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Clinical Psychology and Psychotherapy

Clin. Psychol. Psychother. 19, 187–202 (2012)

Published online 2 March 2011 in Wiley Online Library ( DOI: 10.1002/cpp.743

Exploring In‐Session Focus on the

Patient–Therapist Relationship: Patient
Characteristics, Process and Outcome
Klara Kuutmann1 and Mark J. Hilsenroth2*
Department of Psychology, Uppsala University, Uppsala, Sweden
Derner Institute, Adelphi University, Garden City, NY, USA

This study explored the amount of in‐session focus on the patient–therapist relationship during early
treatment with patient pre‐treatment interpersonal style, personality pathology, patient ratings of
session process and outcome. The sample consisted of 76 outpatients engaged in short‐term
psychodynamic psychotherapy. Results showed that higher levels of pre‐treatment personality
pathology and interpersonal problems were positively related to a greater focus on the patient–
therapist relationship early in treatment. This was especially true for patients with a cold/distant
interpersonal style and low self‐esteem. Moreover, these two patient pre‐treatment characteristics
demonstrated a significant change over the course of therapy. These post‐treatment changes also
demonstrated a significant relationship with greater early treatment focus on the patient–therapist
relationship. In addition, we found an interaction effect between quality of object relations (i.e., higher
levels of object relations) and greater early treatment focus on the patient–therapist relationship with
subsequent changes in patient cold/distant interpersonal problems. Greater in‐session focus on the
therapeutic relationship was not significantly related to patient ratings of session process. Implications
for clinical practice and future research are discussed. Copyright © 2011 John Wiley & Sons, Ltd.

Key Practitioner Message:

• Greater levels of pre‐treatment patient personality pathology and interpersonal problems were
positively related to a more here‐and‐now focus on the patient–therapist relationship in early treatment.
• This was especially true of patients with a cold and withdrawn interpersonal style or lower levels of
• These patient pre‐treatment characteristics, cold/distant interpersonal style and low self‐esteem,
exhibited significant change over the course of psychodynamic psychotherapy.
• The amount of change in these specific patient characteristics, cold/distant interpersonal style and low
self‐esteem, was significantly related with a greater focus on the patient–therapist interactions that
occurred in early sessions.
• For those patients with less impaired object relations, greater patient–therapist focus helped improve a
cold/distant interpersonal style even more.

Keywords: Therapeutic Relationship, Interpersonal Problems, Rupture, Transference, Object Relations,

Psychodynamic Psychotherapy

A focus on in‐session patient–therapist interactions Jacobson, 2001; Safran & Muran, 2000; Strupp & Binder,
has been identified for its importance in several 1984; Yalom, 1995, 2002). The significance of working in
different approaches in psychotherapy (Beck, 1995; Beck, the therapeutic relationship was first recognized by Freud
Rush, Shaw, & Emery, 1979; Horvath & Greenberg, 1994; (1916) in his development of the concept of transference,
Kiesler, 1988, Kohlenberg & Tsai, 1991; Martell, Addis, & an intrapsychic phenomenon based on fantasies when
patients ascribe to the therapist qualities based on their
previous relational experiences with important figures
*Correspondence to: Mark J. Hilsenroth, Ph.D., ABAP, Professor of from their past. Subsequent psychoanalytic authors have
Psychology, The Derner Institute of Advanced Psychological
Studies, Adelphi University, 302 Weinberg Bldg, 158 Cambridge
suggested that the transference concept should include
Ave, Garden City, NY 11530‐0701, USA. additional aspects of the interaction between the therapist
E‐mail: and the client, which also take into account the

Copyright © 2011 John Wiley & Sons, Ltd.

