MOA and psychotherapy process Sanders et al.

Object representation quality, therapeutic alliance, and psychotherapy process Avihay Sanders, PhD Mark Hilsenroth, PhD J. Christopher Fowler, PhD

This is the first study to demonstrate the existence of a relationship between patient pretreatment object relations functioning as measured by the Mutuality of Autonomy (MOA) Scale and patient-rated therapeutic alliance. Specifically, MOA scores were related to a patient-rated alliance Bond score (lower, more adaptive object-relations representations were associated with a stronger alliance). In addition, higher MOA scores indicating more malevolent object relations were related to a greater use of psychodynamic techniques. Specific psychodynamic techniques focused on the patient’s relationships with the therapist as well as cyclical patterns in actions, feelings, and experiences. Implications for clinical practice and future research are discussed. (Bulletin of the Menninger Clinic, 78[3], 197–227)

Object relations are the internal representations, or schema, of self, others, and their interaction. Klein (1946/1996, 1952) posited that the experience of the mother as both gratifying and frustrating during infancy leads to representations of the object as “good” or “bad,” and these representations are the focus of the infant’s thought and experience. Winnicott (1958) emphasized the importance of the “holding environment” in which an empathic response of the caregivers to the infant’s needs leads to

Avihay Sanders and Mark Hilsenroth are at The Derner Institute of Advanced Psychological Studies. Adelphi University, Garden City, New York. J. Christopher Fowler is at The Menninger Clinic and the Baylor College of Medicine, Houston, Texas. Correspondence may be sent to Avihay Sanders, MA, at The Derner Institute of Advanced Psychological Studies, Adelphi University, 1 South Ave., P.O. Box 701, Garden City, NY 11530; e-mail: [email protected] (Copyright © 2014 The Menninger Foundation)

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a sense of security and trust of others, and the experience that anxiety can be not only tolerated but also ameliorated. Fairbairn (1952) claimed that infants who experience early attachments as mostly neglectful will end up seeking similar types of relationships because in these types of relationships, they feel connected, and Guntrip (1968) believed that differentiated internal representations of self and others lead to the development of the capacity to relate well to others. Object relations have been shown to predict important variables, including personality development, psychopathology, and style of relating to and interacting with others, including therapists (Blatt, 2008). We will begin by reviewing studies that demonstrate ways in which object relations are related to psychotherapy outcomes and process variables. We will then propose two hypotheses that aim to add to the current body of knowledge. Object relations and psychotherapy attendance Ackerman, Hilsenroth, Clemence, Weatherill, and Fowler (2000) examined the relationship between object relations and therapy attendance among patients with a personality disorder diagnosis who received psychodynamic, insight-oriented therapy in an outpatient community clinic. Using the Mutuality of Autonomy Scale (MOA), a scale derived from the Rorschach Inkblot Method (Rorschach, 1921/1951), they found that those patients who demonstrated elevated levels of pathology attended more therapy sessions. Hilsenroth, Handler, Toman, and Padawer (1995) used other Rorschach variables to assess object relations and their relationship to attendance and found that patients who remained longer in therapy perceived relationships to be more aggressive and less cooperative in nature compared with patients who terminated prematurely. Similar findings emerged in other studies. Horner and Diamond (1996), who focused on female patients with a borderline personality disorder, found that patients who perceived objects to have undifferentiated quality were more likely to complete treatment, and Blatt and colleagues (1994) found that young adult inpatients with disturbed perceptions of objects relations tended to stay longer 198

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in therapy. A recent study (Fowler & DeFife, 2012) conducted in an inpatient unit utilizing a different measure of object relations, the Object Relations Scale: Global Rating Method (SCORS-G; Hilsenroth, Stein, & Pinsker-Aspen, 2007), also demonstrated that patients with higher expectations of affective malevolence in relationships stayed longer in therapy compared to patients with lower expectations of malevolence. These studies consistently demonstrate across different settings and measures that pathological object relations tend to positively relate with one measure of therapy outcomes (attendance). Object relations and the therapeutic alliance The therapeutic alliance captures the quality of the working relationship between therapist and patient and is a key element of the therapeutic process related to outcome (Flückiger, Del Re, Wampold, Symonds, & Horvath, 2012; Horvath, Del Re, Flückiger, & Symonds, 2011). The importance of the alliance, especially in the initial stages of therapy, has led to the exploration of what personality variables might predict the capacity of patients to establish a strong working relationship with their therapists. The capacity to establish mutuality in relationships along with trust appears to play a major role in the alliance (Barber, Connolly, Crits-Christoph, Gladis, & Siqueland, 2000; Kokotovic & Tracey, 1990; Moras & Strupp, 1982; Piper et al., 1991; Ryan & Cicchetti, 1985). Moreover, attachment style and object relations have been found to be predictors of alliance quality (Eames & Roth, 2000; Hilliard, Henry, & Strupp, 2000; Joyce & Piper, 1998; Pinsker-Aspen, Stein, & Hilsenroth, 2007). For example, Pinsker-Aspen et al. (2007) found that patients with less complexity, differentiation, and integration in representations of self and others as captured by their early memories reported a weaker alliance with their therapists compared with patients who had more complexity and integration in their representations. This finding appears to be consistent with findings in an earlier study in which object relations as captured by early memories accounted for 30% of the variance in alliance scores (Ryan & Cicchetti, 1985). Moreover, Pinsker-Aspen et al.

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(2007) discovered that two variables, a more fragmented sense of self (i.e., greater pathology) combined with a strong desire/ need for relationships, were the strongest predictors of patientrated alliance. Also, prior research suggests that an attachment schema facilitates the development of a positive alliance overall and a stronger patient-therapist bond specifically. For example, Eames and Roth (2000) found attachment security to be associated with a stronger patient-therapist bond early in treatment. Thus, patient attachment representations may be particularly important for shaping the bond that develops between client and therapist, as models for attachment are highly influential in regulating emotional closeness, dependence, and trust (Bowlby, 1988; Diener & Monroe, 2011; Mikulincer & Shaver, 2007). Mallinckrodt, Daly, and Chia-Chih (2009) suggested that clients with more adaptive attachment representations are better able to share and explore openly and honestly with the therapist, “strengthening the bond aspect of the working alliance” (p. 241). Another line of inquiry that seems to be relevant for this study is the exploration of specific techniques that therapists use when working with patients with various levels of pathology in terms of their object relations. In a recent study, Mullin and Hilsenroth (2014) reported that when working with patients with less adaptive object relations functioning in terms of affective quality of object representations, self-esteem, and coherence of self, therapists on average used more psychodynamic techniques as opposed to cognitive-behavioral techniques. They also reported that a specific psychodynamic technique—“The therapist addresses the patient’s avoidance of important topics and shifts in mood”—correlated with less adaptive affective quality of object representations, emotional investment in relationships, understanding of social causality, self-esteem, coherence of self, and overall object relations functioning as measured by the SCORSG.

