist several informalsurveys purporting to reflect the state of psy-chiatric practice in this age of economicchange.

A 1993 survey of the chairs of regionalPrivate Practice Committees of the AmericanPsychiatric Association offered the followingdismal impressions:

Psychiatrists as a group have grave mis-givings about their future and that of theirprofession. A sense of anxiety and fore-boding was expressed even by those prac-titioners who personally were doing well.Words such as scared, depressed, anx-ious, apprehensive, confused, subdued,pessimistic, and demoralized were used innearly all the returned questionnaires.Many indicated that incomes were declin-ing or were being maintained only by theexpenditure of a great deal of extra effort.Most said that professional autonomy hadbeen severely eroded by managed careand other forms of oversight.16 (p. 19)

A 1994 New York Times review of theeffects of managed care on the practice ofpsychotherapy across professional disciplinesfurther reported lowered incomes, diminishedautonomy, and general discouragement withprivate practice.17 A 1995 Wall Street Journalseries detailed changes in psychiatric practicewrought by managed care. One article focusedon insurers’ pressuring psychiatrists and otherclinicians to minimize psychotherapy and em-phasize medication for patients, virtually re-gardless of diagnosis:

Managed care companies, with their man-date to cut costs, make no bones abouttheir preference for treating mental healthproblems with drugs. Not only do theylimit coverage for psychotherapy, theyoften pay psychiatrists more per hour tosupervise drug treatment than to providecounseling.18

Another article in the Wall Street Journalseries reported the malaise and discourage-ment of practitioners, detailing the conflicts

within the profession described above. Notingthe 12% decline in U.S. medical school gradu-ates who chose psychiatry residency trainingbetween 1988 and 1994, the authors assertedthat one consequence of the economic deterio-ration of the practice “climate” is diminishinginterest in the specialty by medical students.19

Given the conflicting passions aroused bymanaged care, it is striking that so few dataexist to inform the debates that rage amongpsychiatrists. This dearth of empirical infor-mation prompted our study: an attempt toquantify more systematically the state of pri-vate psychiatric practice in a part of New YorkCity, and to assay the mood, attitudes, andprofessional satisfaction of a group of prac-titioners in the mid-1990s. Our hypotheses:1) MCO providers would report lower profes-sional satisfaction than non–MCO providers;and 2) changes in practice nature (such asdecreased opportunities for performing psy-chotherapy) and economic changes (such aslower income) would be observed as corre-lates for differences in satisfaction rating. Inother words, changed levels of satisfactionwould be linked to MCO-related changes inwhat practitioners do and what they get paidfor doing it.

M E T H O D S

Using the alphabetical faculty directory of theDepartment of Psychiatry of Cornell Univer-sity Medical College, Payne Whitney (Man-hattan) campus, we selected every thirdnonsalaried (voluntary faculty) psychiatristwho had been out of residency for at least3 years and was engaged in full-time privatepsychiatric practice in Manhattan. If a selectedindividual did not meet these criteria, the nextname in sequence was chosen. This procedurewas followed to reach the desired N of 100(representing a balance of feasibility and sta-tistical adequacy). The total pool of eligibleindividuals was approximately 300 from a fac-ulty roster of nearly 500.

A mailing was sent in early 1996 to thisgroup of 100 asking that they anonymously

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complete a two-page questionnaire aboutprivate psychiatric practice. A stamped, pre-addressed envelope was included togetherwith a cover letter that explained the purposeof the study and assured the addressees thattheir responses would be kept confidential. Afollow-up telephone call was made 1 monthafter the mailing in an attempt to maximizereturns.

The questionnaire, designed by the inves-tigators, contained 24 items, some of whichhad multiple components. Areas of inquiryincluded general aspects of practice (such asduration, participation in managed care andMedicare, numbers of patients in treatment,and prescribing activity for non-MD thera-pists), economic factors (including gross prac-tice revenues for 1993–1995, referral activity,and fee schedules), satisfaction with aspects ofpractice, and attitudes about managed careand other issues. Some questionnaire itemsrelated to the practice of providing medicationbackup to nonmedical therapists were drawnfrom a previously published validatingstudy.20 Overall professional satisfaction rat-ings for two times periods, “currently” and “inthe past,” were reported via a Likert scale,ranging from 1 = very dissatisfied to 5 = verysatisfied.

Statistical analysis (t-tests for independentand paired samples) of responses was per-formed by using the Statistical Package for theSocial Sciences (SPSS Inc., Chicago, IL).

