(This section is organized chronologically, from the beginning of our work to the present time.)
How effective is psychoanalytic treatment? How does it compare with other treatments? Moreover, what specific things can psychotherapists do or say, to achieve a better outcome for their patients? What kind of conversation is needed between the participants? How can we more effectively measure the results of psychotherapy, as revealed in the actual process taking place between patient and therapist? In this early article, we offer some guiding principles in answering these important questions.
In early years of research, we studied the work of prominent psychoanalyst Charles Brenner, in order to understand the nature of the effects of various psychoanalytic interventions. How do certain kinds of speech by a therapist immediately affect the patient, and how can we understand these interventions in the overall process?
Waldron, S., Scharf, R.D., Hurst, D, Firestein, S.K. & Burton, A. (2004a). What happens in a psychoanalysis: a view through the lens of the Analytic Process Scales (APS). Int. J. Psychoanal., 85: 443-466.
Relying on past experiences in clinical psychoanalysis, we begin to think about classifying different kinds of speaking that occur in the therapeutic process. Some kinds of speech are uttered by the psychoanalyst in order to foster a relationship with the patient in which the patient’s difficulties can be clarified, elaborated, and interpreted as meaningful. Meanwhile, the patient speaks in order to express his feelings and reflect upon them in accordance with desires, wishes, fears, and internal conflicts. Moreover, patient and psychoanalyst respond to one another interactively and more or less collaboratively at various points in time. We therefore articulated scales to measure these moments in the conversation between therapist and patient, and we called these the Analytic Process Scales (APS). By focusing on three recorded psychoanalyses, we describe ways to understand the conversation that develops between patient and therapist with little, undue bias or jargon. We aim to provide a relatively consistent and parsimonious way to think about how best to intervene at particular times in conversation with our patients.
Waldron, S., Scharf, R.D., Crouse, J., Firestein, S.K. Burton, A., & Hurst, D. (2004b). Saying the right thing at the right time: a view through the lens of the Analytic Process Scales (APS). Psychoanalytic Quarterly,73: 1079-1125.
At nearly the same time as we developed the aforementioned Analytic Process Scales, we considered what made a given type of intervention function better in creating meaningful and helpful conversations with our patients. Psychoanalysts make tactful and well-timed statements to help describe a patient’s thoughts and feelings in relation to one another, how a patient protects him/herself from difficult feelings or feelings that seem inconsistent with one another, and how these emotional processes relate to the patient’s past significant relationships and affect the patient’s ongoing relationship with the psychoanalyst. The quality of what the therapist says has a positive impact upon the patient, whether an interpretation, encouragement of elaboration, or a supportive remark. We found that if these efforts are tactful and well-timed in the context of the conversation between the two of them, the patient responds with greater collaboration and a higher likelihood of successfully managing his/her emotional difficulties.
Waldron, S. & Helm, F. (2004). Psychodynamic features of two cognitive-behavioural and one psychodynamic treatment compared using the Analytic Process Scales. Canadian Journal of Psychoanalysis: 12, 346-368.
Although in our research group, we are trained primarily as psychoanalysts, we became increasingly interested in similarities and differences between successful psychoanalytic treatments and successes in other kinds of therapy. Although cognitive-behavioral therapy is often contrasted with psychoanalytic therapy, therapists of both kinds speak in similar ways in conversation with their patients (despite using distinct terminology). A close study of recorded psychotherapy could help clarify similarities and differences between these kinds of treatments. Using our recently-devised method of classifying different kinds of interventions in treatment, we describe a way of understanding the conversations between patients and therapists in three, theoretically-distinct kinds of treatment.
Our research group at the Psychoanalytic Research Consortium (PRC) has access to a large store of clinical data in the form of recorded treatment conversations between patients and psychoanalysts. We decided to make use of this by focusing in on one treatment in particular. With this, more in-depth case study, we attempted to understand what kinds of interventions were helpful for the patient overall, to articulate how to gauge improvement over the course of long-term treatment, and to describe how a collaborative process between patient and therapist developed over time. We also discussed how our empirical study of conversations between patient and therapist from the outside can help inform the therapist’s assessment and opinion of what is happening in the conversation from the inside. Our hope is that thinking this way may constructively affect the practice and education of future psychotherapists of any kind.
Because of practical differences between therapists in how they understand what is helpful to patients, we focused more specifically on the question of how to measure and understand improvement in the patient over the course of treatment. We made use of a pre-existing personality rating scale that we could apply to our storehouse of data: a large sample of recorded conversations between patients and psychoanalysts in treatment. We started with a scale called the Shedler-Westen Assessment of Personality (i.e. the SWAP-200), which we could apply to the recorded conversations. From this, we derived two additional scales that we felt captured important aspects of improvement in the way patients’ personalities are organized and in their ability to manage emotional difficulties. The Personality Health Index (PHI) is an overall measure of psychological and adaptive personality health that can be used to assess long-term treatment, while the RADIO scale includes assessment of five specific aspects of mental functioning that can change over the course of long-term treatment. The RADIO acronym lists the five components of useful, potential change in long-term psychotherapy (Reality testing, Affect regulation, Defense organization, Identity integration, and Object relations).
