Poster Summaries
D e v e lop m e n t o f a n A d h e r e n c e S c a l e f o r D i f f e r e n t i at i o n B e t w e e n P s yc h o dy n a m i c P s yc h o t h e r a p y a n d P s yc h o a n a ly t i c P s yc h o t h e r a p y
Melanie Ratzek (International Psychoanalytic University, Berlin) Dorothea Huber (International Psychoanalytic University, Berlin; Department of Psychosomatic Medicine and Psychotherapy, Klinikum München) Günther Klug (Klinik und Poliklinic für Psychosomatische Medizin und Psychotherapie, Klinikum rects der Isar, Technische Universität München) DOI: 10.1177/0003065115594457
Especially in the realm of unmanualized outcome studies comparing psychodynamic treatment models (e.g., psychodynamic psychotherapy and psychoanalytic psychotherapy), assessment of adherence is still a problem due to the broad overlap between such models, in both theoretical conceptualization and practical implementation. The aim of this study is to create an adherence scale of high discriminant power for differentiation between the psychodynamic pole and the psychoanalytic pole of psychotherapeutic technique. Background
Adherence is defined as the extent to which therapists follow the rules specified in treatment manuals or to which they apply the principles and techniques prototypical of a given treatment model. Thus, the assessment of adherence plays an essential role in both manualized RCTs and quasi-experimental unmanualized outcome studies to assure replicability and comparability (Kendall, Holmbeck, and Verduin 2004). Adherence to manuals or treatment models also serves as a criterion of quality in
Downloaded from apa.sagepub.com at UNIV MASSACHUSETTS BOSTON on September 29, 2015
NP23
Poster Summaries
outcome studies, contributing to their internal validity, statistical validity, and external validity, and also to the construct (see Leichsenring et al. 2011). Usually adherence is measured by rating scales grasping the extent to which psychotherapeutic techniques viewed as prototypical of a treatment have been implemented as intended. An adherence scale like this was developed by Caligor et al. (2012) as part of the Comparative Outcomes in Psychotherapy and Psychoanalysis Study (COPPS). The scale, known as COPPS-AS, was devised to distinguish between unmanualized psychoanalysis, supportive-expressive therapy, and cognitive behavioral therapy. The psychometric properties of COPPS-AS are highly promising, as the three subscales discriminate satisfactorily between cognitive behavioral therapy and psychodynamic treatment models. Its differentiation between psychoanalysis and supportive-expressive therapy, however, is less than satisfactory, because at the moment the two subscales responsible for differentiation between the two psychodynamic models differentiate these treatments only approximately. Method
The development of our scale involved a two-sided approach integrating both the empirical and the theoretical. The theoretical side relied on the literature distinguishing psychodynamic and psychoanalytic techniques (e.g., Busch 2010; Gill 1954), while the empirical used audiotaped real-world therapy sessions. The sessions were sampled from the Munich Psychotherapy Study (MPS; Huber et al. 2013), which compares two unmanualized treatment conditions (psychoanalytic psychotherapy, psychodynamic psychotherapy) using a randomized prospective design.The psychodynamic pole is represented by psychodynamic psychotherapy sessions and the psychoanalytic pole by psychoanalytic psychotherapy sessions. Both treatment models are based on the German psychotherapy guidelines. These guidelines define psychoanalytic psychotherapy as a long-term treatment at a maximum of 300 sessions. Sessions take place two or three times a week on the couch. By contrast, psychodynamic psychotherapy takes place once or twice a week and is conducted face to face for a short or moderate duration (maximum 100 sessions). The scale was developed in four steps. Step 1. An extensive literature review was conducted to identify conceptualizations of the psychoanalytic pole and of the psychodynamic pole to be used in formulating items for the scale. The items should briefly
NP24
Downloaded from apa.sagepub.com at UNIV MASSACHUSETTS BOSTON on September 29, 2015
Poster Summaries