R E S U L T S

Forty recipients returned completed or par-tially completed questionnaires. An additional7 were returned to the investigators undeliv-ered, yielding an overall response rate of 43%(40/93).

General Characteristics ofRespondents’ Practices

Forty-six percent of respondents identi-fied themselves as participants in one or moremanaged care programs. Eighty-seven and a

half percent reported that in the past year theyhad been asked by a prospective new patientwhether they belonged to a managed carepanel. Seventy-five percent of respondentsstated that they treat Medicare patients.Twenty-five respondents (62.5%) identifiedthemselves as providing psychopharma-cologic treatment for patients treated by anonmedical psychotherapist, with 28% report-ing that they were doing more medicationbackup than they had 3 years earlier. Generalcharacteristics of the respondents are listed inTable 1.

Economics

Mean annual gross revenues of all respon-dents from patient care showed minimalchanges during the interval surveyed:$195,724, $203,800, and $201,267 for 1993,1994, and 1995, respectively (a 4% increasefollowed by a 1% decrease).

Differentiating respondent revenue dataaccording to years in practice revealed a sig-nificant diminution in the revenue differencebetween older, more veteran psychiatrists(those in practice longer than 15 years) andtheir younger colleagues. Analysis of meanannual revenues by years in practice appearsin Table 2.

There was no statistically significant dif-ference in the age distribution of MCO partici-pants relative to nonparticipants.

Annual average patient care revenues dif-fered considerably according to respondents’managed care participation status (Table 3).

Medication Backup

Nearly two-thirds of the respondents pro-vide medication backup for nonmedical psy-chotherapists. Seventy-six percent of thoseproviding medication backup believed thatthis activity involves greater liability exposurethan if they were the sole providers of care(providing both psychotherapy and medica-tion). Thirty-six of 37 respondents agreed withthe statement: “Medication backup could im-

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plicate the psychiatrist as legally responsiblefor the patient’s treatment by the nonmedicaltherapist.” Almost half of respondents whoprovide medication backup (48%) feared adecline in income should they cease to providesuch services. One hundred percent of respon-dents (n = 40) reported that prescribing forpatients in psychotherapy with someone elseis less gratifying than providing both compo-nents of care.

Satisfaction With Practice

The satisfaction ratings of the respondentsare listed and compared in Table 4; as notedabove, 5 is the highest level of satisfaction and1 is the lowest.

The data indicate a significant differencebetween current and past (3 years earlier)mean levels of professional satisfaction (3.9 vs.4.4). But when respondents’ satisfaction scoresare broken down according to managed careparticipation, the decline in satisfaction from3 years earlier appears attributable to the sub-group of respondents who are managed careproviders (3.4 [current] vs. 4.4 [past]). In con-trast, non–managed care participants’ satisfac-tion scores remained steady (4.2 [current] vs.4.4 [past]). Managed care participants andnonparticipants did not significantly differ inpast levels of satisfaction (4.4 vs. 4.4), but diddiffer significantly with respect to current sat-isfaction (3.5 vs. 4.2; t = 2.28, P < 0.03). Halfof the respondents who were managed careparticipants reported participation in greatermanaged clinical activity than 3 years ago,further suggesting that managed care partici-pation is associated with declining profes-sional satisfaction with practice.

Among non–managed care providers (n =22), the most common reasons cited for non-participation were eroded confidentiality(73%), inadequate fees (55%), and comfort inthe solvency and security of their practices(50%).

Thirty-three of 40 respondents (83%)found practice more difficult now than 3 yearsago; 70% were happier in practice 3 yearsago than currently; and 70% of respondentsreported that they would not recommend acareer in private practice to a graduating psy-chiatry resident. Seventy percent of respon-dents felt that psychiatry as a specialty is worse

TABLE 1. General characteristics

Characteristic n %

Years in practice < 15 17 47.5 > 15 23 57.5Number of active patients < 25 11 27.5 25–40 19 47.5 > 40 10 25.0MCO panelist Yes 18 45.0 No 22 55.0Treat Medicare patients Yes 30 75.0 No 10 25.0Medication backup Yes 25 62.5 No 15 37.5

2Note: MCO = managed care organization.

TABLE 2. Mean annual revenues by years in practice

Category 1993 1994 1995

Practicing < 15 yrs (n = 12, 13, 13) $135,417 $157,308 $158,308Practicing > 15 yrs (n = 17, 17, 17) $238,294 $239,353 $234,118Difference $102,877 $82,045 $75,810t-test of difference t = 3.18, P < 0.004 t = 2.34, P = 0.027 t = 2.00, P = 0.055All respondents (n = 29, 30, 30) $195,724 $203,800 $201,267

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off in the current economic climate than othermedical specialties.