Waldron, S., Gazzillo, F., Genova, F., and Lingiardi, V. (2013). Relational and classical elements in psychoanalyses: an empirical study with case illustrations. Psychoanalytic Psychology, 30, 567-600.
Particularly since the 1980s, psychoanalysts have made important distinctions between an earlier, Freudian or ‘classical’ approach by psychoanalysts, and a later-developing approach, often described as ‘relational’ psychoanalysis. We examined two recorded treatments, which occurred about two decades apart from one another. The earlier one could be characterized as more classical, and the other as more relational. Relational thinking has highlighted the importance of the interaction between patient and therapist in conversation, and specific conversational elements that are distinct from a sum of the contributions of each participant in the conversation. These concern cultivating an openness, intimacy, and warmth in the relationship between patient and therapist, and a focus on both participants feeling understood in this context, rather than the illuminating or understanding of a hidden insight about the patient. Using these, new Dynamic Interaction Scales (DIS), our previously-reported Analytic Process Scales (APS), and our assessments of overall improvements in personality health (PHI), we understood sometimes-subtle, but important differences in the process of developing a helpful conversation between patient and analyst in each case, and meaningful differences in results of relational and classical psychoanalytic approaches.
Gazzillo, F, Waldron, S., Genova, F., Angeloni, F., Ristucci, C. and Lingiardi, V. (2014). An empirical investigation of analytic process: contrasting a good and poor outcome case. Psychotherapy, 51: 270-282.
We became increasingly interested in a more specific understanding of which kinds of conversations lead to a good treatment outcome, and which kinds of conversations do not. We examined two recorded psychoanalyses that began relatively similarly, in terms of various characteristics of patient and psychoanalyst, one of which ended with the patient feeling much better, and the other with a more negative outcome. By studying a few of the earliest sessions in each treatment using our rating scales, we identified specific aspects of the conversation between patient and therapist that could foreshadow a more or less collaborative relationship between the two and therefore lead to a more helpful result for patients with emotional difficulties.
Waldron, S., Gazzillo, F. & Stukenberg, K. Ph.D. (2015).Do the Processes of Psychoanalytic Work Lead to Benefit? Studies by the APS Research Group and the Psychoanalytic Research Consortium, Psychoanalytic Inquiry, 35:sup1, 169-184, DOI: 10.1080/07351690.2015.987602.
We attempted to synthesize our knowledge from the PRC’s store of recorded conversations between psychoanalysts and patients, the various scales we had developed to describe the therapeutic process (APS, DIS) and measure how it can be helpful (PHI, RADIO), and the prior research studies we had already completed with these measurement instruments. By articulating a history of how we came to develop our thinking, we hope to inspire others to contribute to further understanding of psychotherapy, via recording of psychotherapy and psychoanalysis, or further research using our and other research instruments.
Gazzillo, F., Waldron, S., Gorman, B. S., Stukenberg, K., Genova, F., Ristucci, C., Faccini, F., Mazza, C. (2018). The Components of Psychoanalysis: Factor Analyses of Process Measures of 27 Fully Recorded Psychoanalyses. Psychoanalytic Psychology, 35: 184-195.
Prior research by the PRC had been limited by the study of only a few recorded treatments at a time. We therefore attempted to further our understanding of the psychotherapeutic process, by studying recordings of 27 fully-recorded psychoanalytic treatments (i.e. 540 sessions), using the APS and DIS scales. By looking at how various parts of these scales correlated with one another in all of the treatments, we discovered several over-arching factors that are worthy of further attention and study. Some concerned contributions to the therapeutic conversation centered on the patient (Patient’s Experience of the World, Patient’s Experience of the Therapist, Patient’s Dynamic Competence), some concerned contributions centered on the therapist (Therapist’s Relational Competence, Therapist’s Dynamic Competence), and one was oriented on the quality of interaction between the two (Quality of Interaction). This broader understanding of changing aspects of the conversation developing between patient and therapist may help us understand more general, overarching changes over the course of long-term treatment, not losing the forest for the trees.
Waldron, S., Stukenberg, K., Gazzillo, F. & Gorman, B. Advancing Psychoanalysis through Research. In Progress in Psychoanalysis: Envisioning the Future of the Profession. Axelrod, S., Naso, R. & Rosenberg, L. Eds. Routledge, 2018.
[From the conclusion:] “Over the next ten years, if we are able to increase the collection of recorded analyses and to study them closely, we will be able to ask more and more fine-grained questions about which kinds of communications at what points in an analysis help which patients achieve deeper engagement… We can expect that close study of many more recorded analyses, and comparing the processes of the analytic work with the outcomes both at the end of each treatment, and in post-analytic lives, should lead to many improvements in our theories of technique, in relation to the particularities of each individual patient, each individual analytic couple, and differences in the analysts themselves. As we help tease out the factors that contribute to better treatment outcomes, we hope that psychoanalytic and psychodynamic techniques will improve. This improvement will lead to increased attention to aspects of analytic processes in training and practice, and also to increased confidence in their importance as a result of further accumulated evidence.”