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The current study In the current study, we aim to add to the current literature on the relationship between object relations and psychotherapy process. Specifically, we will focus on the relationship between a measure of object relations, the Mutuality of Autonomy Scale (MOA; Urist, 1977; Urist & Shill, 1982), and its relationship with patient-rated therapeutic alliance and therapists’ tendency to utilize specific interventions (psychodynamic vs. cognitivebehavioral). We chose to focus on the MOA because it provides a way to assess patients’ ability to relate based on a sense of individual autonomy, expectations regarding benevolence and malevolence in relationships, and the capacity to establish mutuality. This specific component of object relations appears to be of special interest when considering the quality of the working relationship between a therapist and a patient and the various ways in which they choose consciously and unconsciously to engage with each other. Consistent with previous studies’ findings (Pinsker-Aspen et al., 2007; Ryan & Cicchetti, 1985) that patients with less complexity, differentiation, and integration in representations of self and others as captured by their early memories reported weaker alliance with their therapists, we hypothesize that those patients who expect more malevolence and experience fears of engulfment in relationships will report weaker alliance with their therapists. In addition, given prior research on attachment representations (Diener & Monroe, 2011; Mallinckrodt et al., 2009; Mikulincer & Shaver, 2007), we were interested in examining the relationship between attachment representations and the specific component of the alliance, the client-therapist bond. We expected more adaptive MOA scores to be associated with greater levels of client-therapist bond. Finally, informed by Mullin and Hilsenroth (2014), we hypothesize that those therapists working with patients who expect more malevolence and experience fears of engulfment in relationships will utilize more psychodynamic techniques as opposed to cognitive-behavioral techniques.

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This is the first study to explore the relationship between the Rorschach, patient- rated alliance, and the utilization of specific clinical techniques. Method Participants All the participants in this study (N = 69) were patients admitted to a psychodynamic psychotherapy treatment team at a university-based community outpatient clinic (Hilsenroth, 2007). Cases were assigned to treatment practitioners and clinicians in an ecologically valid manner based on real-world issues regarding aspects of clinician availability, caseload, and so on. Moreover, patients were accepted for treatment regardless of disorder or comorbidity. In this sample, 50 patients were female and 19 were male. The mean age for this sample was 28.20 years (SD = 9.90). Table 1 displays the demographic information as well as the distribution of patients’ primary axes I and II diagnoses for the entire sample in accordance with the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSMIV; American Psychiatric Association, 1994; based on the psychological assessment process described in what follows). All 69 patients in this study received a DSM-IV Axis I diagnosis, and 38 patients received an Axis II diagnosis (cluster A = 3, cluster B = 22, cluster C = 13). In addition, 18 patients were assessed to have subclinical but prominent Axis II features or traits (cluster A = 4, cluster B = 3, cluster C = 11). Thus, this sample consisted of primarily mood-disordered patients with relational problems manifested in either Axis II personality disorders or subclinical traits/features of Axis II personality disorders (see Table 1). Therapists Clinicians in the study were 26 advanced doctoral students (13 men and 13 women) enrolled in a clinical PhD program approved by the American Psychological Association (APA). Each clinician received a minimum of 3.5 hours of supervision per week (1.5 hours of individual supervision and 2 hours of group supervision) on the Therapeutic Model of Assessment (TMA; 202

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MOA and psychotherapy process Table 1. Demographic information of sample (N = 69) Variable

n (%)

Gender Male Female Mean age (SD)

50 (27) 19 (73) 28.20 (9.90)

Marital Status Single

45 (65.20)

Married

16 (23.20)

Divorced

7 (10.10)

Widowed

1 (1.40)

Primary Axis I diagnosis Adjustment disorder Anxiety disorder Eating disorder Impulse Mood disorder

9 (13) 10 (14.50) 3 (4.30) 1 (1.40) 34 (49.30)

Substance-related disorder

1 (1.40)

V code relational problems

11 (15.90)

Axis II diagnosis

38 (55)

Axis II trait/features

18 (26)

Pretreatment Psychiatric Severity Mean BSI-GSI (SD)

1.06 (0.60)

Mean GAF (SD)

60.11 (5.90)

Finn & Tonsager, 1997; Hilsenroth, 2007), clinical interventions, organization of collaborative feedback, psychodynamic therapy, and review of videotaped case material. Individual and group supervision focused heavily on the review of the videotaped case material and technical interventions. All clinicians were trained in psychodynamic psychotherapy by using guidelines delineated by Book (1998), Luborsky (1984), McCullough et al. (2003), and Wachtel (1993), as well as selected readings on psychological assessment, psychodynamic theory, and psy-

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chodynamic psychotherapy (for a more detailed description of this training process, see Hilsenroth, DeFife, Blagys, & Ackerman, 2006). Treatment Examiners provided psychological evaluations using the TMA model (Finn & Tonsager, 1997; Hilsenroth, 2007), which attempts to optimize the evaluation phase with its utilization of a multimethod assessment (i.e., interview, self-report, performance tasks, and free-response measures). The TMA model focuses on examiners developing and maintaining empathic connections with patients, the patients’ factors contributing to the maintenance of life problems, and the examiner’s and patients’ collaboration to define individualized treatment goals and tasks, as well as the examiner sharing and exploring assessment results with patients. The TMA used in this study consisted of four steps, including three meetings between the patient and the clinician totaling approximately 4.5 hours, and one patient appointment to complete a battery of self-report measures. The three meetings included (1) a semistructured diagnostic interview (Westen & Muderrisoglu, 2003, 2006); (2) an interview follow-up; and (3) a collaborative feedback session. During the collaborative feedback session, there was an emphasis on the prominent interpersonal/intrapersonal themes derived from the testing results, the patient–therapist interaction, and the factors that contribute to the maintenance of life problems, as well as the opportunity to explore these new understandings and apply them to their current problems in living. The patient and the clinician also reviewed a socialization interview, developed by Luborsky (1984) on what to expect in psychodynamic psychotherapy, and the patient’s and the clinician’s roles during formal treatment. The interview highlighted the relational focus of the therapeutic process, which enables the patient to become aware of issues that were not known before the start of psychotherapy, and outlined potential outcomes (both positive and negative) of this new insight. Finally, the clinician and the patient worked together to develop treatment goals and negotiate an explicit

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treatment frame (i.e., scheduling session times, frequency of treatment sessions, missed sessions and payment plan). In all cases, the clinician who carried out the psychological assessment was also the clinician who conducted the formal psychotherapy sessions. Individual psychotherapy consisted of once-or twiceweekly sessions of short-term psychodynamic psychotherapy organized, aided, and informed (but not prescribed) by the technical guidelines delineated in the treatment manuals detailed earlier. The key features of the short-term psychodynamic psychotherapy treatment model utilized in these sessions included (1) focus on affect and the expression of emotion; (2) exploration of attempts to avoid topics or engage in activities that may hinder the progress of therapy; (3) identification of patterns in actions, thoughts, feelings, experiences, and relationships; (4) emphasis on past experiences; (5) focus on interpersonal experiences; (6) emphasis on the therapeutic relationship; and (7) exploration of wishes, dreams, or fantasies (Blagys & Hilsenroth, 2000). In addition to these areas of treatment focus, relational patterns, case presentations, and symptoms were conceptualized in the context of cyclical patterns (Book, 1998; Luborsky, 1984; McCullough et al., 2003; Wachtel, 1993). The method described by Safran and Muran (2000) was used to identify and repair treatment ruptures as they occurred in the process of psychotherapy. Treatment was open ended in length rather than of a fixed duration. Whenever a termination date was set, this became a frequent area of intervention as issues related to the termination were often linked to key interpersonal, affective, and thought patterns prominent in that patient’s treatment. Treatment goals were first explored during the assessment feedback session, and a formal treatment plan was reviewed with each patient early in the course of psychotherapy and was subsequently reviewed at regular intervals for changes, additions, or deletions. Reassessment of patient functioning on a standard battery of outcome measures as well as process ratings were completed by patients and therapists immediately after selected sessions prior to these review points. Regarding these ratings, patients were informed both verbally and in writing that

