DETAILED DESCRIPTION OF THE ANALYTIC PROCESS SCALES (APS)

 

We here describe the thirty-one analyst and patient variables of our scales. The inter-rater reliability of the 25 variables already evaluated has been good, and are detailed in appendix 2. For each of the more than a dozen variables scored for each patient and analyst segment, the rater must choose one of five Likert-type scale points, ranging from “not at all” to “strongly.” These points are illustrated here only for the first variable. Although a segment is usually either an analyst segment or a patient segment, the interchange between patient and analyst is sometimes so rapid and interrelated that it is necessary to group a series of patient and analyst statements together as a “joint segment,” and rate it for both the patient and analyst variables. Variations in the pattern and frequency of joint segments from one patient-analyst pair to another will no doubt turn out to reflect important differences in the process.

The Analyst Scale

Analyst interventions can be categorized according to their type, aim, characteristics, and quality. Many previous attempts to assess therapies fell short of their goals because they neglected to assess the variety of therapist behaviors. The APS avoids this pitfall by using multiple dimensions and many segments to rate the variety of therapist activity in each session.

Types of intervention

While achieving a high degree of reliability by using four types of intervention, we believe we have categorized all interventions in a meaningful way. Much of the difficulty in categorizing interventions in previous studies was the result of not recognizing that an intervention is often a blend of types. Accordingly, we measure the degree to which a given intervention meets the criteria for each type. By allowing raters to indicate the mixed nature of interventions, instead of forcing them to make inappropriate “either-or” choices, we have removed a major source of unreliability.

A method for identifying types of interventions should be generally useful to researchers in psychoanalysis and allied psychotherapies, because it enables them to compare the results following a certain type of intervention in a particular case with what happens when other types of interventions are made in the same case.

When evaluating the quality of an intervention, it is important to know its type. A good interpretation will usually have more potential impact than a good encouragement to elaborate. A therapy which exclusively uses encouragement of elaboration may well have less power to induce change than one which also uses interpretation. The type and quality of analytic work needs to be characterized in relation to one another, rather than in isolation.

  1. To what degree does the analyst encourage elaboration?

(0) (1) (2) (3) (4)

not at all moderately strongly

  1. To what degree does the analyst clarify?
  2. To what degree does the analyst make an interpretation?
  3. To what degree does the analyst provide support?

This last category includes support, guidance, advice, praise, education and other strategies to enhance the patient’s work.

Aims of the intervention

Here we score for features which are central to an analytic approach: addressing the patient’s conflicts, defenses as manifest in the session (commonly characterized as resistance), manifestations of transference, and degree to which the intervention has a developmental focus. Finally we assess the presence of self-esteem issues. We assess whether libidinal or aggressive aspects of conflict are addressed, to give further information about the analytic work.

  1. To what degree does the analyst’s intervention address the patient’s defenses in action during the analytic session?
  2. To what degree does the analyst’s intervention draw attention to the patient’s reactions to the analyst or the analytic situation?
  3. To what degree does the analyst focus on the patient’s conflicts?
  4. To what degree does the analyst address romantic or sexual issues? (NEW VARIABLE)
  5. To what degree does the analyst address aggressive or hostile issues? (NEW VARIABLE)
  6. To what degree does the analyst specifically demonstrate a developmental focus?
  7. To what degree does the analyst’s intervention concentrate on self-esteem issues?

Other characteristics of the intervention

Interventions have many interesting aspects in addition to those already described, and we reviewed a number of these while developing our instrument. Only two, however, appeared to have enough general relevance and to be sufficiently variable from segment to segment to warrant inclusion. The first is how confrontational the analyst is in a particular segment. We are interested in finding out how emphatic or insistent the analyst is in asking the patient to address emotional issues. Our clinical impression has been that the ability to pursue an issue is extremely important. Often, a treatment will fail if the analyst does not confront the patient with major character pathologies and with how his or her usual ways of solving conflicts lead to unfavorable consequences. The second variable in this subgroup assesses how much the analyst’s feelings contribute to the intervention. Past research has provided support for the idea that there is a potential for important change when the analyst has good emotional contact with the patient. The significance of these characteristics–whether they help or hinder the analytic process in given instances–needs empirical study. In order to facilitate this, we further break down the nature of the analyst’s expressed feeling into amicable or hostile feelings.

