Journal of Consulting and Clinical Psychology 1996, Vol. 64, No. 2, 41 I--416
Copyright 1996 by the American Psychological Association, Inc. 0022-006X/96/$3.00
Dynamic Change in Psychotherapy: Mastery of Interpersonal Conflicts Brin E S. Grenyer
Lester Luborsky
University of WoUongong
University of Pennsylvania
This study investigated the relationship between the mastery of maladaptive interpersonal patterns (assessed from narratives told during psychotherapy) and outcome of psychotherapy. Transcripts from the psychodynamic psychotherapy of 41 patients were scored using a content analysis mastery scale. Changes in mastery level over the course of therapy were significantly related to changes in observer and therapist ratings. In addition, the patients' own judgments of changes in their symptoms and main problems paralleled changes in the mastery of interpersonal conflicts found in their narratives. These results are consistent with the proposition that symptoms abate with the mastery of core interpersonal conflicts.
When patients seek psychotherapy, it is often because they are overwhelmed by symptoms and relationship conflicts. An almost universal goal of all psychotherapy approaches is to promote mastery over these problems (Liberman, 1978). One of the central propositions in the psychoanalytic theory of change in psychotherapy is that symptoms arise after the activation of core relationship conflicts, a view supported recently by two strands of research: first, studies that show the structural pattern of these conflicts using the Core Conflictual Relationship Theme (CCRT) method (Luborsky & Crits-Christoph, 1990); second, studies that link these relationship conflicts with the emergence of symptoms ( Luborsky, in press). The goal of our study was to assess changes in the mastery of these core interpersonal conflicts over the course of psychotherapy and examine their relationship to changes in symptoms. Gains in mastery are part of the working through process. Mastery is defined as the acquisition of emotional self-control and intellectual self-understanding in the context of interpersonal relationships (Grenyer, 1994).
We propose that the conflictual relationship narratives brought by patients to psychotherapy are told in the service of mastery, just as Freud discussed how children's repetitive games are attempts to master traumatic situations (Freud, 1920/ 1959). Freud first made the connection between patterns in the patient's narratives about conflictual problems outside of therapy with the kind of problems encountered in the therapeutic relationship. To our knowledge, there have been no previous attempts to measure this process of mastery in psychotherapy. Previous research explored the changes brought about in dynamic psychotherapy using the CCRT (Luborsky & CritsChristoph, 1990). The CCRT documents three components in narratives: the wishes or needs expressed by the patient, the positive or negative reaction of others (CCRT-RO) to their wishes, and the positive or negative reaction of the self (CCRT-RS). It was reasoned that the repetitive maladaptive relationship conflicts should become less pervasive over the course of therapy; that is to say, the CCRT pattern should become more positive, with a wider range of relationship patterns indicating greater flexibility in emotional responding to conflicts. The results supported the hypothesis, with a striking finding that, despite the decrease in pervasiveness, much of the CCRT patterns were still evident, supporting the view that central relationship patterns remain relatively intact over psychotherapy. Although the changes in the positive and negative components of the CCRT provide some indication of changes in the pervasiveness of the pattern (Luborsky & Crits-Christoph, 1990), the CCRT is limited in its scope as a measure that reflects mastery. The content analysis Mastery Scale was therefore constructed, which could be applied to the same database of narratives of relationship encounters but also focus on quantifying degrees of mastery. Table 1 shows a brief summary of the Mastery Scale. For the full scale including scoring conventions and practice examples, consult Grenyer (1994). The content of the scale was developed on the basis of our deftnition of mastery and our review of the literature, and it was developed through the intensive study of verbatim transcripts of two successful pilot cases of dynamic psychotherapy applying a taskanalysis approach (Rice & Greenberg, 1984). Task analysis is a
Brin E S. Grenyer, Departments of Nursing and Psychology, University of Wollongong, New South Wales (NSW), Australia; Lester Luborsky, Department of Psychiatry, University of Pennsylvania. Portions of the data included in this article were presented in June 1994, at the 26th Annual Meeting of the Society for Psychotherapy Research, York, England. This article was supported in part by an APRA-Australian Research Council award, Research Scientist Award MH 40710-22, National Institute on Drug Abuse Grants 2 KO5 DA00168-23A 24 and RO-I DA0785, and National Institute of Mental Health Clinical Research Center Grant MH 45178. Acknowledgment is made to the Penn Psychotherapy Research Project (Lester Luborsky, principal investigator) for generously providing access to data and support. Our thanks are also extended to Vera Auerbach, Mary Carse, Annalisa Dezarnaulds, Louis Diguer, Suzanne Johnson, Nigel Mackay, Richard Rushton, Kelly Schmidt, and Nadia Solowij. Correspondence concerning this article should be addressed to Brin F. S. Grenyer, Departments of Nursing and Psychology, University of Wollongong, NSW 2522, Australia. Electronic mail may be sent via [nternet to
[email protected]. 411
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GRENYER AND LUBORSKY Table 1 Mastery Scale, Version I Level and Score Level 1. Lack of impulse control IA IB
IC ID Level 2. lntrojection and projection of negative affects 2E 2F 2G 2H 2I Level 3. Difficulties in understanding and control 3J 3K 3L Level 4. Interpersonal awareness 4M 4N 40 4P Level 5. Self-understanding
5Q 5R 5S 5T Level 6. Self-control 6U 6V 6W
Component Expressions of being emotionally overwhelmed References to immediacy of impulses References to blocking defenses References to ego-boundary disorders Expressions of suffering from internal negative states Expressions indicative of negative projection on to others Expressions indicative of negative projection from others References to interpersonal withdrawal Expressions of helplessness Expressions of cognitive confusion Expressions of cognitive ambivalence References to positive struggle with difficulties References to questioning the reactions of others References to considering the other's point of view References to questioning the reaction of the self Expressions of interpersonal self-assertion Expressions of insight into repeating personality patterns of self Making dynamic finks between past and present relationships References to interpersonal union Expressions of insight into interpersonal relations Expressions of emotional self-control over conflicts Expressions of new changes in emotional responding References to self-analysis
Note. For full scale details, consult Grenyer (1994).