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their therapist would not have access to their responses on any psychotherapy process measure (e.g., alliance, session process). Also, all sessions of these treatments were videotaped, not just the sessions during in which reassessment ratings were completed. Patient process and independent technique ratings for this study were collected at the same two points in time within the first 3 months of therapy (post-TMA assessment), predominantly the third and the ninth sessions. We chose to use these two early treatment sessions because they are standard process assessment points in our programmatic study of psychodynamic psychotherapy. In addition, we chose to use the average process ratings across these two early treatment sessions in order to provide greater psychometric stability for the variables under investigation (as opposed to scores from only a single session). All patients included in the present analyses attended a minimum of nine sessions and completed at least the ninth session reassessment battery. The mean number of sessions attended by these 69 patients was 28 (SD = 18.66); the median number of sessions was 21. Assessment measures Rorschach Inkblot Test. The Rorschach Inkblot Test was the key assessment measure used in this study, administered and scored using the Exner Comprehensive System (Exner, 2003; Exner & Erdberg, 1993). Two advanced doctoral students enrolled in an APA-approved clinical PhD program underwent supervised training in the Exner Rorschach Scoring System in both a year-long class and a structured assessment practicum. Additional training was provided to obtain criterion-based interrater reliability for Rorschach scoring (for a description of this process, see Hilsenroth, Charnas, Zodan, & Streiner, 2007). Following the guidelines of the Training Manual for Rorschach Interrater Reliability, the raters reached criterion-based interrater reliability for Rorschach scoring (Hilsenroth & Charnas, 2007). They achieved good (>.60) to excellent (≥.75) interrater reliability on all Rorschach variables during this training. These

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raters were blind to the diagnoses of the patients, as well as to the hypotheses and goals of the current study. Mutuality of Autonomy Scale (MOA). The MOA (Urist, 1977; Urist & Shill, 1982) is a scale derived from the Rorschach Inkblot Method (Rorschach, 1921/1951), and it is the most widely utilized scoring system to measure quality and structure of implicit mental representations, indicating various levels or stages of relatedness based on a sense of individual autonomy and the capacity to establish mutuality (Fowler & Erdberg, 2006). Every Rorschach response that included a relationship (stated or clearly implied) between animate (people or animals) or inanimate objects was scored on a 7-point Likert scale (see the Appendix for detailed scoring instructions). Scores represent a range from healthy relationships marked by capacity for mutuality and respect of the other’s autonomy (scores of 1–2) to unhealthy and increasingly malevolent relationships with lack of boundaries (scores of 5–7). MOA summary scores included in the present study are: MOA Mean (i.e., the prototypical representation); MOA Low (i.e., the single healthiest, most adaptive representation in the protocol); MOA High (i.e., the single most pathological representation in the protocol); and MOA Pathological score (MOA-Path; i.e., the total of all scale points 5, 6, and 7 that occur in a given protocol). The reliability and clinical validity of the MOA has been well established (Bombel, 2006; Bombel, Mihura, & Meyer, 2009), including a recent meta-analysis confirming the criterion validity of these scores as measures of object relations (Monroe, Diener, Fowler, Sexton, & Hilsenroth, 2013). The MOA data utilized in the current study were rated by trained external raters (Hilsenroth & Charnas, 2007) who have demonstrated the ability to reliably rate these individual techniques in a good to excellent range (intraclass correlation coefficient [ICC] = .60–.75; Fleiss, 1981). ICC scores for specific MOA variables in the protocols used in this study were as follows: MOA-Mean = .97, MOAPath = .98, MOA-Low = .89, MOA-High = .93.

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Comparative Psychotherapy Process Scale (CPPS). The CPPS is based on the findings of two empirical reviews of the comparative psychotherapy process literature (Blagys & Hilsenroth, 2000, 2002). It is a brief descriptive measure designed to assess therapist activity and techniques used and occurring during the therapeutic hour. Based on these reviews, a list of interventions was developed from the empirical literature that represents characteristic features of psychodynamic-interpersonal (PI; defined broadly to include psychodynamic, psychodynamic-interpersonal, and interpersonal therapies) and cognitive-behavioral (CB; defined broadly to include cognitive, cognitive-behavioral, and behavioral therapies) treatments. The measure consists of 20 randomly ordered techniques rated on a 7-point Likert scale ranging from 0 (not at all characteristic), 2 (somewhat characteristic), 4 (characteristic), to 6 (extremely characteristic). Ten statements are characteristic of PI interventions, and 10 statements are characteristic of CB interventions. These interventions can then be organized into two scales: One measures PI features (CPPS-PI) and one measures CB features (CPPS-CB). The CPPS may be completed by a patient, a therapist, or an external rater. The reliability and clinical validity of the CPPS have been well established (Hilsenroth, Ackerman, & Blagys, 2001; Hilsenroth, Ackerman, Blagys, Baity, & Mooney, 2003; Hilsenroth, Blagys, Ackerman, Bonge, & Blais, 2005; Hilsenroth et al., 2006; Hilsenroth, DeFife, Blake, & Cromer, 2007; Thompson-Brenner & Westen, 2005; Westen, Novotny, & Thompson-Brenner, 2004). We have reported (Hilsenroth et al., 2005; Stein, Pesale, Slavin, & Hilsenroth, 2010) on the excellent interrater reliability and internal consistency of the CPPS, as well as significant results on several separate reliability and validity analyses conducted across several different contexts and samples. The CPPS data we utilized in the current study were derived from these reports according to procedures detailed there, and were rated by trained external raters who have demonstrated the ability to reliably rate these individual techniques in the good (ICC 0.60–0.74; Fleiss, 1981) to excellent (ICC 0.75; Fleiss, 1981) range. In addition, all Spearman–Brown corrected mean ICCs for the individual CPPS-PI and CPPS-CB techniques were also

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in the excellent range (and thus may be examined individually), as were the ICCs for the CPPS-PI and CPPS-CB scale scores. In addition, for the current sample, the mean CPPS-PI scale score for the rated sessions was 3.36 (SD = .66), and the mean CPPSCB scale score was 1.15 (SD = .41), representing a significant level of adherence to a psychodynamic treatment model, t(68) = 24.39, p < .0001. Combined Alliance Short Form–Patient version (CASF-P). The CASF-P (Hatcher & Barends, 1996) is designed to assess the therapeutic alliance from the perspective of the patient. Patients in this sample completed the measure immediately following a session (third or fourth) early in psychotherapy. They were informed both verbally and in writing at the top of the CASF-P that their responses would not be shared with their clinician. In all cases, the patient ratings of the CASF-P were from the same session early in treatment that was rated for therapist technique using the CPPS. The CASF-P was developed through a factor analysis of three major alliance measures: the California Psychotherapy Alliance Scales (CALPAS; Gaston & Marmar, 1991), the Working Alliance Inventory (WAI; Horvath & Greenberg, 1989), and the Helping Alliance Questionnaire (Alexander & Luborsky, 1986; Luborsky, Crits-Christoph, Alexander, Margolis, & Cohen, 1983). The factor analysis was conducted on the responses of 231 patients from a community outpatient clinic. The CASF-P consists of 20 items rated on a 7-point Likert scale ranging from 1 (never) to 7 (always). The CASF-P provides a total score for therapeutic alliance as well as four subscale scores: (1) Confident Collaboration (CC; e.g., “What I am doing in therapy gives me new ways of looking at my problems”), (2) Goals and Tasks (GT; e.g., “My therapist and I are working toward mutually agreed upon goals”), (3) Bond (e.g., “My therapist and I trust each other”) and (4) Idealized Therapist (IT; e.g., “How much do you disagree with your therapist about what issues are most important to work on during these sessions?” [reverse scored]). Coefficient alphas for the four CASF subscales have been reported as ranging from .84 to .93 (Ackerman, Hilsenroth, Baity,

