Therapist Interpretation, Patient-Therapist Interpersonal Process, and Outcome in Psychodynamic Psychotherapy For Avoidant Personality Disorder

Psychotherapy: Theory, Research, Practice, Training
2005, Vol. 42, No. 4, 494 511
Copyright 2005 by the Educational Publishing Foundation

0033-3204/05/$12.00
DOI: 10.1037/0033-3204.42.4.494
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
THERAPIST INTERPRETATION, PATIENTTHERAPIST

INTERPERSONAL PROCESS, AND OUTCOME IN
PSYCHODYNAMIC PSYCHOTHERAPY FOR AVOIDANT
PERSONALITY DISORDER
ALEXANDER J. SCHUT
LOUIS G. CASTONGUAY
KELLY M. FLANAGAN
ALISSA S. YAMASAKI
JACQUES P. BARBER
University of Pennsylvania
Pennsylvania State University
JAMIE D. BEDICS
TRACEY L. SMITH
University of Utah
The authors examined the link between

interpretive techniques, the therapeutic
relationship, and outcome in psychodynamic psychotherapy. Two independent
teams of judges each coded one early
session from patients diagnosed with
avoidant personality disorder. Results
revealed (a) an inverse association between concentration of interpretation
and favorable patient outcome; (b) that
small amounts of disaffiliative patient
therapist transactions before, during,
and after interpretations were reliably
or meaningfully associated with negative patient change; and (c) concentra-
tion of interpretation was positively

associated with disaffiliative therapy
process before and during interpretation and negatively associated with affiliative patient responses to interpretation. The results suggest that therapists
who persisted with interpretations had
more hostile interactions with patients
and had patients who reacted with less
warmth than therapists who used interpretations more judiciously.
Alexander J. Schut and Louis G. Castonguay, Department of

Psychology, Pennsylvania State University; Jacques P. Barber,
Department of Psychiatry, Univerisity of Pennsylvania; Jamie D.
Bedics and Tracey L. Smith, Department of Psychology, University of Utah; and Kelly M. Flanagan and Alissa S. Yamasaki,
Department of Psychology, Pennsylvania State University.
This study was based on the results of the first authors
doctoral dissertation. Financial assistance for this study was
provided by the American Psychological Foundations Council
of Graduate Departments of Psychology, the Research and Graduate Studies Office, College of Liberal Arts, Pennsylvania State
University, and the Pennsylvania Psychological Foundation.
Correspondence concerning this article should be addressed to Alexander Schut, 180 Massachusetts Avenue, Suite
301, Arlington, MA 02474. E-mail: alexander_schut@hms
.harvard.edu
A large number of psychodynamically oriented

authors have posited that the therapists use of
interpretation, particularly transference interpretation, is one of, if not the most powerful technical procedures for promoting patient improvement (Arlow, 1987; Bibring, 1954; Brenner,
1979; Clarkin, Yeomans, & Kernberg, 1999;
Cooper, 1987; Davanloo, 1978; Freud, 1912,
1913, 1914, 1915; Gill, 1982; Klein, 1952; Kohut, 1984; Loewald, 1960; Malan, 1976; Mann,
1973; Sifneos, 1987; Strachey, 1934). However,
only a limited number of investigations have empirically tested whether or not the use of interpretation is associated with therapeutic change in
494
Keywords: interpretation, interpersonal

process, treatment outcome, personality
disorder
Special Issue: Interpretation, Interpersonal Process, and Outcome

psychodynamic psychotherapy1, with many of
these studies limiting themselves to examining
the effects of the amount of interpretation provided on patient outcome. In some of the earliest
works on this issue, Malan (1976) and Marziali
(1984) each purported to find support for a link
between the therapists frequent use of interpretative interventions and patient improvement,
specifically for interpretations that linked the patients feelings toward the therapist with the patients feelings toward his or her parents (T/P
link). However, both Malans (1976) and Marzialis (1984) studies were fraught with significant
methodological and/or conceptual problems,
making their conclusions tentative at best. For
example, in Malans (1976) study, raters were not
blind to patient outcome and used process notes
generated from therapists memory rather than
actual recordings or transcripts of sessions. In
Marzialis study (1984), the use of interpretation
only correlated with a subset of dynamic change
scores. In addition, because raw frequency of
interpretation was used as the predictor variable,
it is possible that the findings were confounded
by verbal activity of the therapist in general.
Piper, Debanne, Bienvenu, de Carufel, and Garant (1986), who sought to correct many of the
weaknesses inherent in these earlier studies,
found little evidence to suggest that raw frequency or concentration of interpretation (including T/P interpretations) was directly associated
with favorable outcome in a sample of patients
receiving short-term individual dynamic treatment.
Stemming from these initial investigations
other authors have explored potential mediators
of the relationship between the amount of interpretation provided and therapeutic change, with
the most common mediators explored to-date being (a) the patients pretreatment level of interpersonal functioning (e.g., Connolly, et al., 1999;
Hglend, 1993; Ogrodniczuk, Piper, Joyce, &
McCallum, 1999; Piper, Azim, Joyce, & McCallum, 1991), (b) the suitability or accuracy of
the therapists interpretations (e.g., CritsChristoph, Cooper, & Luborsky, 1988; Norville,
Sampson, & Weiss, 1996; Silberschatz, Fretter,
& Curtis, 1986), and (c) the patients immediate
response to interpretation (e.g., Luborsky, Bachrach, Graff, Pulver, & Christoph, 1979; McCullough et al., 1991; Winston, McCullough, &
Laikin, 1993). As a whole, the results of these
studies suggest that interpretive interventions in
psychodynamic psychotherapy do not indubita-
bly produce mutative treatment effects but

rather appear associated with positive change
only for certain patients (i.e., depending on the
patients pretreatment levels of interpersonal relatedness) under certain conditions (i.e., depending on the frequency or concentration of interpretation, the degree of accuracy of the therapists
interpretations, and/or the patients immediate reaction to interpretations).
Although these empirical findings have important implications for clinical practice (Schut &
Castonguay, 2001), they have failed to provide a
full investigation of the therapeutic context of
interpretive work. For example, as discussed by
Binder and Strupp (1997), researchers have not
yet determined the effects of the therapists communicative style or the effects of the momentary
interpersonal context between patient and therapist within which interpretations are provided on
the process of change. These aspects of interpretation have long been considered to be of import
within the analytic clinical community (see Josephs, 1992, for a review), and a small body of
empirical research guided by interpersonal and
psychodynamic theories indeed suggests that
such subtle patienttherapist interpersonal process variables may play an important role in the
promotion of therapeutic change.
Henry, Schacht, and Strupp (1986) explored
the moment-to-moment transactions between patients and therapists using Benjamins (1974)
Structural Analysis of Social Behavior (SASB).
Interpersonal process was compared across good
versus bad outcome cases seen by the same therapists. Henry et al. (1986) found that therapists
good outcome cases involved significantly more
affiliative or friendly modes of therapist communication (i.e., communication that was more affirming and understanding, more helping and protecting, and less belittling and blaming), whereas
therapists poor outcome cases involved significantly more disaffiliative (e.g., hostile and controlling) communication patterns between patient
1
The term psychodynamic psychotherapy is broadly
used here to define those treatments that are aimed at resolving unconscious conflict, strengthening ego functioning, consolidating representations of self and other, and/or providing
cohesion of ones subjective sense of self. It is a more
pluralistic designation in line with Wallersteins (1992)
observations regarding the preponderance of supportive
and expressive elements in all psychoanalytically informed
psychotherapies.
495
Schut et al.
and therapist. In a follow-up study that explored
a potential mechanism by which interpersonal
process produces outcome changes, Henry,
Schacht, and Strupp (1990) found that the presence of disaffiliative patienttherapist process
was associated with lower levels of change in
patient self-reported introject ratings (i.e., ratings
of how the patient relates with him/her self).
Therapist disaffiliative process was also highly
correlated with the number of self-blaming and
critical statements made by patients in session.
Patients who showed positive changes in introject
ratings, on the other hand, experienced interactions that were almost completely devoid of disaffiliative therapist process. The authors suggested that these findings were consistent with
their theoretically derived predictions that disaffiliative therapist behaviors serve to confirm the
patients negative view of self through the process of interpersonal introjection. Although
Henry et al. (1986, 1990) did not investigate the
relationship between specific types of interventions (e.g., interpretations) and the quality of
patienttherapist transactions, their results clearly
suggest that the manner and context within which
the therapist provides his or her interventions
may yield radically different therapeutic outcomes.
Work by Piper et al. (1999) has shed light on
the deleterious effects of disaffiliative therapy
process following therapist interpretation. Informal inspection of sessions from patients who
dropped out prematurely from time-limited psychodynamic treatment revealed that there frequently was a deteriorating transactional cycle
between patient and therapist following therapist
interpretations, particularly during those sessions
judged to have the highest levels of patient and
therapist focus on transference issues. According
to Piper et al. (1999), a typical exchange was as
follows: After the patient voiced his or her frustration about the therapy sessions and the therapists repeated focus on his or her painful feelings, the therapist would address these patient
concerns by focusing on the therapeutic relationship
and the transference. The patient resisted the transference interpretations either through verbal disagreement or through silence, which led the therapist to persist even further with interpretations. This
cycle led both parties to argue with one another,
with the therapist often becoming . . .drawn into
being sharp, blunt, sarcastic, insistent, impatient, or
condescending (p. 120). At the end of the session,
after the therapist attempted to encourage the pa-
496
tient to continue therapy, the patient submitted to