  1. To what degree is the analyst’s intervention confronting?
  2. To what degree do the feelings of the analyst contribute to or shape the intervention?
  3. To what degree does the analyst’s intervention appear to be amicable? (NEW VARIABLE)
  4. To what degree does the analyst’s intervention appear to be hostile? (NEW VARIABLE)

Quality of the intervention

We assess the quality of an intervention from two somewhat distinct perspectives: how well the analyst’s remark follows the emotional focus expressed in the most recent patient material, and how globally good the intervention is overall. Naturally, our effort to define a “good intervention” is at the heart of our coding instrument.

  1. To what degree does the analyst’s remark follow the patient’s immediate emotional focus during the previous segment?
  2. To what degree is this a good intervention?

Would a particular type and content of intervention be desirable at this time?

At the end of each patient segment, before the raters know whether an intervention was made, we ask them whether they thought an intervention would be desirable at that point and, if so, of what type and content. Not surprisingly, while our raters agreed about the types of interventions actually made by the analyst, they did not agree about what type should be made. This accords with the great complexity of the possibilities for intervention present in any treatment situation, and with the creative and personal elements which lead a particular analyst to intervene in a particular way at a particular time. These desirability scales serve as a measure of the raters’ technical viewpoints, and provide an opportunity for discourse analysis of the proposed interventions. The scores also serve as a baseline with which to contrast the interventions actually made by the treating analyst. For example, in one case we studied, the analyst made many more interventions and interpretations than any of the raters thought desirable.

THE PATIENT SCALE

The patient variables assess aspects of the patient’s contribution to the analytic process. The first eight variables measure participation and collaboration from two points of view: whether the characteristic being rated is expressed in relation to some aspect of the analyst or analytic situation, or in relation to all other aspects of the patient’s life. This division permits a delineation of the varying roles of transference in psychotherapeutic or psychoanalytic treatments. The differing activity of patients treated by differently trained practitioners, patients with varied suitability for insight-oriented treatment, and of patients at various points of a given treatment process can be studied.

The first two variables measure the patient’s effectiveness in conveying experiences to the rater (and presumably to the treating analyst) which help to delineate the patient’s conflicts. This scale taps into the patient’s ability or inclination to free associate, is related to the emotional freedom of the patient and her/his therapeutic or helping alliance with the analyst. We are interested in the way the patient engages in the analytic work. The second pair of variables concern self-reflection, measuring what has been described as the self-analytic function, a core concern of psychoanalysis. This scale also reflects the degree of self organization and the ability to maintain a therapeutic ego split. The third pair of variables measure the role of feelings as a central dimension of conflict. Effective treatment requires the substantial engagement of the patient’s feelings. And a good outcome must result in important changes in the feelings, particularly the negative and unpleasant ones.

How clearly does the patient convey experiences which permit the rater to delineate his or her conflicts

  1. . in regard to the analyst or analytic situation?
  2. in all respects other than the analyst or analytic situation?

To what degree does the patient maintain self-reflection in a way that promotes self-understanding

  1. in regard to the analyst or analytic situation?
  2. in all respects other than the analyst or analytic situation?

To what degree do the patient’s feelings contribute to the rater’s understanding him or her

  1. in regard to the analyst or analytic situation?
  2. in all respects other than the analyst or analytic situation?

What kinds of feelings does the patient express or show?

  1. To what degree does the patient express romantic or sexual issues? (NEW VARIABLE)
  2. To what degree does the patient express aggressive or hostile issues? (NEW VARIABLE)

One influence leading patients to become effectively involved in treatment is the realization that much of their suffering arises from their own attitudes and feelings. Assessing whether the patient sees his or her own experiences and emotions as sources of difficulty, and therefore grasps the need to change them, gives us an ongoing indicator of an important source of motivation for engaging in treatment.

  1. To what degree does the patient recognize that his or her experiences and emotions cause problems?

The next variable evaluates the extent to which the patient connects current life problems to experiences from the developmental years. Such connections can, of course, help the patient avoid dealing with immediate emotional issues by shifting the focus and responsibility to others in the past. Nevertheless, analysts generally find that, for most patients, gaining a developmental perspective on their problems is a part of increased awareness and mastery. This variable corresponds to the analyst variable #8. We can examine how the references to development of each of the pair dovetail with one another.

  1. To what degree do connections to the patient’s development appear?

As with the previous variable, the self-esteem variable has a corresponding analyst variable, so we are able to compare the relationship between a patient’s expressed problems with self-esteem and the analyst’s activity addressing these same problems. We already have preliminary findings showing that when the analyst’s interventions more closely respond to the patient’s own self-esteem issues, the more successful is the treatment tends to be more successful.