describe therapist techniques prototypical either of psychoanalytic psychotherapy or of psychodynamic psychotherapy. Thirty-six such items were formulated (e.g., “Therapist encourages free association” or “Therapist intervenes in a supportive way [commending, approving, advising]”). These items are conceived as dimensional in the sense of “rather psychoanalytic” or “rather psychodynamic” and not as categorical. Step 2. A group discussion among six experts (three female and three male training analysts) was then convened to consider the discriminant power of all of the formulated items. Three moderators focused the discussion to identify items that describe a prototypical technique or attitude of one or the other therapeutic approach and allow reliable discrimination between them. Twenty-two such items were identified, eleven items representing the psychoanalytic pole and eleven items representing the psychodynamic pole. Step 3. “Expert therapy sessions” were then selected. Fifteen blinded experts (nine training analysts and six training psychodynamic therapists), having carefully listened to an audiotaped therapy session, rated it as either psychoanalytic or psychodynamic. The sampled sessions were all from the middle part of a treatment. Two consecutive sessions were chosen throughout to enhance assessment of aspects of the treatment process. In all, seven such sequences were rated for psychoanalytic and seven for psychodynamic psychotherapy. Each sequence was assessed by varying pairs of expert raters. Sessions were defined as “expert therapy sessions” if both experts agreed in their rating and the rating matched the therapist’s avowed approach. This step resulted in four psychodynamic and three psychoanalytic “expert therapy sessions.” Step 4. Finally, the 22 items were applied to the “expert therapy sessions.” Another group of experts, comprising ten psychodynamic therapists and psychoanalysts with at least five years of clinical experience, was divided into six varying rater groups (three raters in each group). Ratings were based on three psychodynamic and three psychoanalytic “expert therapy sessions.” Raters were blind to the approaches (psychodynamic vs. psychoanalytic sessions). Each expert listened to one or more sequences of these sessions and assessed each item of the therapist’s attitudes and interventions on a 4-point Likert scale (0 = “Not at all characteristic” to 3 = “Extremely characteristic”). Items with a sufficiently high interrater reliability (ICC [3.1] > .4; Fleiss 1981) and that
Downloaded from apa.sagepub.com at UNIV MASSACHUSETTS BOSTON on September 29, 2015
NP25
Poster Summaries
discriminated between the two treatment approaches were considered appropriate for the adherence measure. Conclusion
The majority of currently used adherence scales are suitable for discriminating cognitive behavioral and psychodynamic approaches (e.g., Ablon and Jones 1998; Hilsenroth et al. 2005; Jones and Pulos 1993; McCarthy and Barber 2009) but still fail to provide robust discrimination between different psychoanalytic approaches. Effectiveness studies of high external validity investigating unmanualized long-term treatments require the measurement of adherence to meet a high scientific standard. The present study was conducted to attain this goal and provides an adherence measure that, in a next step, will be examined regarding various aspects of validity. Publication of a manual to train graduates in use of the scale will follow. References
Ablon, J.S., & Jones, E.E. (1998). How expert clinicians’ prototypes of an ideal treatment correlate with outcome in psychodynamic and cognitivebehavioral therapy. Psychotherapy Research 8:71–83. Busch, F. (2010). Distinguishing psychoanalysis from psychotherapy. International Journal of Psychoanalysis 91:23–34. Caligor, E., Hilsenroth, M.J., Devlin, M., Rutherford, B.R., Terry, M., & Roose, S.P. (2012). Will patients accept randomization to psychoanalysis? A feasibility study. Journal of the American Psychoanalytic Association 60:337–360. Fleiss, J.L. (1981). Statistical Methods for Rates and Proportions. 2nd ed. New York: Wiley. Gill, M.M. (1954). Psychoanalysis and exploratory psychotherapy. Journal of the American Psychoanalytic Association 2:771–797. Hilsenroth, M.J., Blagys, M.D., Ackerman, S.J., Bonge, D.R., & Blais, M.A. (2005). Measuring psychodynamic-interpersonal and cognitive techniques: Development of the comparative psychotherapy process scale. Psychotherapy: Theory, Research, Practice, Training 42:340–356. Huber, D., Henrich, G., Clarkin, J.F., & Klug, G. (2013). Psychoanalytic versus psychodynamic therapy for depression: A three-year follow-up study. Psychiatry 76:132–149. Jones, E.E., & Pulos, S.M. (1993). Comparing the process in psychodynamic and cognitive-behavioral therapies. Journal of Consulting & Clinical Psychology 61:306–316.