the therapists encouragement by agreeing to return
but, in fact, never returned.
Such findings, while noteworthy, should be
considered tentative given that the authors did not
formally measure patienttherapist interaction
patterns with a reliable measure of interpersonal
process nor specifically examine the relationship
between patient outcome and therapy process
during interpretation. Nonetheless, we attempted
in this study to expand on Piper et al.s (1999)
results as well as address some of the limitations
of earlier empirical work on the link between
therapist interpretation and patient outcome. Specifically, the present study examined the effects
of the amount of interpretation provided as well
as the interpersonal manner and context within
which such interventions are provided on the
process of change. Both transference and nontransference interpretations were explored given
that previous studies have often neglected to examine these types of interventions concurrently
and given that many authors have advocated the
therapeutic value of both types of interventions
(e.g., Wallerstein & DeWitt, 1997).
In the present study audiotapes and verbatim
transcripts of early sessions of SupportiveExpressive (SE) psychodynamic psychotherapy for
avoidant personality disorder (AVPD) were examined (Barber, Morse, Krakauer, Chittams, & CritsChristoph, 1997). Using a well-established measure
of psychodynamic interventions prescribed by the
SE treatment approach (Connolly, Crits-Christoph,
Shappell, Barber, & Luborsky, 1998), judges rated
each therapist statement for the presence of interpretation. All patient and therapist statements from
these selected sessions were also coded with the
SASB (the same measure employed in Henry et
al.s [1986, 1990] studies) by a separate team of
judges to examine the degree of affiliativeness versus disaffiliativeness in interpersonal communications between patient and therapist.
Based on the previously reviewed empirical
and theoretical literature, the following predictions were made. First, raw frequency and proportion (i.e., concentration) of interpretation
would not be reliably associated with therapeutic
change. Second, therapist interpretations delivered in a disaffiliative (e.g., belittling and blaming) interpersonal manner would be associated
with poor therapeutic outcome. Good outcome,
on the other hand, would be associated with interpretations delivered in a more interpersonally

warm or affiliative (e.g., helping and protecting)
manner. Third, the presence of disaffiliative interpersonal process between therapist and patient
(e.g., therapist belittling and blaming, patient
sulking and appeasing) immediately prior to the
use of interpretations would be associated with
poor therapeutic outcome. Good outcome, on the
other hand, would be associated with more affiliative interpersonal process between therapist and
patient (e.g., therapist affirming and understanding, patient disclosing and expressing) immediately prior to the use of interpretations.
Although the above methods attempt to identify the therapists interpersonal process along
with the relational context within which each
interpretation is delivered, it was also of interest
to elucidate the patients interpersonal process
immediately following these interventions and
determine how such reactions relate to outcome.
It could be, for example, that a patient becomes
resistant when the therapist offers his or her
interpretations in a disaffiliative (e.g., belittling or
accusatory) interpersonal manner. On the other
hand, patient work may occur when the therapist
offers his or her interpretations in more affiliative
interpersonal terms (e.g., when interpretations constructively stimulate the patient and/or show empathic understanding of the patients experience).
Such formulations are consistent with contemporary views on interpersonal complementarity (e.g.,
Benjamin, 1996; Kiesler, 1983; Pincus & Ansell,
2003), which posit that certain classes of interpersonal behavior from one participant pull for or
invite similar responses from another participant.
The present study did not specifically measure
dimensions of patient responses such as defensiveness or involvement, but it was believed that
the quality of patient interpersonal process immediately following the use of interpretations could
be used as analogues of such reactions. For example, patients who have therapeutically positive
reactions to interpretations such as work or
involvement presumably do not disaffiliatively
protest, sulk, or wall-off in relation to the therapist but instead respond by trusting or disclosing
to the therapist in an affiliative manner. Similarly,
patients who become resistant following interpretations presumably do not affiliatively take in
or disclose to the therapist but instead react by
sulking, protesting, or walling him/her self off
from the therapist. Accordingly, a fourth prediction was offered. Specifically, we predicted that
the presence of disaffiliative patient reactions to
interpretation would be associated with poor therapeutic outcome, whereas more affiliative reactions by the patient to interpretation would be
associated with positive therapeutic outcome.
Methods
Participants
Data from 14 patients meeting DSMIIIR
(APA, 1987) criteria for AVPD were examined in
the present study. These data were gathered as
part of an open trial examining the initial efficacy
of a manualized form of SE therapy (Luborsky,
1984) adapted for patients with AVPD (see Barber et al., 1997 for complete details regarding
patient recruiting and interview methods). In
brief, patients who met AVPD diagnostic criteria
were included in the treatment study without regard to Axis I pathology with the exceptions
being diagnoses of substance abuse or dependence in the last 12 months, concurrent psychotic
or bipolar disorder, organic dysfunction, or
schizotypal or borderline personality disorders.
Individuals with active suicidal plans were also
excluded from participating in the treatment.
In terms of the samples demographics, 9 of the
14 patients were female and 5 were male. The
average age of the patients was 35.9 years. The
majority (86%) of the patients were Caucasian; two
female patients were African American. In terms of
educational achievement, 7% had completed high
school, 21% had completed some college, 43% had
completed college, and 14% had completed a graduate degree. One person had not completed high
school and educational data were not available for
one additional patient. Forty-three percent of the
sample had never married; 36% were married, 14%
were divorced, and 7% were single. All but one
patient (full-time student) was employed either fulltime or part-time. In terms of additional psychopathology at the time of intake, 71% of the patients
had at least one concurrent anxiety disorder and
86% had at least one concurrent depressive disorder. In addition, 64% of the patients met criteria for
one additional personality disorder diagnosis.
Treatment
Six Ph.D.-level clinical psychologists (four female, two male) experienced in psychodynamic
psychotherapy provided the treatment protocol.
Each therapist saw two patients on average (three
497
Schut et al.
female therapists saw three patients each, one
male therapist saw one patient) and received
close supervision and training following Luborskys (1984) recommendations. Each patient who
completed the treatment study received 52
weekly individual sessions lasting up to 16
months.2 Treatment was based in large part on
Luborskys (1984) treatment manual for SE psychodynamic psychotherapy that incorporated recommendations from specific published and unpublished preliminary manuals for Axis I and II
disorders.
In SE treatment, the therapist works at creating
a supportive therapeutic relationship and then,
after carefully identifying the patients predominant narratives about self and other, generates a
dynamic formulation of the patients main relationship pattern. This dynamic formulation
entitled the Core Conflictual Relationship Theme
(CCRT: Luborsky & Crits-Christoph, 1990)
consists of three components: The patients
main wishes, the patients main perceived and
expected responses of others, and the patients
main responses of self to these responses of others. Following the generation of the CCRT, the
therapist interprets facets of the formulation with
regard to the patients past and present interpersonal relationships, including the patients transferential relationship with the therapist. Specific
attention is placed on helping the patient with
AVPD see how his or her use of interpersonal
avoidance as it appears in the transference relates
to avoidance in other relationships in his or her
life (Barber et al., 1997).
Measures
Beck Anxiety Inventory (BAI: Beck, Epstein,
Brown, & Steer, 1988). The BAI is a 21-item
self-report measure of the severity of clinical
anxiety symptoms. Patients are asked to rate how
much they are bothered by their anxiety symptoms over the past week using a four-point scale
(0 to 3). High scores on the BAI indicate greater
self-reported levels of anxiety. Beck et al. (1988)
and Steer, Ranieri, Beck, and Clark (1993) have
found the BAI has good-to-excellent internal
consistency, testretest reliability, and convergent and discriminant validity within several outpatient psychiatric samples.
Beck Depression Inventory (BDI: Beck, Ward,
Mendelson, Mock, & Erbaugh, 1961). The BDI is
a 21-item self-report measure of depression. Pa-
498
tients are asked to endorse the extent to which

statements describe their feelings over the past
week using a four-point scale (0 to 3). High
scores on the BDI indicate greater self-reported
levels of depression. A meta-analysis of research
studies using the BDI revealed that the measure
has good-to-excellent internal consistency, test
retest reliability, and convergent and discriminant
validity within psychiatric samples (Beck, Steer,
& Garbin, 1988).
Global Assessment of Functioning (GAF:
DSMIIIR [APA, 1987], Axis V). The GAF is a
single global rating provided by an assessor that
is used to estimate the patients overall psychological, social, and occupational functioning currently and the patients highest overall level of
functioning within the past year. The GAF ranges
from 1 (severe and persistent difficulties in functioning) to 100 (superior levels of functioning).
For the present study, the GAF-current level of
functioning was utilized for data analysis. Williams et al. (1992) reported high levels of interrater agreement using the GAF in a multisite
study of DSMIIIR diagnosis.
Inventory of Interpersonal Problems (IIP:
Horowitz, Rosenberg, Baer, Ureno, & Villasenor,
1988). The IIP is a 127-item self-report questionnaire intended to operationalize various types of
interpersonal problems that are commonly the
focus of psychotherapy. Alden, Wiggins, and
Pincus (1990) developed a shorter 64-item version of the IIP (IIP-C), which consists of eight
8-item scales intended to operationalize the octants of a circumplex of interpersonal problems.
In both versions patients use a five-point scale to
report their amount of distress related to behaviors they find hard to do with others (e.g., It is
hard for me to be assertive with another person)
and for behaviors they do too much with others
(e.g., I put other peoples needs before my own
too much). Studies have found the IIP and IIP-C
exhibit high internal consistency, testretest reliability, sensitivity to clinical change, and predictive validity (Alden et al., 1990; Alden & Capreol, 1993; Horowitz et al., 1988; Horowitz,
2
One patient did not finish the treatment protocol, having
received only 30 therapy sessions. The patient had difficulty
reliably attending sessions but remained an active patient in
the protocol for one year. After careful consideration, it was
decided that patients outcome scores at the second midtreatment evaluation (approximately month 8) would be used to
represent the posttreatment indices.