  1. To what degree do issues of self-esteem appear?

The last three variables evaluate the quality of the patient’s analytic work. First, we are interested in the patient’s productivity in response to the analyst’s intervention. This scale is an important counterpoint to the thirteenth analyst scale, where we assess the degree to which a good intervention was made. Our preliminary data have indicated that good interventions generate useful responses when there is a proper “fit” between patient and analyst, and that the absence of this relationship in the early stages of treatment may well predict an unsuccessful outcome. The next scale measures the degree to which the patient’s material psychologically continues a direction which is similar to the previous material. We have observed clinically that when a patient stays with a meaningful issue, both the patient and the therapist are more likely to do something useful with it. The concluding scale evaluates the patient’s overall productivity in the segment. Once again, the global productivity of the patient serves as a direct means of estimating the quality of his or her contribution to the treatment during each session. We anticipate that these three measures will substantially contribute to the prediction of outcome.

  1. To what degree is the patient identifiably responding to the analyst’s intervention in a useful manner? (For example, by indicating comprehension, developing related affects, integrating the intervention with other known material, or elaborating new material. Include what could be called productive negation, the patient’s disagreeing with the analyst in a way that promotes the analytic process).
  2. To what degree is the material in this segment psychologically continuous with issues that have appeared earlier in this and in previous segments?
  3. What is the degree of the patient’s overall analytic productivity in this segment?

We have found many suggestive correlations between the variables assessing the analyst’s interventions and those measuring the patient’s productivity, whether responding to the analyst or due to the patient’s momentum. In a sample of hours from three cases, the patient’s scores for productivity in a given segment directly reflected the quality of the intervention in the preceding segment, as well as the degree that core analytic features were present in the prior intervention: that is, how much the intervention clarified, interpreted, and addressed defenses, conflicts and self-esteem issues. The higher the analyst scored on these variables, the higher the patient then scored for productivity. We also observed that the overall quality of the process (that is, the quality of both the patient’s and the analyst’s work) correlated with how well the patient responded to the analyst’s interventions. The better the process, the stronger the responsiveness. If the correlation between these findings is confirmed in a larger sample it will constitute, we believe, the first systematic demonstration of how importance well attuned analytic interventions are for the patient! And if there is a substantial therapeutic result in some cases which do not conform to this general pattern, we stand to learn much about when an ordinary analytic approach is beneficial, and when a different approach might be more helpful.

APPENDIX 2

APS VARIABLES WITH INTER-RATER RELIABILITY,

AND PSYCHOTHERAPY PROCESS Q-SET ITEMS

TO BE COMPARED WITH APS VARIABLES
Alphas are listed below following each APS variable which has been evaluated. We use the “alpha” correlational statistic, one of the varieties of intra-class correlation, as our working estimate of reliability between our three different raters. Two sessions were rated with a total of 31 patient segments and 25 therapist segments, using the most recent version of our rating instrument. Two of the raters had been participating from the beginning, and a third was rating for the first time. The median alpha for the thirteen analyst scales tested was .70, with only one scale falling significantly below .50 (this scale had insufficient variation of scores in this sample, and a definitional ambiguity since corrected). The median alpha for the twelve patient scales tested was .77, with none below .60. The new rater’s scores were not distinguishable from those of the two experienced raters. The alpha statistic (using SPSS software) allows us to easily study individual differences between raters as well. In this particular sample, the lower alphas were for variables with a restricted range of scores. Additional samples are in the process of being rated currently as an additional check on the reliability of all variables.

The Psychotherapy Process Q-set was developed by Enrico Jones and co-workers (See Jones, E. E.& Windholz, M. (1990) The Psychoanalytic Case Study. Toward a Method for Systematic Inquiry. Journal of the American Psychoanalytic Association: 39, 985-1016.) In this appendix, APS variables are in uppercase and related Q-items in lowercase. There are 31 Q-items to compare with the therapist variables (27 applying to therapist only, and 4 applying both to therapist and patient). There are 37 Q-items to compare with the patient variables (32 applying to the patient only, and 5 applying to both patient and therapist). Some Q items are the reciprocals of the APS variables and the correlation should be negative. Q-items are occasionally listed under more than one APS variable. It is clear upon inspection that they vary as to the closeness of fit with the APS variables: some are phrased very much like the APS variables and others are merely conceptually related. And some evidently reflect the activity of both analyst and patient, and some are ambiguous as to which individual is being rated.