188 K. Kuutmann and M. J. Hilsenroth

contribution of the therapist (Ehrenreich, 1989; Gabbard, the therapeutic relationship to be an important factor in
2000; Gill, 1984; Gill & Hoffman, 1982; Høglend and the resolution of patient reports of ruptures with their
Gabbard, in press). Most recently, contemporary psycho- therapist. Therefore, identifying and disseminating
dynamic theorists view the therapeutic relationship not strategies for solving treatment ruptures are important
only as an important foundation for the therapeutic for improving effectiveness in psychotherapy. Further
work but also as one of the core mechanisms in the developing this idea, Safran and Muran (2000) proposed
change process itself, i.e., exploring the ‘here‐and‐now’ two stage‐process models for how to resolve ruptures in
in‐session process (Strupp & Binder, 1984). This includes the therapeutic alliance, in which a focus on the
thoughts and feelings about the treatment relationship, therapeutic relationship plays a figural role in the
interactions from a dyadic, interactive, and relational eventual resolution of these ruptures. These two models
perspective (Cooper, 1987; Safran & Muran, 2000; are based on the different rupture subtypes, those
Wachtel, 1993, 2008), without directly linking this representing withdrawal and confrontation. Withdrawal
exploration to a past other from an intrapsychic distor- ruptures may occur with overly compliant patients or
tion perspective. The difference between these theoretical avoidant patients who have difficulties in expressing
perspectives is an important distinction that often their needs in the relationship. Confrontation ruptures
muddies the water in research on in‐session patient– are manifested as directly expressed hostility or resent-
therapist interactions. ment towards the therapist or the treatment. According
To overcome the definitional ambiguity of these to Safran and Muran, the therapist in both withdrawal
perspectives, Hill (2004) made a distinction between and confrontation situations easily becomes embedded
transference interpretations, and what she referred to as in the patients’ cyclical–relational patterns by respond-
therapist immediacy (‘disclosure within the therapy ing to the rupture interactions in a way that reinforces
session of how the therapist is feeling about the client, their feelings and beliefs (expected response of other;
him‐ or herself in relation to the client, or about the Core Conflictual Relational Theme (CCRT); Luborsky,
therapeutic relationship’).1 Immediacy seeks to create a 1984). To disembed himself or herself from the patients’
corrective emotional experience for the patient by a focus enacted cyclical patterns, the therapist needs to direct the
on here‐and‐now awareness, whereas transference inter- patients’ attention to the here‐and‐now of the therapeu-
pretations are used to help the patient discover and tic relationship. Thus, a focus on the here‐and‐now
understand the origin of the displaced interactional therapeutic relationship is one way to explore the
patterns enacted during the session and is therefore patients’ underlying construal of the interaction and
more focused on previous relationships. Hill (2004) helps the patient to become aware of and, through a
suggested that focusing on the therapeutic relationship corrective emotional–relational experience, change his or
can be used for addressing relationships’ problems in her maladaptive interpersonal patterns.
general, discussing issues of importance specific to the Safran, Muran and colleagues have also presented
therapeutic relationship, challenging patients to recognize research that provides some support for the use of their
maladaptive patterns, making covert communication in model, including a focus on the therapeutic relationship,
the session more direct, providing the patient with as effective in rupture resolution (Muran et al., 2009;
feedback and providing the patient with a model of how Safran, Muran, Samstag, & Winston, 2005). Also, one
to resolve interpersonal problems. recent study found that a greater focus on the therapeutic
One area where a focus on the therapeutic relationship relationship was significantly related to patients’ indirect
is particularly important is regarding treatment ruptures rupture markers and to patient’s collaborative process
(Hill, Sim, Spangler, Stahl, & Sullivan, 2008; Muran et al., (Colli & Lingiardi, 2009). This suggests some relationship
2009). For instance, an early study in this area by between a greater focus on the patient–therapist inter-
Rhodes, Hill, Thompson and Elliot (1994) found focus on action, the presence of subtle, less explicit problems in that
relationship as well as patients actively engaging in the
therapeutic work together with the therapist. Likewise,
research from non‐psychodynamic treatments examining
In order to capture the more interactive and dyadic nature of the an explicit focus on the therapeutic relationship has also
therapeutic relationship we offer a slight modification of this
been related to positive outcomes (Bennett, Parry, & Ryle,
definition to also reflect any patient initiated disclosures of feelings
about the therapist or their relationship, and the revised term of 2006; Constantino et al., 2008).
“Therapeutic Immediacy.” Thus, Therapeutic Immediacy involves any In addition to this research, Hill and colleagues
discussion within the therapy session about the relationship between presented two single case studies of brief interpersonal
therapist and patient that occurs in the here‐and‐now, as well as any therapy that focus on the therapeutic relationship and
processing of what occurs in the here‐and‐now patient‐therapist
interaction. Finally, we would offer this term as a more experience examine the qualitative nature of theses interventions as
near alternative to many current uses of the construct “transference” well as their impact on client involvement and outcome
in the Psychodynamic lexicon. (Hill et al., 2008; Kasper, Hill, & Kivlighan, 2008).