Rosenberg, & Bartholomew, 1993). The present
study used the patients average score on the 64
items common to the Horowitz et al., (1988) and
Alden et al., (1990) versions of the IIP. This
average score provides an estimate of the patients overall level of interpersonal distress, with
higher average scores reflecting greater levels of
interpersonal distress (Gurtman & Balakrishnan,
1998).
Wisconsin Personality Disorders Inventory
(WISPI: Klein, et al., 1993). The WISPI is a
240-item self-report questionnaire organized into
11 scales, with each scale corresponding to one of
the DSMIIIR (APA, 1987) Personality Disorders. Although the WISPI items and scales were
derived from the DSMIIIR Personality Disorder symptom criteria, they are different from
other self-report measures of personality disorder
(e.g., SCID-II) because they have been translated
and reformulated according to an interpersonal
theory of personality (Benjamin, 1993, 1996).
Studies by Klein et al. (1993) and Barber and
Morse (1994) have found that the WISPI scales
have excellent internal consistency and test
retest reliability as well as good convergent and
discriminant validity in samples of patients diagnosed with personality disorders.
Each item on the WISPI is rated on a 10-point
scale (1 Never or not at all true of you; 10
Always or extremely true of you) and patients
are asked to rate their usual selves during the past
five years or more. Raw summary scores for each
scale (mean rating of the items for each scale)
were computed and transformed to z-scores using
normative data provided by Klein et al. (1993).
For the present study only the AVPD subscale
score was examined for data analysis, with higher
scores reflecting higher levels of AVPD
symptoms.
Selection of Sessions
Audiotapes and verbatim transcripts of one
early session (e.g., Session 5) of SE treatment
from each of the 14 patients were examined in the
present study. The selection of early sessions for
data analysis is consistent with other investigations that have explored the relationship between
moment-to-moment interpersonal processes between patients and therapists and treatment outcome (e.g., Henry et al., 1986, 1990).
Process Measures
Therapist Interventions. Connolly et al.
(1998) developed a method for assessing therapist interventions consistent with the techniques
of SE treatment in order to provide a detailed,
molecular-level description of individual SE sessions and to link such descriptive data with more
molar measures of therapist adherence and competence. As described in Connolly et al. (1998),
judges classify each therapist speaking turn into
one of eight response mode categories: interpretation, clarification, question, restatement, role
play, informational or directional statement regarding therapy, self-disclosure, or other.
Judges also rate each therapist speaking turn for
the presence of persons (e.g., therapist, parent,
significant other) and time frames (e.g., focus on
childhood through adolescence, adult past to
present, in session). In the present study two
judges (second year graduate students at Penn
State University) independently classified each
therapist speaking turn using the above methods
and reached consensus on any discrepant classifications. Only consensus scores were used for
statistical analyses. Judges were blind to patient
outcome and to the nature of the study.
As in Connolly et al. (1998), interpretations
were defined as therapist statements that pointed
out or suggested: (a) a patient thought, feeling, or
behavior; (b) a link between a patients thoughts,
feelings, or behaviors; (c) that a thought, feeling,
or behavior formed a pattern over settings or
people; or (d) a link between a thought, feeling,
or behavior to past life experiences. An example
of a therapist interpretation taken from a transcript is: You dont seem to think that your
parents are capable of handling anything that is
difficult or upsetting. Transference interpretations were defined as any interpretation that specifically included the therapist as an object of the
statement (Connolly et al., 1999). An example of
a therapist transference interpretation taken from
a transcript is, You seem to be worried that I will
be critical of you if you express how you are truly
feeling. Statements were considered interpretations (transference or nontransference interpretations) only if the judges felt that they went beyond the patients level of awareness, that is, the
statements needed to go beyond what the patient
immediately verbalized and convey an intent to
add awareness to the patients understanding of
what was being discussed. Simple references to
499
Schut et al.
FIGURE 1. The SASB circumplex model, cluster version, interpersonal surfaces. Adapted from Benjamin (1993), Interpersonal
Diagnosis and treatment of personality disorders. New York: Guilford Press.
patient thoughts, feelings, and/or behaviors were

not sufficient to score as interpretations. Previous
research has found that judges can reliably classify therapist statements into these interpretive
categories, with intraclass correlation coefficients
(ICCs) ranging from .66 to .88 (Connolly et al.,
1998, 1999).
PatientTherapist Interpersonal Process. Benjamins (1974, 1993, 1996) SASB model was
utilized to code interpersonal process between
patients and therapists. SASB is a circumplex
model of interpersonal and intrapsychic behavior
that allows for fine-grained description of the
quality of interpersonal communications between
members of any dyad. Its roots lie within the
interpersonal (e.g., Sullivan, 1953) and object
relations (e.g., Fairbairn, 1952) psychoanalytic
traditions as well as in the interpersonal/
personality theories of Leary (1957), Murray
(1938), and Schaefer (1965). A complete description of the history, development, and applications
of SASB is beyond the scope of this study, and so
the reader is directed to several excellent texts
and articles reviewing this approach (Benjamin,
1996; Constantino, 2000; Henry, 1994; Pincus &
Ansell, 2003; Pincus & Benjamin, 2001).
The present study utilized the SASB coding
500
manual of Benjamin, Giat, and Estroff (1981) to

code patient and therapist interpersonal process.
The procedure for coding is as follows. First,
each patient and therapist speaking turn is segmented into individual thought units, which are
defined as any portions of speech expressing one
complete thought (usually about one spoken sentence). Next, each thought unit is coded in terms
of its interpersonal focus, that is, whether the
thought unit has reference to another person or to
the speaker, and in terms of its accompanying
levels of affiliation and interdependence, the two
orthogonal dimensions underlying the SASB
model. The two dimensions of affiliation and
interdependence combine with interpersonal focus to form two interrelated circumplex surfaces
designed to describe interpersonal behavior.3
Figure 1 presents these two circumplex surfaces of the SASB. Surface One: Focus on
3
There is a third circumplex surface of the SASB entitled
introject, which is intended to capture intrapsychic actions
directed toward the self (cf. Sullivan, 1953). However, as
described by Henry et al. (1986), this surface is typically used
in content, rather than process analysis, and so the data from
this surface were not utilized in the present study.

Other describes transitive actions toward a directed object. Surface Two: Focus on Self
describes intransitive reactions to another person.
As can be seen from the figure, these two surfaces
are structurally similar in that both place the
affiliation dimension on the horizontal axis and
the interdependence dimension on the vertical
axis. As one moves from left to right on either
circumplex, interpersonal actions and reactions
progress from being disaffiliative to affiliative in
nature. As one moves from top to bottom on
either circle, interpersonal actions and reactions
progress from being differentiated to enmeshed
in nature.
According to the SASB model, every interpersonal behavior (thought unit) can be described in
terms of interpersonal focus and in terms of varying combinations of affiliation and interdependence. Each point around each circumplex reflects a blend of the two dimensions and is
assigned a SASB code as well as a descriptive
label. These codes/labels are the clinical data that
the SASB approach allows coders and clinicians
to generate. For the present study, the SASB
cluster model was used, which yields SASB
codes that consist of two numbers. The first number of the code reflects interpersonal focus (i.e.,
1 focus on other; 2 focus on self) and the
second number reflects the position (1 through 8)
around the particular circumplex used to describe
the thought unit in question. For example, SASB
code 12 (Affirm) describes a combination of
moderate affiliation and moderate differentiation
focused on another person, whereas SASB code
27 (Recoil) describes a combination of extreme
disaffiliativeness and neutral differentiation focused on the self. As can be seen, interpersonally
complementary behaviors are represented at homologous points across the surfaces. For example, intransitive submitting to another (25) is
the interpersonal complement of transitive control (15).
Benjamin et al. (1981) and Henry et al. (1986,
1990) have found coders to be reliable both in
terms of the segmenting process and in terms of
assigning SASB codes to patient and therapist
thought units. For the present study, coding was
conducted by a pair of advanced graduate students at the University of Utah who were extensively trained and supervised by L. S. Benjamin,
the inventor of the SASB approach.
Judges used both the transcripts and the audiotapes to code for interpersonal process of patient
and therapist. Each transcript was first segmented