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& Blagyes, 2000; Hatcher & Barends, 1996; Hilsenroth, Peters, & Ackerman, 2004). Procedure Advanced graduate students enrolled in an APA-approved clinical psychology PhD program conducted the psychological assessment, feedback sessions, and ratings of DSM-IV diagnoses. All clinicians have completed graduate course training in descriptive psychopathology and were supervised by a licensed PhD clinical psychologist with several years of applied experience. Each clinician also received a minimum of 3.5 hours of supervision per week (1.5 hour individually, and 2 hours in a group treatment team meeting) on the therapeutic assessment model/process, scoring/interpretation of assessment measures, clinical interventions, and presentation/organization of collaborative feedback. Participants were asked to complete the Rorschach as part of the assessment process. The administration and scoring of all the Rorschach protocols followed the procedures delineated by Exner (Exner, 2003; Exner & Erdberg, 1993). Rorschach protocols were then independently scored by two raters (for a description, see Hilsenroth, Charnas, Zodan, & Streiner, 2007). Notably, these raters did not administer any of the assessment measures, nor did they act as external raters when diagnosing any participant. The raters scored all the protocols in the project and were blind to any patient diagnoses. Only after all protocols were scored did a separate researcher organize the data set with the Rorschach and psychotherapy variables. The Rorschach protocols used in this study were collected between 1997 and 2009 from patient assessment as part of programmatic psychotherapy process and outcome research (Hilsenroth, 2007). Results To assess the relationship between object relations, therapeutic alliance, and therapist technique, we conducted Pearson two-

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MOA and psychotherapy process Table 2. Relationship between MOA variables with alliance and technique early in treatment (N = 69) M (SD)

CASF-P (Total)

CASF-P (Bond)

CPPS-PI

CPPS-CB

MOA-L

1.61 (.57)

r = .13

r = .08

r = −.05

r = −.10

p = .27

p = .47

p = .66

p = .38

MOA-H

5.16 (1.52)

r = −.16

r = −.23

r = .28

r = .10

p = .19

p = .06

p = .01

p = .37

MOA-Mean

3.03 (.83)

r = −.13

r = −.24

r = .20

r = .04

p = .28

p = .04

p = .08

p = .69

MOA-Path

1.45 (1.42)

r = −.20

r = −.22

r = .23

r = .00

p = .10

p = .06

p = .05

p = .94

MOA Variable

tailed correlations (r) and report specific p values. Contrary to our initial hypothesis, we did not find statistically significant relationships between the MOA variables and patient-rated therapeutic alliance, Total score (CASF-P; see Table 2). However, the relationship between the four MOA variables and the alliance Bond subscale revealed a statistically significant correlation between MOA-Mean and the therapeutic alliance Bond subscale (r = −.24, p = .04). In other words, patients with more malevolent object relations reported greater difficulty in establishing a bond with their therapists. Examining the relationship between object relations and therapist technique, there was one significant finding and two findings that approached significance (see Table 2). Beginning with the PI subscale, the higher, more maladaptive object relations score on the MOA-High was significantly related to a higher incidence of psychodynamic techniques (r = .28, p = .01). Similarly, the relationship between less adaptive object relations as measured by MOA-Mean and MOA-Path and a higher incidence of psychodynamic techniques approached statistical significance (r = .20, p = .08; r = .23, p = .05, respectively). There was no statistically significant relationship between MOA-Low and the PI subscale, and no statistically significant relationship between all MOA variables and the CB subscale. In other words, more disturbed object relations as measured by the MOA related positively to higher utilization of psychodynamic Vol. 78, No. 3 (Summer 2014)

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techniques, but did not relate to utilization of cognitive-behavioral techniques. Given these findings between MOA-High, MOA-Mean, and MOA-Path with CPPS-PI, we also conducted post-hoc exploratory analyses between these three MOA variables and the 10 individual CPPS-PI items to determine which specific techniques were most related to this patient-moderating characteristic. MOA-High had a significant and positive correlation with the following item: “The therapist identifies recurrent patterns in patient’s actions, feelings, and experiences” (#14, r = .251, p = .03); MOA-Path had a significant and positive correlation with two items: “The therapist focuses attention on similarities among the patient’s relationships repeated over time, settings, or people” and “The therapist focuses discussion on the relationship between the therapist and patient” (#5, r = .24, p = .04; #7, r = .25, p = .03, respectively). In other words, specific psychodynamic techniques that focused on the patient’s relationships with the therapist as well as cyclical patterns in actions, feelings, and experiences were used significantly more often in the treatment of patients who displayed more malevolent object relations on the Rorschach. Discussion As mentioned earlier, this is the first study that examined the relationship between the Rorschach, patient-rated alliance, and the utilization of specific clinical techniques. Our hypotheses were partially confirmed. Although MOA variables were not significantly related to patient-rated total alliance score, analysis revealed a statistically significant relationship between MOA-Mean and the alliance Bond subscale. This suggests that patients with more maladaptive average levels of object relations pathology found it challenging to establish a bond with their therapists. As predicted, we found that disturbed object relations as measured by MOA variables correlated positively with higher utilization of psychodynamic techniques, but not with utilization of cognitive-behavioral techniques. Exploratory analysis revealed that specific psychodynamic techniques uti212

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lized with patients who displayed higher levels of object relations pathology focused on these patients’ relationships with the therapist as well as cyclical patterns in actions, feelings, and experiences. Closer examination of the studies (Pinsker-Aspen et al., 2007; Ryan & Cicchetti, 1985) that informed our hypothesis regarding alliance reveals the existence of differences between the current study and previous ones that might account for our results. Ryan and Cicchetti (1985) used an observer measure of alliance that focused on patient expressiveness and capacity to collaborate. Our measure of alliance captures the capacity to collaborate, agreement about tasks and goals, ability for mutual trust (Bond), and agreement with the therapist. In addition, Ryan and Cicchetti used external raters and therapists’ alliance scores while we used patients’ alliance scores because they were found to be slightly more consistent in predicting outcome measures (Horvath & Bedi, 2001; Martin, Garske, & Davis, 2000). Pinsker-Aspen et al. (2007) used a different measure of object relations, the Social Cognition and Object Relations Scale (SCORS; Westen, 1995), which determines ratings based on narratives of early memories. Pinsker-Aspen et al. found that only one measure of the SCORS, complexity of object representations (which assesses the ability to differentiate between self and others), was related to patient-rated total alliance score, Confident Collaboration, Goals and Tasks, but not to Bond and Idealized Therapist. Researchers focusing on object relations (Huprich & Greenberg, 2003; Stricker & Gooen Piels, 2004) suggest that different measures of object relations tap into different dimensions of this concept, and they advise others to tailor a specific measure to a specific research question. The MOA scale utilized in this study focuses on autonomy, mutuality, and malevolence in representations of objects. Pinsker-Aspen et al. did not find a significant relationship between expectations of malevolent affect in relationships and alliance scores, while we did not find a relationship between MOA and alliance total score and subscale scores with the exception of the Bond score. It is possible that predominant representations captured in the MOA are more related to the capacity to trust others and their intentions, and