 

  1. TO WHAT DEGREE DOES THE ANALYST ENCOURAGE ELABORATION? ( = .75)

Therapist asks for more information or elaboration

Therapist remarks are aimed at facilitating patient speech

 

  1. TO WHAT DEGREE DOES THE ANALYST CLARIFY? ( = .52)

Therapist clarifies, restates, or rephrases patient’s communication

Therapist identifies a recurrent theme in the patient’s experience or conduct

Therapist comments on changes in the patient’s mood or affect

 

  1. TO WHAT DEGREE DOES THE ANALYST MAKE AN INTERPRETATION? ( = .77)

Therapist interprets warded-off or unconscious wishes, feelings or ideas

The patient’s behavior during the hour is reformulated by the therapist in a way not explicitly recognized previously

Therapist presents an experience or event in a different perspective

 

  1. TO WHAT DEGREE DOES THE ANALYST PROVIDE SUPPORT? ( = .49)

Therapist adopts a supportive stance

Therapist gives explicit advice and guidance (vs. defers even when pressed to do so)

Therapist is directly reassuring (n.b. place an uncharacteristic direction if therapist tends to refrain from providing direct reassurance)

Therapist suggests the meaning of others behavior

Therapist acts to strengthen defenses

 

  1. TO WHAT DEGREE DOES THE ANALYST’S INTERVENTION ADDRESS THE PATIENT’S DEFENSES IN ACTION DURING THE ANALYTIC SESSION? ( = .70)

Therapist points out patient’s use of defensive maneuvers, e.g. undoing, denial

 

  1. TO WHAT DEGREE DOES THE ANALYST’S INTERVENTION DRAW ATTENTION TO THE PATIENT’S REACTIONS TO THE ANALYST OR

THE ANALYTIC SITUATION? ( = .71)

Therapist draws connections between the therapeutic relationship and other relationships

The therapy relationship is a focus of discussion

 

  1. TO WHAT DEGREE DOES THE ANALYST FOCUS ON

THE PATIENT’S CONFLICTS? ( = .82)

 

  1. TO WHAT DEGREE DOES THE ANALYST SPECIFICALLY DEMONSTRATE A DEVELOPMENTAL FOCUS? ( = .72)

Patient’s feelings or perceptions are linked to situations or behavior of the past

Memories or reconstructions of infancy and childhood are topics of discussion

 

  1. TO WHAT DEGREE DOES THE ANALYST’S INTERVENTION CONCENTRATE ON SELF-ESTEEM ISSUES? ( = .37)

Self-image is a focus of discussion

 

  1. TO WHAT DEGREE IS THE ANALYST’S INTERVENTION CONFRONTING? ( = .66)

Therapist challenges the patient’s view (vs. validates the patient’s perceptions)

Therapist draws attention to feelings regarded by the patient as unacceptable (e.g. anger, envy, or excitement)

 

  1. TO WHAT DEGREE DO THE FEELINGS OF THE ANALYST CONTRIBUTE TO OR SHAPE THE INTERVENTION? ( = .79)

Therapist’s own emotional conflicts intrude into the relationship

Therapist self-discloses

There is an erotic quality to the therapy relationship

(reciprocal) Therapist is distant, aloof (vs. Responsive and affectively involved)

(reciprocal) Therapist is neutral

 

  1. TO WHAT DEGREE DOES THE ANALYST’S REMARK FOLLOW THE PATIENT’S IMMEDIATE EMOTIONAL FOCUS DURING THE PREVIOUS SEGMENT? ( = .63)

Therapist is sensitive to the patient’s feelings, attuned to the patient; empathetic

(reciprocal) Therapist is tactless

(reciprocal) Therapist condescends to, or patronizes the patient

 

  1. TO WHAT DEGREE IS THIS A GOOD INTERVENTION? ( = .67)

Therapist accurately perceives the therapeutic process

Therapist communicates with patient in a clear, coherent style

(reciprocal) Therapist is tactless

(reciprocal) Therapist condescends to, or patronizes the patient

 

HOW CLEARLY DOES THE PATIENT CONVEY EXPERIENCES WHICH PERMIT THE RATER TO DELINEATE HIS OR HER CONFLICTS?