by one of the two judges. Judges then coded in
tandem all thought units contained within patient
and therapist dialogue. 4 To establish reliability
between coders, judges independently coded 50
thought units (randomly selected within each
transcript) of every other session. A weighted
(Cohen, 1968) coefficient was computed to determine levels of interrater agreement on the assignment of SASB codes to thought units (see
Results). All coding discrepancies between
judges were resolved by consensus, and consensus scores were used for all statistical analyses.
SASB judges were also blind to patient outcome
and to the nature of the study.
Isolation of Specific SASB Variables and
Patient and Therapist Thought Units
Because the studys hypotheses specifically
concern the relationships between the degree of
affiliativeness versus disaffiliativeness in patient
therapist interpersonal process and therapy outcome, a procedure was implemented to extract
these aspects of patient and therapist communications. Based on the procedure of Hilliard,
Henry, and Strupp (2000), the sum of all SASB
codes falling in a given affiliative or disaffiliative
cluster was multiplied by a weight representing
the relative affiliativeness or disaffiliativeness of
the respective cluster. These weighted sums were
then added together, providing global affiliation
and disaffiliation scores. Separate measures of
affiliation and disaffiliation were calculated for
therapist interpersonal process and patient interpersonal process according to the particular
thought units and hypotheses being examined.
To test the hypothesis regarding the relationship between therapist interpersonal process during interpretation and outcome, all thought units
4
Note that while most thought units tend to be described
with one SASB code (i.e., by one specific part of the SASB
model), some thought units can be described with more than
one SASB code if they convey more than one interpersonal
message. An example of the latter would be when a message
simultaneously communicates acceptance and rejection.
Though units that have multiple SASB codes are called complex communications. In the present study, each part of a
complex communication was treated separately (e.g., a 1-2/
1-6 thought unit was counted as one instance of 1-2 and one
instance of 1-6) to increase the frequency count of the corresponding clusters (Henry et al., 1990).
501
Schut et al.
making up each therapist interpretation were isolated for data analysis. Measures of affiliation and
disaffiliation for these thought units were computed and then divided by the total number of
thought units within each therapists interpretations in order to remove the artifact of differing
amounts of therapist speech across patients.
In order to test the hypothesis regarding the
relationship between therapistpatient interpersonal process prior to interpretation and outcome
it was first necessary to define the number of
patient and therapist statements to include in the
analysis. For the present study, all thought units
contained within one therapist and one patient
statement preceding each interpretation were
used to operationalize the interpersonal context
within which the therapist offers his or her interpretations. However, when a therapist interpretation was immediately followed by another interpretation, the thought units used to define the
interpersonal context of the second interpretation
become overlapped with the thought units contained within the first interpretation. To prevent
the inclusion of thought units associated with
more than one interpretation, only interpretations
separated by at least one noninterpretive intervention were analyzed in terms of the quality of
their interpersonal contexts. Once these particular
therapist and patient statements were identified,
affiliation and disaffiliation scores for both therapist and patient communications preceding interpretations were computed and then divided by
the total number of therapist or patient thought
units contained within their respective statements
to correct for amount of therapist and patient
speech.
To test the hypothesis regarding the relationship between patient immediate response to interpretation and outcome, all thought units making up each patient initial speaking turn following
each therapist interpretation were isolated for
data analysis. Patient measures of affiliation and
disaffiliation for the thought units contained
within these statements were then computed and
divided by the total number of thought units
within these statements in order to remove the
artifact of differing amounts of speech across
patients.
Results
Judges exhibited good interrater agreement in
terms of classifying therapist interventions as in-
502
terpretations ( .72) and in terms of assigning

SASB codes to thought units (Weighted .79).
However, it should be noted that the measure of
reliability for the classification of therapist statements into the category interpretations involved aggregating judges ratings of transference and nontransference interpretations. This
was done because of the low base rate of transference interpretations in the sessions sampled.
To clarify, therapists averaged 189 turns of talk
(SD 82.01) per session, with roughly 25 of
these turns (or 14.4% of all therapist turns) classified as interpretations (M 24.86, SD 9.66).
However, the average number of transference
interpretations provided by these therapists was
only about two per session (M 2.29, SD
3.41). In fact, 36% of the patients did not receive
any transference interpretations, and 50% of the
patients received no more than one transference
interpretation in their particular session studied.
Thus the majority of interpretations (90.8% of all
interpretations) focused on aspects of the patients functioning outside of his or her immediate relationship with the therapist.
Despite the fact that transference interpretations occurred infrequently, it was believed that
they should be included in the overall analyses
examining the effects of the amount of interpretation and the effects of patienttherapist interpersonal process associated with interpretation on
outcome. Consequently, all statistical tests described below involving interpretations considered both transference and nontransference interpretations together.
Kazdin (1994) suggested that researchers investigating theoretically important questions with
small sample sizes might decide to reconsider the
alpha level for their statistical analyses. The small
N of the present study, coupled with its exploratory nature and theoretically derived predictions,
led us to set alpha at p .10 (two-tailed). However, based on the recommendations of Cohen
(1988), greater emphasis was placed on the magnitude (effect size) rather than on the p value
associated with each statistical test. Specifically,
any measure of association between predictor and
criterion variables that was equal to or greater
than .30 (medium effect size: Cohen, 1988) was
considered to be meaningful.
One patient had missing values on the IIP and
WISPI at termination. It was decided to replace
these missing values with the mean of the 13

remaining cases on each of the two variables. As
described by Tabachnick and Fidell (2001), estimating missing values for ungrouped data using
mean substitution is a conservative procedure in
that the mean for the distribution as a whole does
not change.
Prior to statistical analyses all predictor and
criterion variables were examined for the presence of outliers. An outlier was defined as any
score having a standardized score (z-score) with
an absolute value greater than or equal to 3.25.
Any case having an outlier on a given variable
was assigned a raw score on the offending variable that was one unit larger (or smaller) than the
next most extreme score in the distribution
(Tabachnick & Fidell, 2001). This procedure resulted in the adjustment of one patients posttreatment BAI score, a second patients score on
the amount of affiliation in reaction to interpretation, and a third patients score on the amount
of disaffiliation in the therapists communications
prior to interpretation.
Hypothesis 1: Relationship Between the Amount
of Interpretation and Therapy Outcome
Partial correlations were conducted in which
raw frequency and concentration of therapist
interpretation were correlated with each outcome variable (controlling for pretreatment
levels of each outcome variable) in order to
determine whether or not the amount of interpretation would be significantly related to patient change. As predicted, raw frequency of
interpretation was not associated with any of
the patient outcome measures (see Table 1).
TABLE 1. Partial Correlations Between Raw Frequency
and Proportion of Interpretation and Outcome
Outcome variable
Frequency of
interpretation
Proportion of
interpretation
BAI
BDI
IIP
.19
.08
.16
.32
.08
.47
WISPI
.25
.62**
GAF
.19
.50*
Note. N 14. BAI Beck Anxiety Inventory; BDI

Beck Depression Inventory; IIP Inventory of Interpersonal Problems Average Score; WISPI Wisconsin Personality Disorders Inventory: AVPD Subscale; GAF
Global Assessment of Functioning. High outcome scores
are undesirable except on GAF. All meaningful partial
correlations (i.e., rs .30) are underlined.
* p .10. ** p .05
However, statistically significant inverse relationships were found between concentration of

interpretation and favorable outcome on the
WISPI, r(11) .62, p .05, and on the GAF,
r(11) .50, p .10. Although not statistically significant, similar meaningful inverse relationships were found between concentration
of interpretation and favorable outcome on the
BAI and IIP.
Hypothesis 2: Relationship Between Therapist

Interpersonal Process During Interpretation
and Therapy Outcome
measures of therapist affiliativeness and disaffiliativeness during the use of interpretation
were correlated with each outcome variable
(controlling for pretreatment levels of the outcome variables) in order to test the hypothesis
that interpretations offered in an affiliative
manner would be positively associated with
patient outcome whereas interpretations offered in a disaffiliative manner would be negatively associated with patient outcome. Consistent with the hypothesis, a statistically
significant inverse relationship was found between therapist disaffiliativeness during interpretation and favorable outcome on the GAF,
r(11) .58, p .05 (see Table 2). Although
not statistically significant, similar meaningful
inverse relationships were found between therapist disaffiliativeness during interpretation
and favorable outcome on the IIP and WISPI.
Therapist affiliativeness during interpretation
did not reliably or meaningfully correlate with
favorable outcome.
Post hoc correlations were conducted in order
to examine the relationship between concentration of interpretation and therapist levels of affiliation and disaffiliation during the use of interpretation. Concentration of interpretation was
found to be positively associated with disaffiliative therapist process during interpretations,
r(14) .70, p .01, and negatively associated
with affiliative therapist process during interpretations, r(14) .52, p .10, suggesting that
persistent use of interpretation was related to
higher levels of therapist hostility and lower levels of therapist warmth during the provision of
interpretive techniques.
503
Schut et al.
TABLE 2. Partial Correlations Between Measures of
Therapist Interpersonal Process During Interpretation
and Outcome
SASB process
variable
Therapist
affiliativeness
Therapist
disaffiliativeness
Outcome variable
BAI
.15
BDI
IIP
.05 .03
.03 .21
.36
WISPI
GAF
.26
.27
.40
.58**