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as such the MOA is scale related to the Bond subscale, which measures the ability to trust the therapist. This finding is consistent with previous attachment research, which indicates that representations of others are related to the capacity to establish trust and closeness (Bowlby, 1988; Diener & Monroe, 2011; Mallinckrodt et al., 2009; Mikulincer & Shaver, 2007). In addition, Pinsker et al. (2007), and Ryan and Cicchetti (1985) assessed object relations as they appear in an early memories task, while we assessed them as they appear in Rorschach responses. One can argue that early memories represent material that is more accessible to patients; however, Rorschach responses represent material that is less close to the surface of consciousness and as such might represent a different quality of object representations. The finding that establishing trust was challenging for those patients struggling with mutuality is consistent with studies showing that the capacity to establish mutuality in relationships along with trust plays a major role in the alliance (Barber et al., 2000; Kokotovic & Tracey, 1990; Moras & Strupp, 1982; Piper et al., 1991; Ryan & Cicchetti, 1985). Our findings regarding higher utilization of psychodynamic rather than cognitive-behavioral techniques with patients displaying higher levels of disturbance in terms of their object relations are consistent with previous findings using a subsample with a different measure of object relations rated using narratives expressed during psychotherapy (Mullin & Hilsenroth, 2014). Exploratory analysis reveals that specific techniques used represent a combination of interpretive interventions (e.g., “The therapist focuses attention on similarities among the patient’s relationships repeated over time, settings, or people” and “The therapist identifies recurrent patterns in the patient’s actions, feelings, and experiences”) and experiential/expressive interventions (e.g., “The therapist focuses discussion on the relationship between the therapist and patient”). This range of interventions is also consistent with a study that demonstrated therapists’ use of these interventions with patients from an overlapping sample with a pattern of maladaptive defensive functioning (Siefert, Hilsenroth, Weinberger, Blagys, & Ackerman, 2006). In light of

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the findings regarding difficulties establishing a bond with these patients, it seems fitting to focus on patterns in relationships in general with a special attention to the relationship with the therapist (for verbatim clinical examples see: Carsky, 2013; Diener & Pierson, 2013; Lingiardi, 2013; Slavin-Mulford, 2013; Stricker, 2013). Clinical implications The current study suggests that careful assessment of patients, including the use of projective techniques, provides meaningful data that can inform treatment planning and process, a finding consistent with previous studies that focused on projective measures, including measures of object relations (Alpher, Henry, & Strupp, 1990; Piper et al., 1991). It is worth noting that careful selection of object relations measures as suggested by others (Huprich & Greenberg, 2003; Stricker & Gooen Piels, 2004) will allow identification of specific components of the therapy process, including alliance that might be affected. Our findings indicate that the MOA scale might inform the techniques that therapists choose to utilize and the need to focus on a specific component of the alliance (e.g., Bond). Previous studies (Ackerman, Hilsenroth, Clemence, et al., 2000; Mullin & Hilsenroth, 2014; Siefert et al., 2006) also suggest that perhaps patients with disturbed object relations might create a “pull” for the utilization of certain psychodynamic techniques. Based on the current study, it appears that difficulties with mutuality and expectations of malevolence might call for a variety of interpretive and experiential techniques where patient and therapist engage in an exploration of relationships, including the therapeutic relationship. The correlational nature of the present study does not allow us to pinpoint whether the pull for the utilization of these techniques originates from the patient, the therapist, or both. Fairbairn (1952) suggested that patients with a history of neglect and disturbed patterns of attachment recreate similar relationships in the present because they feel connected in this type of relationship. Lower levels of trust in the therapeutic relationship reported by patients in our

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sample, along with elevated levels of pathology in their object representations, suggest that patients’ struggle with trust poses a challenge to successful treatment that should be addressed by therapists. Addressing this component of the relationship as therapists did in our sample creates a potential for a corrective emotional experience that can be generalized to other relationships (for verbatim clinical examples see: Carsky, 2013; Diener & Pierson, 2013; Lingiardi, 2013; Slavin-Mulford, 2013; Stricker, 2013). Pesale and Hilsenroth (2009), again using an overlapping sample with the current data, found that greater use of psychodynamic exploratory techniques allows patients to experience their sessions with greater depth, as valuable and meaningful. Limitations and future research First, a sample of outpatient community clinic clients presenting with mild to moderate psychopathology limits our ability to generalize the findings to clients with more severe pathology in other settings. Second, therapists were graduate students in a training program with a psychodynamic orientation providing short-term psychodynamic therapy with supervision that focused on specific techniques. It is worth noting that using experienced therapists, including therapists from different therapeutic orientations, might have resulted in different findings, especially in terms of utilization of cognitive-behavioral techniques. Finally, therapists in this study utilized the TMA model; therefore, therapists who utilize an assessment model with significantly different attributes might result in different findings with regard to alliance and techniques. Future research could expand and enrich our findings in different ways. We measured techniques and alliance early in treatment (third and ninth sessions); thus, future studies are needed to measure these variables along with levels of object relations at different time points, including termination and posttermination. Examining object relations, alliance, and techniques with patients with more severe levels of pathology and different types of pathology (e.g., Axis I, Axis II, and specific disorders), and with therapists with different levels of experience and therapeutic orientations can also expand current findings. In addition, measuring levels of ob216

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ject relations and alliance at different times can help to clarify whether the specific techniques utilized by therapists resulted in improvement in pathology and alliance. Finally, careful analysis of moment-to-moment interactions during sessions can help clinicians and researchers to examine whether the use of these specific techniques was initiated by patients, by therapists, or both.

Appendix Rorschach Mutuality of Autonomy (MOA) Scale1 The Mutuality of Autonomy on the Rorschach developed by Urist (1977) is a scale based on a developmental model that defines various levels or stages of relatedness based on a sense of individual autonomy and the capacity to establish mutuality. Rorschach responses are scored on this 7-point scale if a relationship is stated or clearly implied between animate (people or animals) or inanimate objects. A response is scored even if there is only one animate or inanimate object, but a relationship is clearly implied. Thus, an object that is a consequence of an action (a flag torn in half, a moth shot by a shotgun or a squashed cat) or has the potential for an action on another object (a nuclear explosion) is scored in this analysis of Rorschach responses. Urist (1977) defines 7 scale points for the quality of relations between objects as follows: Scale Point 1. Figures are engaged in some relationship or activity where they are together and involved with each other in such a way that conveys a reciprocal acknowledgment of their respective individuality. The image contains explicit or implicit reference to the fact that the figures are separate and autonomous and involved with each other in a way that recognizes or expresses a sense of mutuality in the relationship (e.g., “two 1. Excerpted with permission from pp. 10–12 in Hilsenroth, M. J., & Charnas, J. W. (2007). Training manual for Rorschach interrater reliability (2nd ed.). Unpublished manuscript, The Derner Institute of Advanced Psychological Studies, Adelphi University, Garden City, NY. This training manual is freely available for download at http:// www.ror-scan.com/RorschachTrainingManual2ndEd.pdf. Vol. 78, No. 3 (Summer 2014)