As shown in Table 5, where revenue dataare combined with satisfaction scores, the in-creasing income disparity between MCO par-ticipants and nonparticipants parallels anincreasing satisfaction rating disparity.

D I S C U S S I O N

This study was undertaken to provide moreinformation about the current state of NewYork City private psychiatric practice in thecontext of the growth of managed carethrough the mid-1990s. The investigatorshoped to discover whether data support per-vasive subjective impressions of pessimismand disillusionment that informal discussionswith colleagues and the aforementioned anec-dotal literature suggest. Unfortunately, the re-sults appear to support many of the commonperceptions.

Although satisfaction scores seem accept-able (mean satisfaction score for all respon-dents was 3.9 of a possible 5), they mayactually constitute a disappointing result whenone considers that private practice representsthe chosen career activity of these highlytrained professionals affiliated with a promi-nent medical college.

Examining satisfaction ratings accordingto managed care provider status lent supportto the hypothesis that the changes wrought bymanaged care are indeed affecting the satisfac-tion of practitioners. Respondents participat-ing in managed care were significantly lesssatisfied than counterparts who were notMCO-affiliated. Further support for the notionthat managed care participation negatively af-

fects professional satisfaction comes from thesignificant decline in satisfaction ratings ofmanaged care providers compared with theirratings 3 years earlier. This decrease suggeststhat exposure to managed care takes its tollover time on the satisfaction of practitioners.Again, non-MCO providers reported no sig-nificant change in professional satisfactionover the three-year interval.

A major short-term cost-cutting (thoughnot necessarily long-term cost-effective) strat-egy of managed care involves selectively refer-ring patients for psychotherapy to nonmedicalprofessionals whose rates of remuneration aresignificantly lower than those of psychiatrists.Thus, MCO psychiatrists are decreasinglyproviding psychotherapy to managed care pa-tients, their role being often limited to brief“med-check” visits. Increased competition forpsychotherapy patients has compelled manypsychiatrists to take on more medication backupcases to maintain their incomes. This constella-tion of circumstances (psychiatrists economi-cally bound to continue providing a service thatis less gratifying yet involves greater liabilityexposure) would seem to yield a climate antago-nistic to professional satisfaction.

A study by Simon and Born20 of physi-cians’ 1994 incomes across all specialties re-vealed a 4% decrease from the previous year.In our study, respondents’ incomes increasedby 4% during the 1993–1994 interval andsubsequently fell by 1% for 1994–1995. Be-cause Manhattan has lagged behind the rest ofthe country in managed care penetration, adelayed income decline among Manhattanpsychiatrists is not surprising. The authors ofthe national survey suggest that physicians’incomes are a useful barometer for tracking

TABLE 3. Mean revenues, in dollars, by managed care provider status

Variable 1993 1994 1995

MCO participant 177,571 183,933 179,286MCO nonparticipant 212,667 223,667 220,500Difference 35,096 39,734 41,214

2Note: MCO = managed care organization.

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changes in the economic climate in whichmedicine is practiced; specifically, they sug-gest that income statistics are valid as a tool fortracking the impact of managed care.20 In ourstudy, even though the finding did not achievestatistical significance, it is striking that non–managed care psychiatrists achieved gross in-comes that were 20% to 23% greater than themean incomes for managed care participantsduring the 3 years surveyed.

As noted, the increasing income disparitybetween MCO participants and nonparticipantsparalleled an increasing satisfaction rating

disparity (Table 5). But those results also showthat money alone cannot explain decliningsatisfaction scores among managed care par-ticipants. A revenue disparity existed in 1993,when satisfaction scores were approximatelyequal, suggesting that other aspects of man-aged care participation (more clinical over-sight, for example) may contribute todeclining professional satisfaction.

The implications of our findings for pa-tient care are collectively ominous. Dimin-ished professional satisfaction and economiccompensation may lead current practitioners

TABLE 5. Mean annual revenues, in dollars, and satisfaction ratings according to managed care partici-pation

Variable 1993 1994 1995

Mean revenues MCO participant 177,600 184,000 179,300 MCO nonparticipant 212,700 224,000 220,500 Difference 35,100 40,000 41,200 Percent difference 20% 22% 23%Satisfaction scores MCO participant 4.41 3.50 MCO nonparticipant 4.41 4.23Comparison No significant difference t = 2.28, P = 0.028

2Note: MCO = managed care organization. Satisfaction scores are ratings on the questionnaire of past versus current satisfaction.