** p .05.
Hypothesis 3: Relationship Between Therapist

Patient Interpersonal Process Prior to
Interpretation and Therapy Outcome
measures of therapist and patient affiliativeness
and disaffiliativeness for statements occurring
immediately before interpretations were correlated with each outcome variable (controlling for
pretreatment levels of each outcome variable) in
order to test the hypothesis that affiliative
therapistpatient interpersonal process prior to
interpretation would be positively associated with
patient outcome whereas disaffiliative therapist
patient interpersonal process prior to interpretation would be negatively associated with patient
outcome. Consistent with the hypothesis, a statistically significant direct relationship was found
between patient affiliativeness prior to interpretation and favorable outcome on the GAF, r(11)
.51, p .10 (see Table 3). Similar meaningful
but nonstatistically significant direct relationships
were also found between patient affiliativeness
prior to interpretation and favorable outcome on
the IIP and WISPI. Contrary to predictions, however, statistically significant inverse relationships
were found between therapist affiliativeness prior
to interpretation and favorable outcome on the
BAI, r(11) .48, p .10, and on the BDI,
r(11) .53, p .10.
With respect to patient and therapist levels of
disaffiliativeness prior to interpretation, statistically significant inverse relationships were found
between patient disaffiliativeness and favorable
outcome on the IIP, r(11) .57, p .05, and on
504
the GAF, r(11) .58, p .05. A similar

meaningful but nonstatistically significant inverse association was found between patient
disaffiliativeness prior to interpretation and favorable outcome on the BAI. Therapist disaffiliativeness prior to interpretation was not found to
be reliably associated with any of the outcome
variables, although several meaningful inverse
associations were found between therapist disaffiliativeness prior to interpretation and favorable
outcome on the BAI, IIP, and GAF.
A series of post hoc correlations were conducted in order to examine the relationship between concentration of interpretation and levels
of patient and therapist affiliation and disaffiliation prior to interpretation. The main findings
from these analyses were that concentration of
interpretation was positively associated with disaffiliative therapist process before interpretation,
r(14) .59, p .05, and disaffiliative patient
process before interpretation, r(14) .60, p
.05, suggesting that persistent use of interpretive
techniques was related to higher levels of hostility in patienttherapist transactions prior to the
use of interpretation.
Hypothesis 4: Relationship Between Patient
Interpersonal Process Immediately Following
Interpretation and Therapy Outcome
measures of patient affiliativeness and disaffiliTABLE 3. Partial Correlations Between Measures of
Therapist-Patient Interpersonal Process Prior to
Interpretation and Outcome
SASB process
variable
Outcome variable
BAI
BDI
IIP
WISPI
GAF
Therapist
affiliativeness
.48* .53* .06
.21
.10
Therapist
disaffiliativeness .30
.24
.42
.19 .46
Patient
affiliativeness
.22 .18 .47
.38
.51*
Patient
disaffiliativeness .36
.29
.57**
.23 .58**
* p .10. ** p .05

ativeness for statements immediately following
interpretations were correlated with each outcome variable (controlling for pretreatment levels
of the outcome variables) in order to test the
hypothesis that affiliative patient process following interpretations would be positively associated
with patient outcome whereas disaffiliative patient process following interpretations would be
negatively associated with patient outcome. Patient levels of affiliativeness and disaffiliativeness
immediately after therapist interpretation were
not reliably associated with any of the outcome
variables (see Table 4). Consistent with the above
prediction, however, nonstatistically significant
but meaningful relationships were found between
patient levels of affiliation and disaffiliation immediately following interpretation and outcome
on the BAI, with patient affiliativeness associated
with lower patient levels of anxiety symptoms at
termination and patient disaffiliativeness associated with higher levels of anxiety symptoms at
termination.
Post hoc correlations were conducted in order
to examine the relationship between concentration of interpretation and levels of patient affiliation and disaffiliation immediately after interpretation. Concentration of interpretation was
found to be negatively related with affiliative
patient process following interpretations, r(14)
.54, p .05, suggesting that persistent use of
interpretations was associated with lower levels
of patient interpersonal warmth immediately after
interpretations were provided.
TABLE 4. Partial Correlations Between Measures of

Patient Interpersonal Process Immediately Following
Interpretation and Outcome
SASB process
variable
Patient
affiliativeness
Patient
disaffiliativeness
Outcome variable
BAI
BDI
IIP
WISPI
GAF
.44
.22
.00
.20
.12
.32
.16
.05
.06
.04

Discussion
Clinical experience and refinements to psychoanalytic metapsychology have led many clinicians and theoreticians to ordain interpretation as
one of the most powerful agents of change in
psychodynamic forms of treatment. The present
study intended to empirically evaluate this core
tenet underlying psychodynamic psychotherapy
and extend the results of earlier research by utilizing a context-sensitive investigative approach
as suggested by various psychotherapy process
researchers (Binder & Strupp, 1997; Greenberg,
1986; Hill, 1990; Winston et al., 1993). Specifically, the present work sought to measure the
effects of the amount of interpretation provided
along with the effects of the moment-to-moment
interpersonal process between patient and therapist before, during, and after such interventions
were provided on the process of change within a
sample of patients diagnosed with AVPD.
Several clear patterns emerged with respect to
the associations between the amount of interpretation, patienttherapist interpersonal process
surrounding interpretation, and patient change.
First, as expected, raw frequency of interpretation
was not found to be associated with any measure
of patient outcome. On the other hand, higher
concentration of therapist interpretation was associated with lower global ratings of patient functioning and higher levels of patient symptoms
and interpersonal distress at treatment termination. This latter finding was somewhat surprising
given that concentration of interpretation in and
of itself has not been found to be a reliable
predictor of patient outcome (e.g., Piper et al.,
1986). However, as reviewed earlier, several
studies have found that the effects of concentration of interpretation on patient outcome may
depend on patients pretreatment level of object
relations (e.g., Connolly et al., 1999; Ogrodniczuk et al., 1999; Piper et al., 1991). Considering
the studys sample, it is relevant to note that
patients with personality disorders typically exhibit lower pretreatment levels of object relations
than patients without personality disorders
(Ogrodniczuk & Piper, 1999). Moreover, patients
with low pretreatment levels of object relations
tend to respond poorly to moderate-to-high levels
of interpretive work, particularly when the focus
of interpretation is on the therapeutic relationship
(e.g., Connolly et al., 1999; Ogrodniczuk et al.,
1999). Although patients pretreatment level of
505
Schut et al.
object relations was not directly used as a predictor variable in the present study, it could be that
the AVPD patients had low quality of object
relations, and that this variable accounted for the
inverse relationship found between concentration
of interpretation and favorable outcome. As
stated earlier, however, therapists in the present
study rarely focused directly on the therapeutic
relationship when making interpretations, and
Hglend (1996) has found that interpreting aspects of patients lives outside the here-and-now
therapeutic relationship can be useful for patients
with personality disorders. At a minimum, the
current findings suggest that clinicians should
refrain from using a high concentration of interpretation with patients with AVPD at such an
early stage of treatment.
The results also suggest that therapists should
be mindful of the interpersonal manner and context within which their interpretations are provided. The data generated from the coding of
early sessions for interpersonal process with the
SASB were generally consistent with predictions
that the degree to which exchanges between patient and therapist immediately before, during,
and after interpretation are affiliative or disaffiliative can be differentially predictive of patient
change. We find it interesting that many of the
effects found with the SASB that were in the
predicted direction occurred with the level of
disaffiliation in patient and therapist process, despite the fact that the overall proportions of disaffiliative therapist and patient process before,
during, and after interpretations were quite low.
Prior to interpretation only 0.6% (SD 1.2%) of
therapist communications and only 0.2% (SD
0.5%) of patient communications were disaffiliative. During interpretation only 2.1% (SD
3.9%) of therapist communications were disaffiliative. And immediately following interpretation
only 0.7% (SD 1.4%) of patient communications were disaffiliative. Taken together, the results provide clear support for the importance of
interpersonal transactions early in therapy during
which interpretive techniques are being used.
Moreover, the findings are consistent with the
results of Henry and colleagues, who suggested
that while the absence of disaffiliative patient or
therapist process may not be sufficient for therapeutic change, the presence of even low levels of
such disaffiliative interpersonal process may be
sufficient to preclude patient change (Henry et
al., 1990, p. 773).
506
The series of post hoc correlations between