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bears toasting each other, clinking glasses;” “two people having a heated political argument”). At this level, the unique contributions of each individual object to the mutual interaction need to be emphasized. Thus, “two people dancing” would receive a 2, because there is no stated emphasis on the mutuality of their endeavor. To receive a score of 1, a response must have a special emphasis on the mutual but separate nature of a dyadic interaction. Each object must maintain its unique identity and contribu­tion to a relationship in which both objects are mutually engaged. Such as: “Two people doing a synchronized dance, like in a ritual ceremony for a wedding” would be scored a 1. This response indicates that the two people are well differentiated, as well as the need to be aware of the others placement and activity with relation to their own. Scale Point 2. Figures are engaged together in some relationship or parallel activity, but there is no stated emphasis of mutuality. There is no stated emphasis or highlighting of mutuality, nor on the other hand is there any sense that this dimension is compromised in any way within the relationship. Despite the lack of direct emphasis on mutuality, the response still conveys the potential for mutuality in the relationship (e.g., “two women doing their laundry”). A response is scored 2 when the integrity of the objects is maintained and there is a potential or an implicit capacity of mutuality, independent of the degree of logic, irrationality, or absurdity to the relationship. Responses such as “Two people eating” or “Animals climbing a tree” convey a sense of autonomy, but without the indication of an explicit recognition of the other’s independence. Both scales scores 1 & 2 are similar to Cooperative movement responses found in the Comprehensive System; however, inanimate movement is also scored in the Mutuality of Autonomy scale. Finally, it is important to note that two objects simply fighting are scored a 2. Only if one figure has an unequal, controlling, or imbalanced advantage over the other is such a response coded a higher score. Scale Point 3. Figures are dependent on each other but without an internal sense of capacity to sustain themselves; leaning

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or hanging on one another. The objects do not “stand on their own two feet;” rather, they each require some degree of external support or direction. The objects lack a sense of being firmly self‑supporting (e.g., “two penguins leaning against a telephone pole”). Scale point 3 reflects dependent relationships in which one or both objects are reliant on the other for stability. Responses such as, “A friendly animal up here reaching down helping these bears up the side of a mountain” or “Two baby birds being fed by the mother bird” clearly indicates that objects do not function independently without external support. Scale Point 4. One figure is seen as the reflection, imprint, or symmetrical image of another. The relationship between objects conveys a sense that the definition or stability of an object exists only insofar as it is an extension or reflection of another. Shadows, footprints, and so on would be included here, as well as responses of Siamese twins or two animals joined together. Scale point 4 captures the prototypic mirroring object relationship and often reveals an emerging loss of autonomy between figures where one object is seen as a reflection, an imprint or a mimetic of the other. Responses such as, “Siamese twins because they are connected at the waist,” “a wolverine looking at its reflection in the water,” or “A butler starring in the mirror and that’s his reflection” imply that relationships between objects exists only in so far as it is seen as a reflection or an extension of the other. Other examples include, “a smeared fingerprint” and “a shadow cast by a figure walking by.” Any Reflection response found in the Comprehensive System would be scored a 4, or perhaps greater if the content was decidedly violent and destructive. Scale Point 5. The nature of the relationship between figures is characterized by malevolent control of one figure by another. Themes of influencing, controlling, or casting spells may be present. One figure, either literally or figuratively, may be in the clutches of another. Such themes portray a severe imbalance in the mutuality of relations between figures. On the one hand, some figures seem powerless and helpless, while at the same time, others seem controlling and omnipotent. Themes of violation of an object’s integrity through domination, malevolence

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and sense of one object controlled or forcibly influenced by another are often present in these types of responses (e.g., puppets on a string, witches casting a spell on someone). Scale Point 6. There is a severe imbalance in the mutuality of relations between figures in decidedly destructive terms, physical damage to the object is present (e.g., a door that has just been kicked in, a flag torn in half, a moth shot by a shotgun, a squashed cat or a bat impaled by a tree). Two figures more than simply fighting—such as a figure being tortured by another, or an object being strangled by another—are considered to reflect a serious attack on the autonomy of the object. Literal physical damage is seen as having occurred. Similarly, included here are relationships portrayed as parasitic, where a gain by one figure results by definition in the diminution or destruction of another (e.g., a leech sucking up this man’s blood, two people feasting after killing this animal, a compression hammer splitting through rock). Many, but not all, Morbid content responses found in the Comprehensive System would be scored a 6 or 7. Scale Point 7. Relationships are characterized by an overpowering enveloping force. Figures are seen as swallowed up, devoured, or generally overwhelmed by forces completely beyond their control. Forces are described as overpowering, malevolent, and perhaps even psychotic. Frequently, the force is described as existing outside of the relationship between two figures or objects, underscoring the massiveness of the force, its overwhelming nature, and the complete passivity and helplessness of the objects or figures involved (e.g., something being consumed by fire, destruction from some cataclysmic disaster (natural or manmade), or God’s wrath). Scale point 7 reflects the complete loss of autonomy of one or more figures by overpowering diffuse and enveloping force (e.g., a tornado, volcano, or nuclear explosion hurtling its debris everywhere). Here the loss of autonomy results in more than just the death or physical damage of the object (as in Scale point 6) but rather its annihilation, such as that found in the following response: “An evil fog enveloping this frog. The poison is dissolving it.”

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Calculating and Summarizing MOA Data Each response may only receive one MOA score. When there is the potential for two possible scores to be assigned (e.g., Two Siamese twins doing an intricate waltz), the higher (more maladaptive) score is always given (e.g., 4 over a 1 in the example above). MOA-R: The number of responses where a MOA score occurs in the protocol (e.g., 1, 2, 2, 4, 5, 6 = 6). MOA-Sum: The raw sum of all MOA scores found in a protocol (e.g., 1+2+2+4+5+6 = 15). MOA-Mean: MOA-Sum divided by MOA-R (e.g., 15/6 = 2.5) MOA-Low: The MOA score representing the single lowest (most adaptive) score found in the protocol (e.g., 1). MOA-High: The MOA score representing the single highest (least adaptive) score found in the protocol (e.g., 6). MOA-Path: The sum of all Scale points 5, 6, & 7 that occur on a given protocol (e.g., 5, 6 = 2).

References Ackerman, S., Hilsenroth, M., Baity, M., & Blagyes, M. (2000). Interaction of therapeutic process and alliance during psychological assessment. Journal of Personality Assessment, 75, 82–109. Ackerman, S. J., Hilsenroth, M. J., Clemence, A. J., Weatherill, R., & Fowler, J. C. (2000). The effects of social cognition and object representation on psychotherapy continuation. Bulletin of the Menninger Clinic, 64(3), 386–408. Alexander, L. B., & Luborksy, L. (1986). The Penn Helping Alliance Scales. In L. S. Greenberg & W. M. Pinsof (Eds.), The psychotherapeutic process: A research handbook (pp. 325–366). New York, NY: Guilford Press. Alpher, V. S., Henry, W. P., & Strupp, H. H. (1990). Dynamic factors in patient assessment and prediction of change in short-term dynamic psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 27(3), 350–361. doi:10.1037/0033-3204.27.3.350 American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

Vol. 78, No. 3 (Summer 2014)

