ORIGINAL RESEARCH
The Quality of Object Relations (QOR) Scale, the Reciprocal Attachment Questionnaire (RAQ), and Psychotherapy Outcome. Ulrich B. Wolfaardt BA and Anthony S. Joyce PhD. Psychotherapy Research and Evaluation Unit, Department of Psychiatry, Faculty of Medicine and Dentistry, University of Alberta. Correspondence to: Ulrich Wolfaardt,
equally predictive of outcome. A
Department of Psychiatry, University
series of post-hoc analyses were
of Alberta, 1E7 WMC 8440 – 112 street
conducted to determine whether
Edmonton, Alberta, Canada. T6G 2B7. Phone: 1-780-407-6626 Fax: 1-780-4076407 E-Mail:
[email protected]
the degree of patient pathology influenced the relationship between the QOR and RAQ. The post-hoc analyses confirmed that the RAQ
Abstract Aspects of interpersonal and
identifier of attachment pathology.
relational functioning are reviewed
The results imply that effective
in a sample of adult psychiatric
application of the RAQ resides in
outpatients receiving group
identifying patients with prominent
psychotherapy for complicated
pathology in their attachment
grief. Two relational measures,
patterns. The results indicate that
the Quality of Object Relations
the RAQ should be employed as
(QOR) Scale and the Reciprocal
an initial assessment measure,
Attachment Questionnaire (RAQ),
administered to patients prior
were administered to the patients.
to the onset of therapy. Elevated
The objectives of the study were to
scores would indicate pathology
examine the relationship between
and provide the clinician with an
the QOR and the RAQ, and the
indication of potential transference
relationship between each measure
issues that may arise in therapy.
and indices of treatment outcome.
Keywords: Short-term group therapy, object relations theory, attachment theory, outcome prediction, relational theory
Thus, the study aimed to evaluate the construct and predictive validity of both measures, and also possibly
Introduction
further informing relational theory.
Problematic interpersonal relationships are a principal feature of many psychiatric disorders, as the patient’s inability to form healthy relationships is a significant risk factor for the development or maintenance of psychopathology. Consequently, a number of relational measures have been developed, focused on assessing a patient’s stereotypical interpersonal patterns and linking these patterns to pathology. Knowledge of the characteristic interpersonal patterns allows the therapist to predict the
The sample consisted of 107 treatment completers participating in a comparative trial of two forms (interpretive, supportive) of shortterm group therapy for complicated grief. The results demonstrated that the RAQ was oriented towards greater pathology on the QOR. Further, the QOR and RAQ appeared 14
functions predominantly as an
University of Alberta Health Sciences Journal • December 2005 • Volume 2 • Issue 2
maladaptive behaviors the patient will present in therapy, and to guide the therapeutic process in a manner to overcome these obstacles. Research on relational measures has confirmed that patients’ interpersonal styles have a profound influence on the process and outcome of psychotherapy. Secure attachment styles have consistently been predictive of beneficial therapeutic outcomes [1, 2] For instance, Eames and Roth [3] observed an association between attachment style and the development of a therapeutic alliance. Patients who exhibited secure attachment styles established closer alliances with the therapist. Conversely, patients with insecure attachment styles were less likely to form an alliance with the therapist. Evidently, relational measures have a proven capacity to predict process and outcome in psychotherapy. Thus, examination of the relationships between different relational measures, and between these measures and indices of treatment outcome, may increase knowledge of the construct and predictive validity of the measures and further inform relational theory. The aim of the current study was to investigate the relationship between two such measures, and between each measure and the indices of outcome following short-term group therapy for complicated grief. Complicated grief refers to the clinical complications, including a variety of associated problems such as anxiety and depression, arising from the occurrence of an unresolved loss. The unresolved loss results in extremes in intensity or duration of grief symptoms, impeding the resolution of the mourning process. The two measures selected for comparison were the Quality of Object Relations (QOR) Scale and the Reciprocal Attachment Questionnaire (RAQ). The QOR scale is based on psychoanalytic and object relations theories and relies on a semi-structured clinical assessment procedure. The RAQ is based on
The QOR Scale The Quality of Object Relations Scale is a clinical assessment developed to quantify a patient’s tendency to develop certain types of relationships that range along a continuum from primitive to mature [4]. The QOR continuum is reflected by a nine-point scale that is rated following a one-hour, semi-structured clinical interview. The interview assesses the patient’s pervasive patterns of relationships in reference to five levels of object relations: primitive, searching, controlling, triangular, and mature. For each level, criteria for behavioral manifestations, regulation of affect, regulation of self-esteem, and historical antecedents are examined. The salient features of the polar endpoints of the scale are as follows: primitive object relations reflect the patient’s tendency to react to perceived separation or loss of the object, or disapproval or rejection by the object, with intense anxiety and affect. Mature object relations are reflected by equitable relationships characterized by love, tenderness, and concern for both sexes. The interview produces two scores: 1) weights assigned to each level (out of 100) and 2) a global score (ranging from 1 to 9). The higher the global score, the higher the quality of object relations [5].
The RAQ Scale The Reciprocal Attachment Questionnaire was developed to evaluate a patient’s pattern of attachment to a significant other with whom a special relationship has been shared for at least 6 months [6]. The RAQ has a different focus than the QOR: the RAQ assesses the quality of a current relationship, while the QOR assesses lifelong relational patterns. The RAQ is a selfreport measure that is completed by the patient prior to the onset of treatment. The RAQ provides two types of scores. Subscale scores are represented by five scales, each capturing features significant in defining the criteria and provisions of adult attachment: perceived availability, proximity seeking, separation protest, feared loss, and use of the attachment figure. Pattern scores are represented by four scales, each developed to evaluate a patient’s pattern of attachment to a significant other: compulsive selfreliance, compulsive care-giving,
Table 1 Intercorrelations between QOR and RAQ
ORIGINAL RESEARCH
attachment theory and relies on a patient self-report.