structured discovery-oriented approach to studying psychotherapy transcripts to reveal recurrent patterns of clinical importance. We were interested in dynamic concepts that were considered indicative of self-control and serf-understanding, such as having insight into common personality traits, making links between past ways of relating and the present, the development of tolerance for thoughts and feelings, and the ability to self-analyze and monitor internal states. These were identified by Luborsky as some of the key curative factors in dynamic therapy (Luborsky, CritsChristoph, Mintz, & Auerbach, 1988). We saw, just as Gottschalk had some 25 years earlier; that psychological constructs could be reliably and validly located, classified, and measured within patient speech ( Gottschalk, Winger, & Gleser, 1969). The scale has three broad levels. Scores 1 and 2 relate to failures of mastery manifested by problems such as cognitive disturbances. Scores 3 and 4 relate to the struggle to improve, such as self-questioning perceptions of relationship conflicts. Scores 5 and 6 demonstrate good levels of mastery; for example, having awareness of one's transference patterns and being able to derive pleasurable experiences from relationships. Self-control was accorded a higher rating than self-understanding on the basis of Freud's well-known views that intellectual self-understanding by itself does not guarantee therapeutic change (Freud, 1913 / 1958). Mastery is gained when one not only understands a situation but feels in control.
We evaluated the following hypotheses: (a) that patients rated as showing greater gains in mastery will have larger gains on measures of general functioning and symptoms than those patients showing fewer gains in mastery, and (b) that changes in mastery will parallel changes in components of the CCRT. The first hypothesis is important because dynamic theory holds that improvements in the mastery of interpersonal conflicts should be associated with higher ratings of functioning made by independent assessors. Method Forty-one patients (29 female, 12 male, mean age, 25; range, 18-48) were chosen as a representative sample from 72 patients constituting the Penn Psychotherapy Project (Luborsky et al., 1988). Twenty-six patients were single, 7 were married, and 6 were divorced or separated. Five had graduated from high school only, 19 had completed some college education, 6 had completed college, and a further 11 were undertaking or had completed a graduate degree. The sample had a mixed diagnostic picture according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders ( 3rd ed.; DSM-III, American Psychiatric Association, 1980). FiReen had primary diagnoses ofdysthymia and I 1 had generalized anxiety disorder, whereas the rest of the primary and secondary diagnoses were mainly Cluster A (8 schizoid, 3 schizotypal), Cluster B (4 histrionic, 1 narcissistic), and Cluster C (3 compulsive, 3 passive-aggressive)Axis II personality disorders.