TABLE 4. Mean satisfaction scores by subgroup

SatisfactionComparison Score n t P

All respondents, current 3.9All respondents, past 4.4 t-test 39 2.88 0.006MCO participants, current 3.5MCO nonparticipants, current 4.2 t-test 18,22 2.28 0.028MCO participants, past 4.4MCO nonparticipants, past 4.4 t-test NSMCO nonparticipants, current 4.2MCO nonparticipants, past 4.4 t-test NSMCO participants, current 3.4MCO participants, past 4.4 t-test 17 3.52 < 0.003

2Note: MCO = managed care organization; NS = not significant.

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away from patient care and deter promisingpotential clinicians from establishing practicesas they choose less embattled career paths.Over time psychiatric practitioners of psycho-therapy may diminish in number, leaving thiswork to the nonmedically trained and jeopard-izing the welfare of patients whose care wouldlack the relevant and often mandatory medicalperspective and expertise. At the very least,declining professional satisfaction can yield adangerously fertile environment for negativecountertransference.

As with most questionnaire surveys, nu-merous caveats apply to interpretation of thesedata. The questionnaire, an original construc-tion, appears to meet the requirements of facevalidity (for instance, individual items mani-festly address issues that relate to an assess-ment of satisfaction with practice),21 but it lacksreplication or control through other uses orstudies. Especially vulnerable to criticism is theretrospective assay of past satisfaction. However,prior to its distribution the questionnaire wasreviewed by experienced researchers, resultingin revisions that achieved consensus accept-ability. Another concern involves the responserate and hence the representativeness of therespondents. For mailed surveys, a response rateof 50% is generally considered adequate for dataanalysis and reporting;21 the current work, witha rate of 43%, falls below that level.

Further reasons for caution in interpretingthe generalizability of the results are that thisstudy canvassed a particular geographic re-gion (New York City) and a particular eco-nomic market (the upper east side ofManhattan). However, the service delivery re-gion we looked at may represent, for reasonsalready mentioned, one of the final frontiersof managed care’s impact on psychiatry,thereby providing a fertile substrate for assess-ing managed care’s current influence on pri-vate practice. Offsetting this shortcoming isthe likely representativeness of the respon-dents. Since the questionnaire was mailed to arandomly selected subgroup drawn from ahomogeneous population (voluntary faculty,full-time private practitioners), there is little

reason to suspect significant variation amongrespondents, nonrespondents, and those whowere not included in the mailing.

Yet despite these caveats, the dilemmaseems clear: without managed care participa-tion, a practitioner may lack an adequate flowof new patients, so the future may mandate areconciliation to lower earnings and adminis-trative oversight. MCOs have not had diffi-culty filling their provider panels, suggestingthat the fear of declining patient flow withnonparticipation in managed care has so faroutweighed the decreased compensation forworking in such settings.

Perhaps the greatest irony in this still-evolving saga is that the upheaval may beunwarranted: outpatient psychiatric practicemay never have contributed to the runawayexpenditures that so alarmed third-party pay-ers.22 As reforms aimed at inpatient abusesspread, the private psychiatrist became caughtup in the juggernaut of cost-control mecha-nisms and oversight. Hymowitz remarked ina Wall Street Journal article:

What’s really sad is that outpatient ther-apy was never part of the rising-cost prob-lem. Even when therapy benefits werevery generous, every study showed that85% of patients ended treatment beforethe 25th visit on their own. . . . In addi-tion, utilization rates have been steady for15 or 20 years. There really is no reasonto manage outpatient therapy, and themanagement of it costs almost as much asthe therapy itself. . . . The big cost prob-lem was inpatient care. . . . The averagenumber of outpatient therapy visits has beensix to eight (per patient) for decades . . . sotrying to clamp down on outpatient servicesto control costs doesn’t make sense.8

Q U E S T I O N S A N D A N S W E R S

A B O U T M A N A G E D C A R E

T R E N D S

Q: What can we as psychiatrists do about thetrends you report?

A: Well, on the provider side, if psychiatrists

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refused to join MCOs, that would have animpactbut there’s no sign of that beingremotely possible. There is no shortage ofpsychiatrists willing to join MCO providerpanels.

Q: You have focused on provider-side satis-faction. Is there any good information re-garding satisfaction on the consumer side?