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Poster Summaries
Kendall, P.C., Holmbeck, G., & Verduin, T. (2004). Methodology, design, and evaluation in psychotherapy research. In Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change: Fifth Edition, ed. M.J. Lambert. New York: Wiley, pp. 16–43. Leichsenring, F., Salzer, S., Hilsenroth, M.J., Leibing, E., Leweke, F., & Rabung, S. (2011). Treatment integrity: An unresolved issue in psychotherapy research. Current Psychiatry Reviews 7:313–321. McCarthy, K.S., & Barber, J.P. (2009). The multitheoretical list of therapeutic interventions (MULTI): Initial report. Psychotherapy Research 19:96– 113. Melanie Ratzek IPU Berlin Stromstrasse 3 10555 Berlin GERMANY E-mail: [email protected]
F e a r o f P s yc h i c a n d P h y s i c a l D e s t r u c t i o n : T h e R e l at i o n o f C h i l d Ab u s e , N e g at i v e L i f e E v e n t s , a n d A d u lt At ta c h m e n t t o A n n i h i l at i o n A n x i e t y
Caroline Schiek-Gamble and Marvin Hurvich (Department of Psychology, Long Island University, Brooklyn) DOI: 10.1177/0003065115594785
Anxiety is an evolutionary construct, our understanding of which has grown significantly. Research has shown that 15.7 million people living in the United States are affected by anxiety in any given year and that as many as 30 million suffer from anxiety at one point during their life (Lépin 2013). Different manifestations of anxiety indicate its nature and often severity. For instance, Spielberger, Gorsuch, and Lushene (1970), describing anxiety as commonly experienced, distinguished state anxiety from trait anxiety. However, people often experience a more severe, more
Downloaded from apa.sagepub.com at UNIV MASSACHUSETTS BOSTON on September 29, 2015
NP27
D e v e lop m e n t o f a n A d h e r e n c e S c a l e f o r D i f f e r e n t i at i o n B e t w e e n P s yc h o dy n a m i c P s yc h o t h e r a p y a n d P s yc h o a n a ly t i c P s yc h o t h e r a p y
Melanie Ratzek (International Psychoanalytic University, Berlin) Dorothea Huber (International Psychoanalytic University, Berlin; Department of Psychosomatic Medicine and Psychotherapy, Klinikum München) Günther Klug (Klinik und Poliklinic für Psychosomatische Medizin und Psychotherapie, Klinikum rects der Isar, Technische Universität München) DOI: 10.1177/0003065115594457
Especially in the realm of unmanualized outcome studies comparing psychodynamic treatment models (e.g., psychodynamic psychotherapy and psychoanalytic psychotherapy), assessment of adherence is still a problem due to the broad overlap between such models, in both theoretical conceptualization and practical implementation. The aim of this study is to create an adherence scale of high discriminant power for differentiation between the psychodynamic pole and the psychoanalytic pole of psychotherapeutic technique. Background
Adherence is defined as the extent to which therapists follow the rules specified in treatment manuals or to which they apply the principles and techniques prototypical of a given treatment model. Thus, the assessment of adherence plays an essential role in both manualized RCTs and quasi-experimental unmanualized outcome studies to assure replicability and comparability (Kendall, Holmbeck, and Verduin 2004). Adherence to manuals or treatment models also serves as a criterion of quality in
Downloaded from apa.sagepub.com at UNIV MASSACHUSETTS BOSTON on September 29, 2015
NP23
Poster Summaries
outcome studies, contributing to their internal validity, statistical validity, and external validity, and also to the construct (see Leichsenring et al. 2011). Usually adherence is measured by rating scales grasping the extent to which psychotherapeutic techniques viewed as prototypical of a treatment have been implemented as intended. An adherence scale like this was developed by Caligor et al. (2012) as part of the Comparative Outcomes in Psychotherapy and Psychoanalysis Study (COPPS). The scale, known as COPPS-AS, was devised to distinguish between unmanualized psychoanalysis, supportive-expressive therapy, and cognitive behavioral therapy. The psychometric properties of COPPS-AS are highly promising, as the three subscales discriminate satisfactorily between cognitive behavioral therapy and psychodynamic treatment models. Its differentiation between psychoanalysis and supportive-expressive therapy, however, is less than satisfactory, because at the moment the two subscales responsible for differentiation between the two psychodynamic models differentiate these treatments only approximately. Method