DYNAMIC CHANGE IN PSYCHOTHERAPY Treatment was based on weekly individual time-unlimited psychoanalytic psychotherapy within a mean treatment length of 54 weeks (range, 21-149 weeks). Therapy was conducted by 31 psychiatrists (mean age, 36; range, 26-56). Of these, 17 were residents, 9 had up to 10 years postresidency experience, and 5 had more than l0 years experience. The residents saw their patients in an outpatient clinic, and the postresidents saw their patients in private practice. Thirty of the therapists were married, and 23 had children. The orientation of the group was divided between "psychodynamic eclectic" (21 adherents) and "Freudian analytic" ( 10 adherents). Verbatim transcripts of psychotherapy sessions collected during the Penn Psychotherapy Project formed the database. For each patient, these were transcripts from early in therapy (generally Sessions 3 and 5 ) and two or three transcripts from late in therapy (at the 90% completion mark). Narratives of interactions ( relationship episodes, or REs) served as the scorable units of analysis of mastery. Relationship episodes had been identified from the transcripts of early and late sessions in an earlier CCRT study ( Luborsky & Crits-Christoph, 1990). There were usually 10 REs from early in therapy and 10 REs from late in therapy. The REs were randomized between sessions and patients. The REs were divided into grammatical clauses (whether independent or dependent) by marking off the claused speech units with a slash according to the conventions adopted by Gottschalk et al. (1969). The following is an example of three marked clauses, with Mastery Scale scores in parentheses: ~I'm afraid of myself ( 2E)/because it's a father-lover sort of
thing ( SQ)/It's also this hangoverfrom when I was real young (5R)/. To facilitate the process of scoring, one judge read all the REs and identified all the clauses that could be scored with the Mastery Scale, a technique also used in CCRT research to control for location or position disagreement (as opposed to scoring disagreement ). All the data were scored twice. Each RE was independently scored by two of a pool of four trained judges. Each judge was given a random portion of the total number of REs to score. No individualjudge scored the same RE twice. Judges were not informed of which patient told the RE, the time in therapy at which the RE occurred, or treatment outcome status and other clinical variables. Judges were trained in the methods of scoring to an interrater reliability of >.90. One of the 23 Mastery Scale categories from IA to 6W was assigned to each of the codable clauses by the judges. Each of the 23 category choices comes with its own built-in score ranging from 1 to 6 to represent one of the six levels in the scale. These scores were used in the compilation of statistics. We calculated Mastery Scale scores for each RE by summing all the scores and dividing by the number of scorable clauses to arrive at a mean score per narrative. These scores were then used to calculate average levels of mastery for each patient early and late in therapy. Outcome measures were collected at the commencement and the termination of therapy by an independent assessor using the Health-Sickness Rating Scale (HSRS; Luborsky, 1962) and the Control and Insight ratings of the Prognostic Index (Luborsky et al., 1988); by the therapist's using a composite rating of patient satisfaction, success, and improvement; and by patient self-report with the Hopkins Symptom Checklist (SCL; Derogatis, Lipman, Covi, Rickels, & Uhlenhuth, 1970) and a rating of improvement on the primary target complaint identified by the patient at the start of therapy (Target; Battle et al., 1966). The CCRT-RS and the CCRT-RO components from late in therapy were used. To obtain a score late in therapy that reflected the overall degree of positivity-negativityfor each of the two CCRT components (CCRTRS and CCRT-RO) for each participant near termination, we subtracted the sum of the negative responses from the sum of the positive responses and divided that by the total number of responses. Results Interjudge agreement was uniformly high, with correlation coefficients among the four independent judges as follows: A
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versus B, r = .75 (n = 187 REs scored in c o m m o n ) ; A versus C, r = .77 (n = 161 ); A versus D, r = .81 (n = 89); B versus C, r = .79 (n = 149); B versus D, r = .85 (n = 127); C versus D, r = .89 (n = 81 ). Judges' Mastery Scale scores were therefore averaged in all subsequent analyses. To investigate changes in Mastery Scale scores across the 41 patients over the course of therapy, we calculated a paired t test between early and late scores. The change in mastery was highly statistically significant, t(40) = 4.94, p > .0001. The effect size calculated was large ( 1.35). When compared with the published effect sizes in other psychotherapy studies, the changes detected by the Mastery Scale can be considered to be of clinical significance ( L a m b e r t & Bergin, 1994). Thus, the trend in this psychotherapy sample was for patients to display greater levels of self-understanding and self-control in their interpersonal relations late in therapy. Pretreatment-posttreatment change estimates were corrected for initial levels by the calculation of residual gain scores for the Mastery Scale and other outcome variables in which change estimates were required. The relationship between Mastery Scale change scores and outcome variables were calculated and appear in Table 2. Significant relationships were found among Mastery Scale change scores and observer, therapist, patient, and transference ratings of outcome. Figure 1 shows the data for the HSRS residual change scores plotted against the Mastery Scale residual change scores. Figure 2 shows the percentage of change in the frequency of Mastery Scale categories appearing in narratives from early to late in psychotherapy for all 41 patients. To illustrate these typical changes in mastery from early to late in therapy, we briefly present one patient. Ms. S, a 24-year-old divorced graduate student with no children, was seen in weekly therapy for 41 weeks with the goal to help change her difficult "personality patterns." Her psychodynamic therapist was a 3 l-year-old married resident psychiatrist. Early in therapy, she expressed suffering (2E) that was due to conflictual interactions with others, which led to her avoiding relationships ( 2 H ) . When in close relationships,
Table 2
Pearson Correlations Between Mastery Scale Residual Change Scores and Clinical Outcome Scores
Rating Observer Ratings of Outcome Heaith-Sickness Rating Scale residual change score Prognostic Index, Control item Prognostic Index, Insight item Therapist rating of outcome Therapist rating of patient satisfaction, success, and improvement Therapist rating of patient achieving insight Patient ratings of outcome Rating of change of primary target complaint Symptom Checklist residual change score Transference outcome ratings CCRT: Response of self late in therapy CCRT: Response of other late in therapy
r
.51"** .30 .0 l .47** .12 .59*** -.53***
Note. N = 41. CCRT = Core Conflictual Relationship Theme. *p