concentration of interpretation and SASB interpersonal process variables also suggest the importance of measuring the impact of therapist
interpretive techniques within their interpersonal
contexts. Analyses revealed several statistically
significant associations between the amount of
interpretation provided and the precise nature of
patienttherapist interpersonal process before,
during, and after interpretations. Specifically,
therapists who persisted with interpretive interventions appeared to have significantly more hostile interaction sequences with their patients and
had their patients react to interpretation with significantly less warmth than therapists who used
interpretations more judiciously. These findings
are consistent with the observations of Piper et al.
(1999), who described disaffiliative transactions
between therapists and patients during those sessions with the highest concentration levels of
interpretive interventions.
It is our contention that these findings are noteworthy from a scientific as well as from a clinical
standpoint. First, technical and relational aspects
of psychodynamic psychotherapy, which have
historically been difficult to operationalize and
thus rarely empirically tested, were not only reliably assessed in our study but also meaningfully
linked to patient change. Second, surprisingly
small amounts of disaffiliative process were
found to have a rather dramatic negative impact
on treatment outcome. Third, the overall patterns
found between concentration of interpretation,
patienttherapist interpersonal process, and treatment outcome emerged from studying very early
sessions of psychotherapy. Fourth, in contrast to
those who may recommend actively using interpretation, particularly transference interpretation,
our data suggest that clinicians need to be more
actively mindful of the frequency, interpersonal
manner, and relational context within which interpretations are offered.
Indeed, our results appear to lead to some
practical clinical recommendations for therapists
who may be involved in the treatment of patients
with AVPD. In order to promote therapeutic
change the therapist should refrain from using a
disproportionate concentration of interpretations
early in treatment. Interpretations should not be
made under poor interpersonal contexts, that is,
when the therapist and patient are engaging in
disaffiliative interaction patterns, and the interpretations themselves should be devoid of disaf-

filiative process. Finally, the interpersonal reaction of the patient to interpretation should be
monitored by the therapist and used as a potential
marker as to whether he or she should proceed
with further interpretive work or engage in alternative modes of intervening (e.g., supportive
techniques). Although the strength of the relationship found between patient reaction to interpretation and outcome was relatively weak with
the exception of the BAI, a consistent affiliative
response by the patient to interpretation may be
indicative of eventual positive outcome, whereas
a consistent disaffiliative patient response may be
indicative of eventual less positive outcome.
These findings, obviously, do not imply that
interpretations should be avoided altogether in
the treatment of patients with AVPD. On the
contrary, interpretations that were provided in
small concentrations under mutually affiliative
therapistpatient interactions were generally associated with positive patient change. What the
take home message appears to be is that the
therapist should carefully consider the degree to
which interpretations make up his or her overall
intervention strategy as well as the interpersonal
manner and relational context in which such interventions are used in the early stages of treatment of patients with AVPD.
Although speculative, it may be that the links
found between high concentration of interpretation and negative therapistpatient process before, during, and after interpretation reflect the
matrix of transference-countertransference dynamics stemming, in part, from these patients
habitual modes of relating. As described by Benjamin (1996), patients with AVPD often rely on
social withdrawal and fearful restraint as a defensive adaptation to early experiences of being
blamed, belittled, and/or rejected. Perhaps some
of the therapists in our study may have unwittingly been pulled to disaffiliatively engage with
patients via interpretation during moments when
patients were becoming increasingly walled off
from them, leading these patients to feel attacked
by their therapists. Those therapists who persisted
with interpretation may have then attempted to
use the intervention to reengage the patient
and/or repair a perceived rupture in the therapy
relationship as a result of the initial interpretation(s), but, as our data suggest, such a strategy
only exacerbated patient negative process, and, in
turn, exacerbated therapist disaffiliativeness. Of
course, it may be that the content of some of the
interpretations themselves were experienced by

some of the patients as accusatory. As described
by Wile (1984), interpretations that are derived
from theoretical views of the patient as being
defensive, avoidant, and so forth, may serve to
perpetuate patient self-criticism and increase disengagement between therapist and patient.
Binder and Strupp (1997) argue that negative
exchanges between patients and therapists that
involve overt or covert hostility, such as those
found in the present study, may be unavoidable
aspects of the therapy process. The key is
whether such processes can be readily identified
and managed therapeutically early enough in
treatment so as to prevent further disengagement
between patient and therapist from taking place.
Clearly, the presence and impact of disaffiliative
process early in the treatment of these AVPD
patients suggests that therapists need to closely
monitor their reactions to patients during the initial stages of the therapeutic process and be careful not to provide interpretations in a manner or
negative interpersonal context that serves to
maintain patients disaffiliative self-states and interpersonal schemas. As described by Benjamin
(1996), therapists working with patients with
AVPD should be particularly sensitive to interactions in which they notice themselves feeling
pulled to either ignore or blame the patient for his
or her situation.
How might therapists come to readily identify
and manage disaffiliative transactions in their
therapeutic work with patients? This issue is of
great significance given that previous research
has found that projects designed specifically to
help therapists detect and manage such negative
interactions in session have not been particularly
successful (Henry, Strupp, Butler, Schacht, &
Binder, 1993). According to several authors
(Binder & Strupp, 1997; Constantino, Castonguay, & Schut, 2001; Safran & Muran, 2000),
one therapeutic strategy that shows great promise
is the process of metacommunication. In metacommunication, the therapist processes his or her
observations with the patient about their hereand-now interaction, which entails having both
parties examine their own contribution to the
unfolding of the relationship. In many ways
metacommunication serves as a disarming
strategy (Burns, 1990) in that it suggests to the
patient that he or she is not the sole contributor to
ruptures in the therapy process. However, as discussed by Binder and Strupp (1997), metacom-
507
Schut et al.
munication is a complex skill that is difficult to
acquire without substantial practice and supervision, as it requires that the therapist first be able
to observe process as he or she is participating in
it and then devise helpful strategies while he or
she is engaged with the patient in the therapy
hour. Binder and Strupp (1997) thus suggest that
clinical researchers continue to intensively study
sequences of therapistpatient interaction in
cases where disaffiliative process is successfully
and unsuccessfully managed in order to increase
the fields understanding of the nature of negative
process and the specific skills required to manage
it (Binder & Strupp, 1997, p. 135).
Although coming from a tradition of understanding and effectively managing therapist
countertransference, Gelso and Hayes (2001)
have argued that five factors need to be considered and monitored in order to reduce the likelihood of therapist acting out negatively toward
the patient, and thereby hindering the treatment
process. They are: therapist self-insight (the extent to which the therapist is aware of his or her
own feelings and their origins), therapist selfintegration (the degree to which the therapist has
a healthy character structure), anxiety management (the extent to which the therapist can experience anxiety but not let it take hold of his or her
interventions), empathy (the extent to which the
therapist can climb into the patients world), and
conceptualizing ability (the capacity to understand patient and therapy dynamics).
Given our data and the extant reviews of therapy process, it may be that therapists who find
themselves entrenched in negative therapeutic
process, the roots of which may stem from
transference-countertransference dynamics or interpersonal complementarity, might need to first
step back, offer validation to the patient of their
present moment experience, including an acknowledgment of the therapists own contribution to the patients upset, and be open to refraining from offering interpretations of the patients
experience until more mutually affiliative transactions ensue.
Conceptual Issues and Limitations of the
Present Study
Although the results suggest that clinicians
need to be more actively mindful of the frequency, manner, and interpersonal context within
which they offer interpretation, several caveats
508
and limitations of the study warrant discussion.

First, the results should be considered very preliminary given the small sample size and therefore low statistical power. On the one hand, with
increased power perhaps more of the analyses
would have been statistically significant. On the
other hand, a large number of tests were conducted using a small N, and thus some of the
findings reported above may be due to chance. In
other words, while the findings as a whole form a
cohesive and predicted pattern, one has to be
tentative in making generalizations about the results. Second, it is possible that therapists varied
in other important dimensions of interpretation.
For example, it is not clear to what extent therapists were accurate in their interpretations or to
what extent therapists offered interpretations of
various depths (e.g., therapists may have differed
in the degree to which their interventions highlighted highly defended material, archaic fantasies, preoedipal wishes and fears, etc.). Therapists might have varied in accuracy and/or depth
of their interpretations, which, in conjunction
with concentration, patient quality of object relations, and/or patienttherapist interpersonal process, led to the pattern of results. Third, it is
unclear why therapist affiliation prior to interpretation was inversely associated with favorable
outcome on the BAI and BDI. Although this
unexpected finding could have been due to
chance, future research should examine whether
such results replicate. Specifically, given that the
affiliation score reflects an aggregate of therapist
actions and reactions, qualitative and quantitative
studies should be conducted in order to delineate
what specifically is taking place when therapists
engage affiliatively with their patients prior to
using interpretations. One possibility is that the
therapists in the present study were too accepting
and not challenging enough to help patients face
their interpersonal fears and avoidant behaviors
and that such responses resulted in poor change
on the BAI and BDI (cf. Barber & Muenz, 1996).
Other statistical techniques, such as sequential
analyses, could be used to explore the momentby-moment interaction sequences between patients and therapists to address this issue.
Future researchers should begin to address
these conceptual and methodological issues and
find more creative ways to examine the role and
impact of patient and therapist interpersonal process associated with interpretation on the outcome of psychodynamic psychotherapy. Doing
so will allow psychodynamic clinicians to have