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Sanders et al. Barber, J., Connolly, M., Crits-Christoph, P., Gladis, L., & Siqueland, L. (2000). Alliance predicts patients’ outcome beyond in-treatment change in symptoms. Journal of Counseling Psychology, 68(6), 1027–1032. Blagys, M. D., & Hilsenroth, M. J. (2000). Distinctive features of shortterm psychodynamic–interpersonal psychotherapy: A review of the comparative psychotherapy process literature. Clinical Psychology: Science and Practice, 7, 167–188. Blagys, M. D., & Hilsenroth, M. J. (2002). Distinctive activities of cognitive–behavioral therapy: A review of the comparative psychotherapy process literature. Clinical Psychology Review, 22, 671–706. Blatt, S. J. (2008). Polarities of experience: Relatedness and self-definition in personality development, psychopathology, and the therapeutic process. Washington, DC: American Psychological Association. doi: 10.1037/11749-000 Blatt, S. J., Ford, R. Q., Berman, W. H., Jr., Cook, B., Cramer, P., & Robins, C. E. (1994). Therapeutic change: An object relations perspective. New York, NY: Plenum Press. Bombel, G. A. (2006). A meta-analysis of interrater scoring reliability for the Rorschach Mutuality of Autonomy (MOA) Scale. Unpublished master’s thesis, University of Toledo, Toledo, OH. Bombel, G. A., Mihura, J. L., & Meyer, G. J. (2009). An examination of the construct validity of the Rorschach Mutuality of Autonomy (MOA) Scale. Journal of Personality Assessment, 91, 227–237. doi:10.1080/00223890902794267 Book, H. (1998). How to practice brief psychodynamic psychotherapy: The core conflictual relationship theme method. Washington, DC: American Psychological Association. Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development. New York, NY: Basic Books. Carsky, M. (2013). Supportive psychoanalytic therapy for personality disorders. Psychotherapy, 50, 443–448. Diener, M. J., & Monroe, J. M. (2011). The relationship between adult attachment style and therapeutic alliance in individual psychotherapy: A meta-analytic review. Psychotherapy, 48(3), 237–248. doi:10.1037/ a0022425 Diener, M., & Pierson, M. (2013). Technique and therapeutic process from a supportive-expressive relational psychodynamic approach. Psychotherapy, 50, 424–427. Eames, V., & Roth, A. (2000). Patient attachment orientation and the early working alliance: A study of patient and therapist reports of alliance quality and ruptures. Psychotherapy Research, 10(4), 421–434. doi:10.1093/ptr/10.4.421

222

Bulletin of the Menninger Clinic

MOA and psychotherapy process Exner, J. E., Jr. (2003). The Rorschach: A comprehensive system. Vol. 1: Basic foundations and principles of interpretation (4th ed.). Hoboken, NJ: John Wiley. Exner, J. E., Jr., & Erdberg, P. (1993). The Rorschach: A comprehensive system. Vol. 1: Basic foundations (3rd ed.). New York, NY: John Wiley. Fairbairn, W. R. D. (1952). Psychoanalytic studies of the personality. London, England: Routledge & Kegan Paul. Finn, S., & Tonsager, M. (1997). Information-gathering and therapeutic models of assessment: Complementary paradigms. Psychological Assessment, 9, 374–385. Fleiss, J. L. (1981). Statistical methods for rates and proportions (2nd ed.). New York, NY: John Wiley & Sons. Flückiger, C., Del Re, A. C., Wampold, B. E., Symonds, D., & Horvath, A. O. (2012). How central is the alliance in psychotherapy? A multilevel longitudinal meta-analysis. Journal of Counseling Psychology, 59(1), 10–17. doi:10.1037/a0025749 Fowler, J. C., & DeFife, J. A. (2012). Quality of object representations related to service utilization in a long-term residential treatment center. Psychotherapy, 49(3), 418–422. doi:10.1037/a0029566 Fowler, J. C., & Erdberg, P. (2006). The Mutuality of Autonomy Scale: An implicit measure of object relations for the Rorschach Inkblot Method. South African Rorschach Journal, 2, 3–10. Retrieved from http://www.ikpp.si/izobrazevanje-in-usposabljanje/publikacije Gaston, L., & Marmar, C. R. (1991). Manual of California Psychotherapy Alliance Scales (CALPAS). Unpublished manuscript. Guntrip, H. (1968). Schizoid phenomena, object relations and the self. Oxford, England: International Universities Press. Hatcher R. L., & Barends, A. (1996). Patients’ view of the alliance in psychotherapy: Exploratory factor analysis of three alliance measures. Journal of Consulting and Clinical Psychology, 64, 1326–1336. Hilliard, R. B., Henry, W. P., & Strupp, H. H. (2000). An interpersonal model of psychotherapy: Linking patient and therapist developmental history, therapeutic process, and types of outcome. Journal of Consulting and Clinical Psychology, 68(1), 125–133. doi:10.1037/0022006X.68.1.125 Hilsenroth, M. J. (2007). A programmatic study of short-term psychodynamic psychotherapy: Assessment, process, outcome, and training. Psychotherapy Research, 17(1), 31–45. Hilsenroth, M., Ackerman, S., & Blagys, M. (2001). Evaluating the phase model of change during short-term psychodynamic psychotherapy. Psychotherapy Research, 11, 29–47. Hilsenroth, M., Ackerman, S., Blagys, M., Baity, M., & Mooney, M. (2003). Short-term psychodynamic psychotherapy for depression: An

Vol. 78, No. 3 (Summer 2014)

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Sanders et al. evaluation of statistical, clinically significant, and technique specific change. Journal of Nervous and Mental Disease, 191, 349–357. Hilsenroth, M. J., Blagys, M., Ackerman, S., Bonge, D., & Blais, M. (2005). Measuring psychodynamic–interpersonal and cognitive–behavioral techniques: Development of the Comparative Psychotherapy Process Scale. Psychotherapy, 42, 340–356. Hilsenroth, M., & Charnas, J. (2007). Training manual for Rorschach interrater reliability (2nd ed.). Unpublished manuscript, The Derner Institute of Advanced Psychological Studies, Adelphi University, Garden City, NY. Hilsenroth, M. J., Charnas, J., Zodan, J., & Streiner, D. L. (2007). Criterion based training for Rorschach scoring. Training and Education in Professional Psychology, 1, 125–134. Hilsenroth, M. J., Cromer, T., & Ackerman, S. (2012). How to make practical use of therapeutic alliance research in your clinical work. In R. A. Levy, J. S. Ablon, & H. Kaechele (Eds.), Psychodynamic psychotherapy research: Evidence-based practice and practice-based evidence (pp. 361–380). New York, NY: Springer Press. Hilsenroth, M. J., DeFife, J., Blagys, M., & Ackerman, S. (2006). Effects of training in short-term psychodynamic psychotherapy: Changes in graduate clinician technique. Psychotherapy Research, 16, 292–303. Hilsenroth, M. J., DeFife, J. A., Blake, M. M., & Cromer, T. D. (2007). The effects of borderline pathology on short-term psychodynamic psychotherapy for depression. Psychotherapy Research, 17, 175–188. Hilsenroth, M. J., Handler, L., Toman, K. M., & Padawer, J. R. (1995). Rorschach and MMPI-2 indices of early psychotherapy termination. Journal of Consulting and Clinical Psychology, 63(6), 956–965. doi:10.1037/0022-006X.63.6.956 Hilsenroth, M. J., Peters, E. J., & Ackerman, S. J. (2004). The development of therapeutic alliance during psychological assessment: Patient and therapist perspectives across treatment. Journal of Personality Assessment, 83(3), 332–344. Hilsenroth, M. J., Stein, M. B., & Pinsker-Aspen, J. H. (2007). Social Cognition and Object Relations Scale: Global Rating Method (SCORS-G) (3rd ed.). Unpublished manuscript, The Derner Institute of Advanced Psychological Studies, Adelphi University, Garden City, NY. Horner, M. S., & Diamond, D. (1996). Object relations development and psychotherapy dropout in borderline outpatients. Psychoanalytic Psychology, 13(2), 205–223. doi:10.1037/h0079648 Horvath, A., & Bedi, R. (2001). The alliance. In J. Norcross (Ed.), Psychotherapy relationships that work. New York, NY: Oxford University Press. Horvath, A. O., Del Re, A. C., Flückiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48, 9–16.