The development of our scale involved a two-sided approach integrating both the empirical and the theoretical. The theoretical side relied on the literature distinguishing psychodynamic and psychoanalytic techniques (e.g., Busch 2010; Gill 1954), while the empirical used audiotaped real-world therapy sessions. The sessions were sampled from the Munich Psychotherapy Study (MPS; Huber et al. 2013), which compares two unmanualized treatment conditions (psychoanalytic psychotherapy, psychodynamic psychotherapy) using a randomized prospective design.The psychodynamic pole is represented by psychodynamic psychotherapy sessions and the psychoanalytic pole by psychoanalytic psychotherapy sessions. Both treatment models are based on the German psychotherapy guidelines. These guidelines define psychoanalytic psychotherapy as a long-term treatment at a maximum of 300 sessions. Sessions take place two or three times a week on the couch. By contrast, psychodynamic psychotherapy takes place once or twice a week and is conducted face to face for a short or moderate duration (maximum 100 sessions). The scale was developed in four steps. Step 1. An extensive literature review was conducted to identify conceptualizations of the psychoanalytic pole and of the psychodynamic pole to be used in formulating items for the scale. The items should briefly
NP24
Downloaded from apa.sagepub.com at UNIV MASSACHUSETTS BOSTON on September 29, 2015
Poster Summaries
describe therapist techniques prototypical either of psychoanalytic psychotherapy or of psychodynamic psychotherapy. Thirty-six such items were formulated (e.g., “Therapist encourages free association” or “Therapist intervenes in a supportive way [commending, approving, advising]”). These items are conceived as dimensional in the sense of “rather psychoanalytic” or “rather psychodynamic” and not as categorical. Step 2. A group discussion among six experts (three female and three male training analysts) was then convened to consider the discriminant power of all of the formulated items. Three moderators focused the discussion to identify items that describe a prototypical technique or attitude of one or the other therapeutic approach and allow reliable discrimination between them. Twenty-two such items were identified, eleven items representing the psychoanalytic pole and eleven items representing the psychodynamic pole. Step 3. “Expert therapy sessions” were then selected. Fifteen blinded experts (nine training analysts and six training psychodynamic therapists), having carefully listened to an audiotaped therapy session, rated it as either psychoanalytic or psychodynamic. The sampled sessions were all from the middle part of a treatment. Two consecutive sessions were chosen throughout to enhance assessment of aspects of the treatment process. In all, seven such sequences were rated for psychoanalytic and seven for psychodynamic psychotherapy. Each sequence was assessed by varying pairs of expert raters. Sessions were defined as “expert therapy sessions” if both experts agreed in their rating and the rating matched the therapist’s avowed approach. This step resulted in four psychodynamic and three psychoanalytic “expert therapy sessions.” Step 4. Finally, the 22 items were applied to the “expert therapy sessions.” Another group of experts, comprising ten psychodynamic therapists and psychoanalysts with at least five years of clinical experience, was divided into six varying rater groups (three raters in each group). Ratings were based on three psychodynamic and three psychoanalytic “expert therapy sessions.” Raters were blind to the approaches (psychodynamic vs. psychoanalytic sessions). Each expert listened to one or more sequences of these sessions and assessed each item of the therapist’s attitudes and interventions on a 4-point Likert scale (0 = “Not at all characteristic” to 3 = “Extremely characteristic”). Items with a sufficiently high interrater reliability (ICC [3.1] > .4; Fleiss 1981) and that