A: Not much. One reason for this, especiallyin psychotherapy delivery, is that as qualityassessment becomes more data-driven, theissue of patient confidentiality remains a largeand unresolved problem. But large numbersof anecdotal reports of dissatisfaction withquality are showing signs of producing ef-fectsfor instance, in the form of possiblefederal legislation leading to better MCOquality assessments (such as HMO reportcards) and guaranteeing patient rights.

Q: Satisfaction is a complex concept. Areyou sure your survey elicited all the impor-tant determinants that affect professional

satisfaction for your study sample?A: No. In fact, we’re sure that it didn’t. More

detailed demographic data, better measure-ment of putative MCO-related practice ef-fects, and consideration of factors related tothe overall medical economic environmentare crucial additional points that futurestudies should incorporate.

Q: Given that we will never go back to theold ways and that cracks are appearing inthe managed care system, do you see anysigns of going to a single-payer system?

A: It may be on the horizon, but relativelyfar off. When President Clinton’s federalhealth care initiative was defeated, insur-ance companies were empowered to createtheir own product. So given the relativelyrecent political defeat of a national healthplan, and the economic power of healthinsurance companies, it’s unlikely that afederally based single-payer system willarise in the near future.

R E F E R E N C E S

1. Wines M, Pear R: President finds benefits in defeat onhealth care. The New York Times, July 30, 1996, pA1:B8

2. New York State HMO Council, January 1, 1996 3. Borenstein DB: Does managed care permit appropri-

ate use of psychotherapy? Psychiatric Services47:971–974

4. Strum R, Weils KB: How can care for depressionbecome more cost effective? JAMA 1995; 273:51–58

5. Inglehart JK: Health policy report: managed care andmental health. N Engl J Med 1996; 334:131–135

6. Dorwart RA: Physicians’ incomes under health re-form: psychiatrists’ dilemma. Harvard Rev Psychiatry1994 Jul/Aug, 113–114, p 114

7. Pear R: Experts foresee health plan shift for mental care.The New York Times, September 21, 1996, pp A1, 7

8. Hymowitz C: Shrinking coverage: has managed carehurt mental health care? The Wall Street Journal, Oct24, 1996, p R19

9. Dorwart RA, Chartock LR, Dial T, et al: A nationalstudy of psychiatrists’ professional activities. Am JPsychiatry 1992; 149:1499–1505

10. Stroup TS, Dorwart RA, Hoover CW, et al: Organizedsystems of care and psychiatrists’ fees. PsychiatricServices 1996; 47:461

11. Private practice holds its own. Psychiatric News, April7, 1995, pp 11, 28

12. Parker S: Group practice psychiatrists see “surprising”

rise in income. Clinical Psychiatry News, Dec 1994, p13

13. Goldman AJ: Managed care may save the profiteersbut kill the doctors. Psychiatric Times, Apr 1996, p 38

14. Schreter RK: Earning a living: a blueprint for psychi-atrists. Psychiatric Services 1995; 46:1233–1235

15. Schoenholtz JC: Reversing managed denial. Acad-emy Forum 1996; 40(1,2):4–6

16. Mizner GL: Current problems in the private practiceof psychotherapy. Psychiatric Times, Aug 1994, pp19–21

17. Henneberger M: Managed care changing practice ofpsychotherapy. The New York Times, Oct 9, 1994, pp1, 50

18. Pollock EJ: Managed care’s focus on psychiatric drugsalarms many doctors. The Wall Street Journal, Dec 1,1995, pp A1, 11

19. Hymowitz C: High anxiety: in the name of Freud, whyare patients complaining so much? The Wall StreetJournal, Dec 12, 1995, pp A1, 10

20. Simon C, Born P: Physician earnings in a changingmanaged care environment. Health Affairs 1996;13:124–133

21. Babbie E: Survey Research Methods, 2nd edition.Belmont, CA, Wadsworth, 1980, p 133

22. Olfson M, Pincus HA: Outpatient psychotherapy inthe United States: patterns of utilization. Am J Psychi-atry 1994; 151:1289–1294

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Weiner MF: The Symptom-Context Method: Symp-toms as Opportunities in Psychotherapy, by Luborsky L(book review). J Psychother Pract Res 1998; 7(3):____–____ Books Reviewed

The Symptom-Context Method:Symptoms as Opportunities inPsychotherapy

By Lester LuborskyWashington, DC, American PsychologicalAssociation, 1996, 422 pages, ISBN1-55798-354-2, $39.95

Reviewed by Myron F. Weiner, M.D.