  1. In regard to the analyst or analytic situation? ( = .61)

The therapy relationship is a focus of discussion

  1. In all respects other than the analyst or analytic situation? ( = .82)

Patient brings up significant issues and material

Patient understands the nature of therapy and what is expected

Patient talks of feelings about being close to or needing someone

Sexual feelings and experiences are discussed

Patient has cathartic experience (n.b. rate as uncharacteristic if emotional expression is not followed by a sense of relief)

 

TO WHAT DEGREE DOES THE PATIENT MAINTAIN SELF-REFLECTION IN A WAY THAT PROMOTES SELF-UNDERSTANDING

  1. In regard to the analyst or analytic situation? ( = .77)

The therapy relationship is a focus of discussion

 

  1. In all respects other than the analyst or analytic situation? ( = .89)

Patient is introspective, readily explores inner thoughts and feelings

(reciprocal) Patient resists examining thoughts, reactions or motivations related to problems

(reciprocal) Patient blames others, or external forces, for difficulties

Patient is clear and organized in self-expression

 

TO WHAT DEGREE DO THE PATIENT’S FEELINGS CONTRIBUTE TO THE RATER’S UNDERSTANDING HIM OR HER

  1. In regard to the analyst or analytic situation? ( = .67)

Patient is concerned about what therapist thinks of him or her.

Patient is concerned or conflicted about his or her dependence on the therapist (vs. comfortable with dependency, or wanting dependency)

Patient is provocative, tests limits of the therapy relationship. (n.b. placement toward uncharacteristic end implies patient behaves in a compliant manner)

Patient experiences ambivalent or conflicted feelings about the therapist

Patient seeks therapist’s approval, affection, or sympathy

Patient verbalizes negative feelings (e.g., criticism, hostility) toward the therapist (vs. makes approving or admiring remarks)

Patient seeks greater intimacy with the therapist

Patient does not feel understood by therapist

(reciprocal) Patient discusses experiences as if distant from his or her feelings. (n.b. rate as neutral if affect and import are apparent but modulated.

 

  1. In all respects other than the analyst or analytic situation? ( = .87)

Patient talks of feelings about being close to or needing someone

Patient experiences discomforting or troublesome (painful) affect

Patient is animated or excited

Patient feels shy and embarrassed (vs. unselfconscious and assured)

Patient expresses angry or aggressive feeling

Patient struggles to control feelings or impulses

Patient experiences discomforting or troublesome (painful) affect

Patient feels wary or suspicious (vs. trusting and secure)

(reciprocal) Patient discusses experiences as if distant from his or her feelings. (n.b. rate as neutral if affect and import are apparent but modulated.

 

  1. TO WHAT DEGREE DOES THE PATIENT RECOGNIZE THAT HIS OR HER EXPERIENCES AND EMOTIONS CAUSE PROBLEMS? ( = .87)

(reciprocal) Patient resists examining thoughts, reactions or motivations related to problems

(reciprocal) Patient blames others, or external forces, for difficulties

Patient has cathartic experience (n.b. rate as uncharacteristic of emotional expression is not followed by a sense of relief)

 

  1. TO WHAT DEGREE DO CONNECTIONS TO THE PATIENT’S DEVELOPMENT

APPEAR? ( = .80)

Memories or reconstructions of infancy and childhood are topics of discussion

Patient’s feelings or perceptions are linked to situations or behavior of the past

 

  1. TO WHAT DEGREE DO ISSUES OF SELF-ESTEEM APPEAR? ( = .77)

Patient feels inadequate or inferior (vs. effective and superior)

Patient is self-accusatory; expresses shame or guilt

Patient feels sad or depressed (vs. joyful or cheerful)

Self-image is a focus of discussion

 

  1. TO WHAT DEGREE IS THE PATIENT IDENTIFIABLY RESPONDING TO THE ANALYST’S INTERVENTION IN A USEFUL MANNER? (For example, by indicating comprehension, developing related affects, integrating the intervention with other known material, or elaborating new material. Include what could be called productive negation, the patient’s disagreeing with the analyst in a way that promotes the analytic process). ( = .61)

(reciprocal) Patient has difficulty understanding the therapist’s comments

(reciprocal) Patient resists examining thoughts, reactions or motivations related to problems

Patient has cathartic experience (n.b. rate as uncharacteristic of emotional expression is not followed by a sense of relief)

Patient achieves a new understanding or insight

 

  1. TO WHAT DEGREE IS THE MATERIAL IN THIS SEGMENT PSYCHOLOGICALLY CONTINUOUS WITH ISSUES THAT HAVE APPEARED EARLIER IN THIS AND IN PREVIOUS SEGMENTS? ( = .70)

Patient is clear and organized in self-expression

 

  1. WHAT IS THE DEGREE OF THE PATIENT’S OVERALL ANALYTIC PRODUCTIVITY IN THIS SEGMENT? ( = .70)

Patient brings up significant issues and material

Patient achieves a new understanding or insight

Patient has cathartic experience (n.b. rate as uncharacteristic of emotional expression is not followed by a sense of relief)

(reciprocal) Patient resists examining thoughts, reactions or motivations related to problems

(reciprocal) Patient blames others, or external forces, for difficulties

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