Downloaded from apa.sagepub.com at UNIV MASSACHUSETTS BOSTON on September 29, 2015
NP25
Poster Summaries
discriminated between the two treatment approaches were considered appropriate for the adherence measure. Conclusion
The majority of currently used adherence scales are suitable for discriminating cognitive behavioral and psychodynamic approaches (e.g., Ablon and Jones 1998; Hilsenroth et al. 2005; Jones and Pulos 1993; McCarthy and Barber 2009) but still fail to provide robust discrimination between different psychoanalytic approaches. Effectiveness studies of high external validity investigating unmanualized long-term treatments require the measurement of adherence to meet a high scientific standard. The present study was conducted to attain this goal and provides an adherence measure that, in a next step, will be examined regarding various aspects of validity. Publication of a manual to train graduates in use of the scale will follow. References
Ablon, J.S., & Jones, E.E. (1998). How expert clinicians’ prototypes of an ideal treatment correlate with outcome in psychodynamic and cognitivebehavioral therapy. Psychotherapy Research 8:71–83. Busch, F. (2010). Distinguishing psychoanalysis from psychotherapy. International Journal of Psychoanalysis 91:23–34. Caligor, E., Hilsenroth, M.J., Devlin, M., Rutherford, B.R., Terry, M., & Roose, S.P. (2012). Will patients accept randomization to psychoanalysis? A feasibility study. Journal of the American Psychoanalytic Association 60:337–360. Fleiss, J.L. (1981). Statistical Methods for Rates and Proportions. 2nd ed. New York: Wiley. Gill, M.M. (1954). Psychoanalysis and exploratory psychotherapy. Journal of the American Psychoanalytic Association 2:771–797. Hilsenroth, M.J., Blagys, M.D., Ackerman, S.J., Bonge, D.R., & Blais, M.A. (2005). Measuring psychodynamic-interpersonal and cognitive techniques: Development of the comparative psychotherapy process scale. Psychotherapy: Theory, Research, Practice, Training 42:340–356. Huber, D., Henrich, G., Clarkin, J.F., & Klug, G. (2013). Psychoanalytic versus psychodynamic therapy for depression: A three-year follow-up study. Psychiatry 76:132–149. Jones, E.E., & Pulos, S.M. (1993). Comparing the process in psychodynamic and cognitive-behavioral therapies. Journal of Consulting & Clinical Psychology 61:306–316.
NP26
Downloaded from apa.sagepub.com at UNIV MASSACHUSETTS BOSTON on September 29, 2015
Poster Summaries
Kendall, P.C., Holmbeck, G., & Verduin, T. (2004). Methodology, design, and evaluation in psychotherapy research. In Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change: Fifth Edition, ed. M.J. Lambert. New York: Wiley, pp. 16–43. Leichsenring, F., Salzer, S., Hilsenroth, M.J., Leibing, E., Leweke, F., & Rabung, S. (2011). Treatment integrity: An unresolved issue in psychotherapy research. Current Psychiatry Reviews 7:313–321. McCarthy, K.S., & Barber, J.P. (2009). The multitheoretical list of therapeutic interventions (MULTI): Initial report. Psychotherapy Research 19:96– 113. Melanie Ratzek IPU Berlin Stromstrasse 3 10555 Berlin GERMANY E-mail: [email protected]
F e a r o f P s yc h i c a n d P h y s i c a l D e s t r u c t i o n : T h e R e l at i o n o f C h i l d Ab u s e , N e g at i v e L i f e E v e n t s , a n d A d u lt At ta c h m e n t t o A n n i h i l at i o n A n x i e t y
Caroline Schiek-Gamble and Marvin Hurvich (Department of Psychology, Long Island University, Brooklyn) DOI: 10.1177/0003065115594785
Anxiety is an evolutionary construct, our understanding of which has grown significantly. Research has shown that 15.7 million people living in the United States are affected by anxiety in any given year and that as many as 30 million suffer from anxiety at one point during their life (Lépin 2013). Different manifestations of anxiety indicate its nature and often severity. For instance, Spielberger, Gorsuch, and Lushene (1970), describing anxiety as commonly experienced, distinguished state anxiety from trait anxiety. However, people often experience a more severe, more
Downloaded from apa.sagepub.com at UNIV MASSACHUSETTS BOSTON on September 29, 2015
NP27