something that they have lacked thus far in their
work with patients: empirical evidence supporting the use and parameters of interpretive interventions. Continuing this line of research will
also address the need to investigate the individual
and combined roles of technical and relationship
factors in effective forms of psychotherapy, a
major concern voiced by numerous psychotherapy researchers (Hill, 1990).
References
ALDEN, L. A., & CAPREOL, M. J. (1993). Avoidant personality disorder: Interpersonal problems as predictors
of treatment response. Behavior Therapy, 24, 357376.
ALDEN, L. A., WIGGINS, J. S., & PINCUS, A. L. (1990).
Construction of circumplex scales for the Inventory of
Interpersonal Problems. Journal of Personality Assessment, 55, 521536.
American Psychiatric Association. (1987). Diagnostic
and statistical manual of mental disorders (3rd ed., revised). Washington, DC: Author.
ARLOW, J. A. (1987). The dynamics of interpretation.
Psychoanalytic Quarterly, 56, 68 87.
BARBER, J. P., & MORSE, J. Q. (1994). Validation of the
Wisconsin Personality Disorders Inventory with the
SCID-II and PDE. Journal of Personality Disorders, 8,
307319.
BARBER, J. P., MORSE, J. Q., KRAKAUER, I. D., CHITTAMS, J., & CRITS-CHRISTOPH, K. (1997). Change in
obsessive-compulsive and avoidant personality disorders following time-limited supportive-expressive therapy. Psychotherapy, 34, 133143.
BARBER, J. P., & MUENZ, L. R. (1996). The role of
avoidance and obsessiveness in matching patients to
cognitive and interpersonal psychotherapy: Empirical
findings from the Treatment for Depression Collaborative Research Program. Journal of Consulting and Clinical Psychology, 64, 951958.
BECK, A. T., EPSTEIN, N., BROWN, G., & STEER, R. A.
(1988). An inventory for measuring clinical anxiety:
Psychometric properties. Journal of Consulting and
Clinical Psychology, 56, 893 897.
BECK, A. T., STEER, R. A., & GARBIN, M. G. (1988).
Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. Clinical Psychology Review, 8, 77100.
BECK, A. T., WARD, C. H., MENDELSON, M., MOCK, J., &
ERBAUGH, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561571.
BENJAMIN, L. S. (1974). Structural analysis of social behavior. Psychological Review, 81, 392 425.
BENJAMIN, L. S. (1993). Interpersonal diagnosis and treatment of personality disorders (1st ed.). New York: Guilford Press.
BENJAMIN, L. S. (1996). Interpersonal diagnosis and treatment of personality disorders (2nd ed.). New York:
Guilford Press.
BENJAMIN, L. S., GIAT, L., & ESTROFF, S. (1981). Coding
manual for structural analysis of social behavior
(SASB). Unpublished manuscript, University of Wisconsin, Department of Psychiatry, Madison, WI.

BIBRING, E. (1954). Psychoanalysis and the dynamic psychotherapies. Journal of the American Psychoanalytic
Association, 2, 745770.
BINDER, J. L., & STRUPP, H. H. (1997). Negative process: A recurrently discovered and underestimated
facet of therapeutic process and outcome in the individual psychotherapy of adults. Clinical Psychology:
Science and Practice, 4, 121139.
BRENNER, C. (1979). Working alliance, therapeutic alliance, and transference. Journal of the American Psychoanalytic Association, 27, suppl., 137157.
BURNS, D. D. (1990). The feeling good handbook. New
York: Plume.
CLARKIN, J. F., YEOMANS, F. E., & KERNBERG, O. F.
(1999). Psychotherapy for borderline personality. New
York: Wiley.
COHEN, J. (1968). Weighted kappa: Nominal scale agreement with provision for scale disagreement or partial
credit. Psychological Bulletin, 70, 213220.
COHEN, J. (1988). Statistical power analysis for the social
sciences (pp. 75107). Hillsdale, NJ: Erlbaum.
CONNOLLY, M. B., CRITS-CHRISTOPH, P., SHAPPELL, S.,
BARBER, J. P., & LUBORSKY, L. (1998). Therapist interventions in early sessions of brief supportive-expressive
psychotherapy for depression. Journal of Psychotherapy Practice and Research, 7, 290 300.
CONNOLLY, M. B., CRITS-CHRISTOPH, P., SHAPPELL, S.,
BARBER, J. P., LUBORSKY, L., & SHAFFER, C. (1999).
Relation of transference interpretations to outcome in
the early sessions of brief supportive-expressive psychotherapy. Psychotherapy Research, 9, 485 495.
CONSTANTINO, M. J. (2000). Interpersonal process in psychotherapy through the lens of the Structural Analysis
of Social Behavior. Applied and Preventative Psychology, 9, 153172.
CONSTANTINO, M. J., CASTONGUAY, L. G., & SCHUT, A. J.
(2001). The working alliance: A flagship for the
scientist-practitioner model in psychotherapy. In
G. S. Tryon (Ed.), Counseling based on process research: Applying what we know (pp. 81131). Boston:
Allyn & Bacon.
COOPER, A. M. (1987). Changes in psychoanalytic ideas:
Transference interpretation. Journal of the American
Psychoanalytic Association, 35, 7798.
CRITS-CHRISTOPH, P., COOPER, A., & LUBORSKY, L.
(1988). The accuracy of therapists interpretations and
the outcome of dynamic psychotherapy. Journal of
Consulting and Clinical Psychology, 56, 490 495.
DAVANLOO, H. (1978). Basic principles and techniques in
short-term dynamic psychotherapy. New York: Spectrum Publications.
FAIRBAIRN, W. R. D. (1952). An object relations theory of
the personality. New York: Basic Books.
FREUD, S. (1912). The dynamics of transference. SE, 12,
99 108.
FREUD, S. (1913). On beginning the treatment (Further
recommendations on the technique of psycho-analysis
I). SE, 12, 123144.
FREUD, S. (1914). Remembering, repeating, and workingthrough (Further recommendations on the technique of
psycho-analysis II). SE, 12, 147156.
FREUD, S. (1915). Observations on transference-love
509
Schut et al.
(Further recommendations on the technique of psychoanalysis III). SE, 12, 159 171.
GELSO, C. J., & HAYES, J. A. (2001). Countertransference
management. Psychotherapy, 38, 418 422.
GILL, M. (1982). Analysis of transference (Vol. 1): Theory
and technique. New York: International Universities
Press.
GREENBERG, L. S. (1986). Change process research. Journal of Consulting and Clinical Psychology, 54, 4 9.
GURTMAN, M. B., & BALAKRISHNAN, J. D. (1998). Circular measurement redux: The analysis and interpretation
of interpersonal circle profiles. Clinical Psychology: Science and Practice, 5, 344 360.
HGLEND, P. (1993). Transference interpretations and
long-term change after dynamic psychotherapy of brief
to moderate length. American Journal of Psychotherapy, 47, 494 507.
HGLEND, P. (1996). Analysis of transference in patients
with personality disorders. Journal of Personality Disorders, 10, 122131.
HENRY, W. P. (1994). Differentiating normal and abnormal personality: An interpersonal approach based on
the Structural Analysis of Social Behavior. In S. Strack
& M. Lorr (Eds.), Differentiating normal and abnormal
personality (pp. 316 340). New York: Springer.
HENRY, W. P., SCHACHT, T. E., & STRUPP, H. H. (1986).
Structural analysis of social behavior: Application to a
study of interpersonal process in differential therapeutic outcome. Journal of Consulting and Clinical Psychology, 54, 2731.
HENRY, W. P., SCHACHT, T. E., & STRUPP, H. H. (1990).
Patient and therapist introject, interpersonal process,
and differential psychotherapy outcome. Journal of
Consulting and Clinical Psychology, 58, 768 774.
HENRY, W. P., STRUPP, H. H., BUTLER, S. F., SCHACHT,
T. E., & BINDER, J. L. (1993). Effects of training in
time-limited dynamic psychotherapy: Changes in therapist behavior. Journal of Consulting and Clinical Psychology, 61, 434 440.
HILL, C. E. (1990). Exploratory in-session process research in individual psychotherapy: A review. Journal
of Consulting and Clinical Psychology, 58, 288 294.
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 outcomes. Journal of Consulting
and Clinical Psychology, 68, 125133.
HOROWITZ, L. M., ROSENBERG, S. E., BAER, B. A.,
UREN O, G., & VILLASEN OR, V. S. (1988). Inventory of
interpersonal problems: Psychometric properties and
clinical applications. Journal of Consulting and Clinical
Psychology, 56, 885 892.
HOROWITZ, L. M., ROSENBERG, S. E., & BARTHOLOMEW,
K. (1993). Interpersonal problems, attachment styles,
and outcome in brief dynamic psychotherapy. Journal
of Consulting and Clinical Psychology, 61, 549 560.
JOSEPHS, L. (1992). The timing of an interpretation: A
comparative review of an aspect of the theory of therapeutic technique. Psychoanalytic Review, 79, 3154.
KAZDIN, A. E. (1994). Methodology, design, and evaluation in psychotherapy research. In A. E. Bergin &
S. L. Garfield (Eds.), Handbook of psychotherapy and
behavior change (4th ed., pp. 19 71). New York: Wiley.
KIESLER, D. J. (1983). The 1982 interpersonal circle: A
510
taxonomy for complementarity in human transactions.