Lester Luborsky has been a psychotherapyresearcher for 50 years. In this compli-

cated and data-filled volume, which containsmuch work published earlier, he summarizeshis work on examining events in individualpsychotherapy through contemporaneous re-cordings. His technique, the symptom-contextmethod, analyzes by the Core Conflictual Re-lationships Theme (CCRT) method the con-text in which symptoms occur or are reportedin psychotherapy.

After describing the origins of his methodand his techniques of data collection andanalysis, Luborsky presents material on theresults of the CCRT method for determiningthe context of both psychological and psycho-physiological phenomena. Psychological phe-nomena include momentary forgetting anddepressive mood shifts occurring within psy-chotherapy sessions and the reporting ofphobic symptoms occurring outside the thera-peutic situation. Psychophysiologic phenom-ena include abdominal pain, migraine-likeheadache (subjective perceived phenomena),and petit mal seizures and premature ventricu-lar contractions of the heart (physiologicevents). He contrasts symptomatic behaviors(a symptom defined as something that impairsfunction) with nonsymptomatic behaviorsthat occur in psychotherapylaughing, self-touching, crying (in a family therapy)andhe also includes touching of treasured objectsby young children in day care. The bookconcludes with application of the symptom-context technique to psychotherapy.

In Luborsky’s intraindividual method,

each person serves as his or her own control.Multiple raters blinded to the symptomaticbehavior or physiologic event determine thepredominant context in which it occurs duringpsychotherapeutic sessions by sampling a seg-ment of 50 to 500 words from process notes ortape recordings before and after the behavioror physiologic event occurs or is reported.

From these samples, raters formulatethemes, which are then contrasted with themesfrom portions of sessions in which no symp-tom emerges or was reported. Sessions as awhole are rated by the CCRT method toascertain the central relationship patterns thatemerge from the narratives (what the patientwanted from the other person, how the otherperson responded, and how the patient re-sponded in turn).

By this method, Luborsky reports, for exam-ple, that momentary forgetting during psycho-therapy was associated with Involvement withTherapist, Rejection, Helplessness, Hopeless-ness, and Hostility to Therapist. He suggests thatan individually specific theme precedes asymptom that arises in psychotherapy.

With regard to depressive mood shiftsduring treatment, he finds support for the dy-namic theories of depression and for a depres-sive cognitive style. Luborsky holds that hismethod will be a valid basis for testing theoriesof symptom formation. He predicts that futureresearchers will learn more about the biologyof symptom formation, but that they will al-ways continue to find that psychological issuesare contributing factors.

With regard to the technique of psycho-therapy, in Luborsky’s view his work showsthat for treatment to be effective, it is importantto interpret the main symptom-context themewhile not alienating the patient and whilemaintaining the therapeutic alliance. Thesymptom-context theme (usually Hopeless-ness, Lack of Control, Anxiety, FeelingBlocked, or Helplessness) parallels the CCRT,whose resolution is held to be associated withpositive outcome of therapy. Thus, dynamictherapists may need to attend more directly tothe origin of symptoms, and behavior thera-

B O O K R E V I E W

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pists may need to increase their attention tothe context in which symptoms occur.

The strength of Luborsky’s method is itscapacity to detect the psychological determi-nants of symptom formation that occurs dur-ing and outside of psychotherapeutic sessions.A weakness of his method is that it equatestherapy outcome with CCRT resolution. Onecannot argue that a good therapeutic result isprima facie evidence of having achieved athorough CCRT resolution. The result may beunrelated to CCRT resolution. Another weak-ness in terms of outcome is the absence of acontrol condition in which CCRT resolutionwas not used, or even a placebo condition.Who can say that CCRT resolution is anybetter than placebo or medication?

The strength of this book is the rigorousapplication of a specific technique to a varietyof psychological and physiologic events. Go-

ing through the data is tedious, but the exten-sive data presented make it clear that Lubor-sky’s conclusions are externally validatedrather than based on the clinical impressionsthat may often be misleading.1 Not for theaverage clinician, this book is for those inter-ested in the process of scientific psychotherapyresearch.

Dr. Weiner is professor and vice-chairman for clini-cal services in the Department of Psychiatry, Uni-versity of Texas Southwestern Medical Center,Dallas, TX.

R E F E R E N C E

1. Davies RM: House of Cards: Psychology and Psycho-therapy Built in Myth. New York, Free Press, 1994

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