224

Bulletin of the Menninger Clinic

MOA and psychotherapy process Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the Working Alliance Inventory. Journal of Counseling Psychology, 36, 223–233. Huprich, S. K., & Greenberg, R. P. (2003). Contemporary advances in the assessment of object relations. Clinical Psychology Review, 23, 665–698. Joyce, A. S., & Piper, W. E. (1998). Expectancy, the therapeutic alliance, and treatment outcome in short-term individual psychotherapy. Journal of Psychotherapy Practice & Research, 7(3), 236–248. Klein, M. (1952). Some theoretical conclusions regarding the emotional life of the infant. In M. Klein, P. Heimann, S. Isaacs, & J. Riviera (Eds.), Developments in psycho-analysis (pp. 61–93). London, England: Hogarth Press. Klein, M. (1996). Notes on some schizoid mechanisms. Journal of Psychotherapy Practice & Research, 5(2), 164–179. (Original work published 1946) Kokotovic, A. M., & Tracey, T. J. (1990). Working alliance in the early phase of counseling. Journal of Counseling Psychology, 37(1), 16–21. doi:10.1037/0022-0167.37.1.16 Lingiardi, V. (2013). Trying to be useful: Three different interventions for one therapeutic stance. Psychotherapy, 50, 413–418. Luborsky, L. (1984). Principles of psychoanalytic psychotherapy: A manual for supportive–expressive treatment. New York, NY: Basic Books. Luborsky, L., Crits-Christoph, P., Alexander, L., Margolis, M., & Cohen, M. (1983). Two helping alliance methods for predicting outcomes of psychotherapy: A counting signs vs. a global rating method. Journal of Nervous and Mental Disease, 171, 480–491. Mallinckrodt, B., Daly, K., & Chia-Chih, D. C. (2009). An attachment approach to adult psychotherapy. In J. Obegi & E. Berant (Eds.), Attachment theory and research in clinical work with adults (pp. 234–268). New York, NY: Guilford Press. Martin, D., Garske, J., & Davis, K. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Counseling and Clinical Psychology, 68(3), 438–450. McCullough, L., Kuhn, N., Andrews, S., Kaplan, A., Wolf, J., & Hurley, C. (2003). Treating affect phobia: A manual for short term dynamic psychotherapy. New York, NY: Guilford Press. Mikulincer, M., & Shaver, P. R. (2007). Attachment in adulthood: Structure, dynamics, and change. New York, NY: Guilford Press. Monroe, J. M., Diener, M. J., Fowler, J. C., Sexton, J. E., & Hilsenroth, M. J. (2013). The criterion validity of the Rorschach Mutuality of Autonomy (MOA) Scale: A meta-analytic review. Psychoanalytic Psychology, 30, 535–566.

Vol. 78, No. 3 (Summer 2014)

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Sanders et al. Moras, K., & Strupp, H. H. (1982). Pretherapy interpersonal relations, patients’ alliance, and outcome in brief therapy. Archives of General Psychiatry, 39(4), 405–409. doi:10.1001/archpsyc.1982.04290040019003 Mullin, A. S., & Hilsenroth, M. J. (2014). The relationship between patient pre-treatment object relations functioning and psychodynamic techniques early in treatment. Clinical Psychology & Psychotherapy, 21, 123–131. Pesale, F. P., & Hilsenroth, M. J. (2009). Patient and therapist perspectives on session depth in relation to technique during psychodynamic psychotherapy. Psychotherapy: Theory, Research and Practice, 46, 390–396. Pinsker-Aspen, J. H., Stein, M. B., & Hilsenroth, M. J. (2007). Clinical utility of early memories as a predictor of early therapeutic alliance. Psychotherapy: Theory, Research, Practice, Training, 44(1), 96–109. doi:10.1037/0033-3204.44.1.96 Piper, W. E., Azim, H. F., Joyce, A. S., McCallum, M., Nixon, G. W. H., & Segal, P. S. (1991). Quality of object relations versus interpersonal functioning as predictors of therapeutic alliance and psychotherapy outcome. Journal of Nervous and Mental Disease, 179(7), 432–438. doi:10.1097/00005053-199107000-00008 Rorschach, H. (1951). Psychodiagnostics: A diagnostic test based on perception (5th ed.). Oxford, England: Grune & Stratton. (Original work published 1921) Ryan, E. R., & Cicchetti, D. V. (1985). Predicting quality of alliance in the initial psychotherapy interview. Journal of Nervous and Mental Disease, 173(12), 717–725. doi:10.1097/00005053-19851200000002 Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational treatment guide. New York, NY: Guilford Press. Siefert, C. J., Hilsenroth, M. J., Weinberger, J., Blagys, M. D., & Ackerman, S. J. (2006). The relationship of patient defensive functioning and alliance with therapist technique during short-term psychodynamic psychotherapy. Clinical Psychology & Psychotherapy, 13(1), 20–33. doi:10.1002/cpp.469 Slavin-Mulford, J. (2013). The dance of psychotherapy. Psychotherapy, 50, 419–425. Stein, M. B., Pesale, F. P., Slavin, J. M., & Hilsenroth, M. J. (2010). A training outline for conducting psychotherapy process ratings: An example using therapist technique. Counselling and Psychotherapy, 10(1), 50–59. Stricker, G. (2013). The process of assimilative psychodynamic integration. Psychotherapy, 50, 404–407.

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MOA and psychotherapy process Stricker, G., & Gooen Piels, J. (2004). Projective assessment of object relations. In M. Hersen (Ed.), Comprehensive handbook of psychological assessment (pp. 449–465). Hoboken, NJ: Wiley. Thompson-Brenner, H., & Westen, D. (2005). A naturalistic study of psychotherapy for bulimia nervosa, part 2: Therapeutic interventions in the community. Journal of Nervous and Mental Disease, 193, 585–595. Urist, J. (1977). The Rorschach test and the assessment of object relations. Journal of Personality Assessment, 41, 3–9. doi:10.1207/ s15327752jpa4101_1 Urist, J., & Shill, M. (1982). Validity of the Rorschach Mutuality of Autonomy Scale: A replication using excerpted responses. Journal of Personality Assessment, 46, 450–454. doi:10.1207/s15327752jpa4605_1 Wachtel, P. L. (1993). Therapeutic communication. New York, NY: Guilford Press. Westen, D. (1995). Social Cognition and Object Relations Scale: Q-Sort for Projective Stories (SCORS–Q). Unpublished manuscript. Westen, D., & Muderrisoglu, S. (2003). Reliability and validity of personality disorder assessment using a systematic clinical interview: Evaluating an alternative to structured interviews. Journal of Personality Disorders, 17, 350–368. Westen, D., & Muderrisoglu, S. (2006). Clinical assessment of pathological personality traits. American Journal of Psychiatry, 163, 1285–1287. Westen, D., Novotny, C., & Thompson-Brenner, H. (2004). The empirical status of empirically supported psychotherapies: Assumptions, findings, and reporting in controlled clinical trials. Psychological Bulletin, 130, 631–663. Winnicott, D. W. (1958). The capacity to be alone. London, England: Hogarth Press.

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