Psychological Review, 90, 185214.
KLEIN, M. (1952). The origins of transference. International Journal of Psychoanalysis, 33, 433 438.
KLEIN, M. H., BENJAMIN, L. S., ROSENFELD, R., TREECE,
C., HUSTED, J., & GREIST, J. H. (1993). The Wisconsin
Personality Disorders Inventory: Development, reliability, and validity. Journal of Personality Disorders, 7,
285303.
KOHUT, H. (1984). How does analysis cure? Chicago:
University of Chicago Press.
LEARY, T. F. (1957). Interpersonal diagnosis of personality. New York: Ronald Press.
LOEWALD, H. (1960). On the therapeutic action of psychoanalysis. International Journal of Psychoanalysis,
41, 16 33.
LUBORSKY, L. (1984). Principles of psychoanalytic psychotherapy: A manual for supportive-expressive treatment. New York: Basic Books.
LUBORSKY, L., BACHRACH, H., GRAFF, H., PULVER, S., &
CHRISTOPH, P. (1979). Preconditions and consequences
of transference interpretations: A clinical-quantitative
investigation. Journal of Nervous and Mental Disease,
167, 391 401.
LUBORSKY, L., & CRITS-CHRISTOPH, P. (1990). Understanding transference: The core conflictual relationship
theme method. New York: Basic Books.
MALAN, D. H. (1976). Toward the validation of dynamic
psychotherapy. New York: Plenum Press.
MANN, J. (1973). Time-limited psychotherapy. Cambridge, MA: Harvard University Press.
MARZIALI, E. (1984). Prediction of outcome of brief psychotherapy from therapist interpretive interventions.
Archives of General Psychiatry, 41, 301304.
MCCULLOUGH, L., WINSTON, A., FARBER, B. A., PORTER,
F., POLLACK, J., LAIKIN, M., VINGIANO, W., & TRUJILLO, M. (1991). The relationship of patienttherapist
interaction to outcome in brief psychotherapy. Psychotherapy, 28, 525533.
MURRAY, H. A. (1938). Explorations in personality. New
York: Oxford University Press.
NORVILLE, R., SAMPSON, H., & WEISS, J. (1996). Accurate
interpretations and brief psychotherapy outcome. Psychotherapy Research, 6, 16 29.
OGRODNICZUK, J. S., & PIPER, W. E. (1999). Use of
transference interpretations in dynamically oriented individual psychotherapy for patients with personality
disorders. Journal of Personality Disorders, 13, 297
311.
OGRODNICZUK, J. S., PIPER, W. E., JOYCE, A. S., & MCCALLUM, M. (1999). Transference interpretations in
short-term dynamic psychotherapy. Journal of Nervous
and Mental Disease, 187, 572579.
PINCUS, A. L., & ANSELL, E. B. (2003). Interpersonal
theory of personality. In T. Millon & M. J. Lerner
(Eds.), Comprehensive handbook of psychology, Vol. 5:
Personality and SocialPsychology (pp. 209 229). New
York: Wiley.
PINCUS, A. L., & BENJAMIN, L. S. (2001). Structural analysis of social behavior (SASB): A method for the scientific study of psychopathology and psychotherapy. In
preparation.
PIPER, W. E., AZIM, H. F. A., JOYCE, A. S., & MCCALLUM, M. (1991). Transference interpretations, thera-

peutic alliance, and outcome in short-term individual
psychotherapy. Archives of General Psychiatry, 48,
946 953.
PIPER, W. E., DEBBANE, E. G., BIENVENU, J. P., DE CARUFEL, F. L., & GARANT, J. (1986). Relationships between the object focus of therapist interpretations and
outcome in short-term individual psychotherapy. British Journal of Medical Psychology, 59, 111.
PIPER, W. E., OGRODNICZUK, J. S., JOYCE, A. S., MCCALLUM, M., ROSIE, J. S., OKELLY, J. G., & STEINBERG,
P. I. (1999). Prediction of dropping out in time-limited,
interpretive individual psychotherapy. Psychotherapy,
36, 114 122.
SAFRAN, J. D., & MURAN, J. C. (2000). Negotiating the
therapeutic alliance: A relational treatment guide. New
York: Guilford Press.
SCHAEFER, E. S. (1965). Configurational analysis of childrens reports of parent behavior. Journal of Consulting
Psychology, 29, 552557.
SCHUT, A. J., & CASTONGUAY, L. G. (2001). Reviving
Freuds vision of a psychoanalytic science: Implications
for clinical training and education. Psychotherapy, 38,
40 49.
SIFNEOS, P. E. (1987). Short-term dynamic psychotherapy:
Evaluation and technique, (2nd ed.). New York: Plenum Press.
SILBERSCHATZ, G., FRETTER, P. B., & CURTIS, J. T.
(1986). How do interpretations influence the process of
psychotherapy? Journal of Consulting and Clinical Psychology, 54, 646 652.
STEER, R. A., RANIERI, W. F., BECK, A. T., & CLARK,
D. A. (1993). Further evidence for the validity of the

Beck Anxiety Inventory with psychiatric outpatients.
Journal of Anxiety Disorders, 7, 195205.
STRACHEY, J. (1934). The nature of the therapeutic action
of psychoanalysis. International Journal of Psychoanalysis, 15, 127159.
SULLIVAN, H. S. (1953). The interpersonal theory of psychiatry. New York: Norton.
TABACHNICK, B. G., & FIDELL, L. S. (2001). Using multivariate statistics (4th ed.). Boston: Allyn & Bacon.
WALLERSTEIN, R. S. (1992). Psychoanalysis: The common
ground. In R. S. Wallerstein (Ed.), The common
ground of psychoanalysis (pp. 203242). Northvale, NJ:
Jason Aronson.
WALLERSTEIN, R. S., & DEWITT, K. N. (1997). Intervention modes in psychoanalysis and in psychoanalytic
psychotherapies: A revised classification. Journal of
Psychotherapy Integration, 7, 129 150.
WILE, D. B. (1984). Kohut, Kernberg, and accusatory
interpretations. Psychotherapy, 21, 353364.
WILLIAMS, J. B. W., GIBBON, M., FIRST, M. B., SPITZER,
R. L., DAVIES, M., BORUS, J., HOWES, M. J., KANE, J.,
POPE, H. G., JR., ROUNSAVILLE, B., & WITTCHEN, H.-U.
(1992). The structured clinical interview for DSM
IIIR (SCID) II. Multisite test-retest reliability. Archives of General Psychiatry, 49, 630 636.
WINSTON, A., MCCULLOUGH, L., & LAIKIN, M. (1993).
Clinical and research implications of patienttherapist
interaction in brief psychotherapy. American Journal of
Psychotherapy, 47, 527539.
511

Therapist Interpretation, Patient-Therapist Interpersonal Process, and Outcome in Psychodynamic Psychotherapy For Avoidant Personality Disorder

Uploaded by

Copyright:

Available Formats

Therapist Interpretation, Patient-Therapist Interpersonal Process, and Outcome in Psychodynamic Psychotherapy For Avoidant Personality Disorder

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Therapist Interpretation, Patient-Therapist Interpersonal Process, and Outcome in Psychodynamic Psychotherapy For Avoidant Personality Disorder

Uploaded by

Copyright:

Available Formats

Psychotherapy: Theory, Research, Practice, Training

2005, Vol. 42, No. 4, 494 511

Copyright 2005 by the Educational Publishing Foundation

THERAPIST INTERPRETATION, PATIENTTHERAPIST

Pennsylvania State University

The authors examined the link between

tion of interpretation was positively

Alexander J. Schut and Louis G. Castonguay, Department of

A large number of psychodynamically oriented

Keywords: interpretation, interpersonal

Special Issue: Interpretation, Interpersonal Process, and Outcome

bly produce mutative treatment effects but

tient to continue therapy, the patient submitted to

Special Issue: Interpretation, Interpersonal Process, and Outcome

tients are asked to endorse the extent to which

Special Issue: Interpretation, Interpersonal Process, and Outcome

patient thoughts, feelings, and/or behaviors were

manual of Benjamin, Giat, and Estroff (1981) to

Special Issue: Interpretation, Interpersonal Process, and Outcome

and therapist. Each transcript was first segmented

terpretations ( .72) and in terms of assigning

Special Issue: Interpretation, Interpersonal Process, and Outcome

Note. N 14. BAI Beck Anxiety Inventory; BDI

However, statistically significant inverse relationships were found between concentration of

Hypothesis 2: Relationship Between Therapist

Note. N 14. BAI Beck Anxiety Inventory; BDI

Hypothesis 3: Relationship Between Therapist

the GAF, r(11) .58, p .05. A similar

Special Issue: Interpretation, Interpersonal Process, and Outcome

TABLE 4. Partial Correlations Between Measures of

Note. N 14. BAI Beck Anxiety Inventory; BDI

The series of post hoc correlations between

Special Issue: Interpretation, Interpersonal Process, and Outcome

interpretations themselves were experienced by

and limitations of the study warrant discussion.

Special Issue: Interpretation, Interpersonal Process, and Outcome

so will allow psychodynamic clinicians to have

(SASB). Unpublished manuscript, University of Wisconsin, Department of Psychiatry, Madison, WI.

taxonomy for complementarity in human transactions.

Special Issue: Interpretation, Interpersonal Process, and Outcome

D. A. (1993). Further evidence for the validity of the

You might also like