QOR Global and Level Scores RAQ Scales
Primitive
Searching
Controlling
Triangular
Mature
RAQ Subscales Perceived availability
.23*
.13
-.07
-.09
-.23*
Proximity seeking
.06
.13
-.01
-.03
-.09
Separation protest
.19
.13
-.06
-.06
-.14
Feared loss
.26**
.17
-.13
-.07
-.23*
Use of attachment figure
.22*
.17
.05
-.09
-.21*
Compulsive self-reliance
.17
.09
-.09
.03
-.18
Compulsive care-giving
-.18
-.03
.10
.08
.09
Compulsive care-seeking
.06
.15
-.01
-.03
-.08
Angry withdrawal
.22*
.13
.02
-.08
-.24*
RAQ Pattern Scales
*p ≤ .05, two-tailed. **p ≤ .01, two-tailed.
compulsive care-seeking, and angry withdrawal. Subscale scores provide a representation of an individual’s attachment system, capturing the aspects of an adult relationship formed to promote and maintain security [7]. Conversely, pattern scores capture the degree of pathology present in an individual’s stereotypical attachment style. Each of the nine scales consists of between 3 - 7 items rated on a five-point Likert-type scale: the greater the score, the greater is the pathology associated with the scale’s attachment feature. The objectives of the current study were: 1) examine the degree of overlap between the QOR and the RAQ, and 2) examine the strength of outcome prediction afforded by each measure.
Methods
in pairs on the basis of key demographic variables (i.e., QOR, medication use, and when possible gender and age). Analyses suggested that no significant differences emerged between the groups in terms of these demographics. The average age of the patients was 43 years (SD = 10.3, range = 19-67) and 77% (n=82) of the patients were women. 41% were married or living with a partner, 26% were separated or divorced, 18% were widowed, and 15% had never been married. 47% were educated beyond high school, and 52% were employed at the time of treatment. The losses reported by the patients (and their prevalence) were: parent (45%), partner (14%), child (13%), sibling (12%), friend (3%), grandparent (4%), and other (9%). The average time since the loss(es) was 9.0 years (SD = 10.7, range = 0.25 – 47.0).
Therapies
Setting Patients treated in the parent study [8] were referred from the outpatient Psychiatric Treatment Clinic of the Department of Psychiatry, University of Alberta Hospital Site in Edmonton, Alberta, Canada. The clinic is part of a large multifaceted, psychodynamicallyoriented outpatient service operating out of a 600-bed tertiary care university hospital.
Patients were randomly assigned to either an interpretive or supportive form of group therapy. The main objective of interpretive therapy is to enhance the patient’s insights about repetitive conflicts (intrapsychic and interpersonal) that cause and maintain the patient’s pathology. The main objective of supportive therapy is to improve the patient’s immediate adaptation to his/ her life situation.
Patients
Outcome Measures
Patients in the current sample participated in a comparative trial of two forms (interpretive, supportive) of short-term group therapy for complicated grief [8]. The final sample included 107 patients who completed treatment. The research coordinator attempted to match patients
The outcome battery for the comparative trial of short-term group therapy [8] included 14 measures addressing 15 variables, including indices of grief symptoms, interpersonal distress, social functioning, psychiatric symptoms, selfesteem, life satisfaction, and physical
University of Alberta Health Sciences Journal • December 2005 • Volume 2 • Issue 2
15
ORIGINAL RESEARCH
Table 2 Correlation between QOR, RAQ and Outcome within each treatment condition Outcome factors General Symptoms
Variable
Grief Symptoms
TOLS
Interpretive Condition QOR QOR Global
-.22
-.37*
-.16
Primitive
.28
.39*
.24
Searching
-.14
.02
-.17
Controlling
.05
.03
.06
Triangular
-.08
-.23
-.10
-.20
-.34*
-.12
Mature
Supportive Condition QOR QOR Global
.20
.14
.13
Primitive
-.26
-.25
-.22
Searching
-.10
.06
-.08
Controlling
.32*
.01
.25
Triangular
-.00
.16
.11
Mature
.04
.16
.11
Interpretive Condition RAQ subscale Proximity seeking
.17
.16
.14
Separation protest
.13
.36*
.19
Feared loss
.01
.15
.04
Availiabilty
.13
.35*
.15
Use
.13
.14
.03
Angry withdrawal
.29
.42**
.25
Compulsive care-giving
-.06
.22
.04
Compulsive self-reliance
.28
.17
.22
Compulsive care-seeking
.20
.26
.22
RAQ pattern scale
Supportive Condition RAQ subscale Proximity seeking
.18
.16
-.04
Separation protest
.19
.29
.03
Feared loss
-.09
-.03
-.01
Availiabilty
-.20
-.19
-.05
Use
-.17
-.29*
.03
Angry withdrawal
-.11
-.01
.13
Compulsive care-giving
.36*
.30*
.07
Compulsive self-reliance
-.16
-.08
.12
Compulsive care-seeking
.25
.28
.19
RAQ pattern scale
Note: TOLS = Target Objectives and Life Satisfaction *p< .05, two-tailed. **p