Copyright © 2011 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 19, 187–202 (2012)
Patient–Therapist Interactions 189

The studies showed that a focus on the therapeutic mixed and were challenging to interpret. For instance,
relationship can take on various forms (confronting and two studies have demonstrated that a greater number of
challenging, supportive and empowering etc.), can be transference interpretations have led to negative outcome
used for different reasons (i.e., processing the therapeutic effects for patients with high QOR (Høglend, 1993; Piper,
relationship as an end goal versus using the technique Azim, Joyce, & McCallum, 1991), whereas two studies
only when needed), can be helpful depending on different have found positive or equivalent effects for patients with
circumstances and contexts (e.g., the patients need, when high QOR (Connolly et al., 1999; Ogrodniczuk, Piper,
in treatment it is applied etc.) and can lead to an increased Joyce, & McCallum, 1999). These studies have discussed
client involvement. These authors expressed a need for this discrepancy in terms of the frequency of transference
future research to examine what characteristics of the interpretations, with the former studies having high levels
therapist and the patient, as well as situational factors, may per session (i.e., five to six), whereas the latter studies
be related to a greater focus on the therapeutic relationship. utilizing low to moderate levels per session (i.e., one to
Regarding this connection between patient pre‐ four; Høglend, 2004; Piper, Ogrodniczuk & Joyce, 2004).
treatment characteristics and the therapeutic relationship, Most recently, in an experimental study, patients with
several studies have demonstrated that the patient’s high QOR benefitted equally from treatments with and
capacity for affiliation influences the development of the without transference interpretations, whereas patients
affective bond between patient and therapist (Diener, with low QOR benefitted more from treatment including
Hilsenroth & Weinberger, 2009). Saunders (2001) examined transference interpretations, an effect that was sustained
this relationship and found that greater patient interper- during long‐term follow‐up (Høglend et al., 2006;
sonal problems, particularly an overly detached style and Høglend et al., 2008; Høglend, Johansson, Marble,
lower self‐esteem, were associated with a poorer quality Bøgwald, & Amlo, 2007).
of the therapeutic bond. Similar results were found by To our knowledge, no studies have specifically examined
Beretta et al. (2005) in that alliance was negatively what pre‐treatment patient characteristics are related to the
associated with interpersonal problems of a cold/distant subsequent focus by therapists on the here‐and‐now
style. Recently, Hersoug, Monsen, Havik and Høglend therapeutic relationship with their patients during
(2002) and Hersoug, Høglend, Havik, von der Lippe and treatment, irrespective of outcome. Therefore, our study
Monsen (2009) found that higher levels of interpersonal aimed to explore what patient interpersonal/relational
problems of a cold/distant style were associated with characteristics might be related to the therapists’ focus on
poorer early alliance, rated by both therapists and patients. the therapeutic relationship early in treatment (i. e., two
Moreover, the quality of past significant relationships was sessions within the first 3 months of therapy) and then to
related to both patient and therapist ratings of working follow this line of inquiry with regard to other relevant
alliance. However, despite this initial poor relationship processes and outcome analyses. In addition, the study
with alliance, a central finding was that patients with examined this technique not from the traditional perspec-
cold/distant problems demonstrated positive change over tive of a transference interpretation (i.e., explicit link
the course of therapy (Hersoug et al., 2009). In relation to between the current therapy relationship with a person’s
that, Luyten, Lowyck and Vermote (2010) found that past/present or internal dynamic components) but more
although patients may only demonstrate limited gains in broadly as any in‐session discussion of the therapeutic
cold and socially avoidant interpersonal functioning over relationship. We first examined how pre‐treatment
the course of treatment, these changes have a significant patient interpersonal style and personality pathology
relationship to overall symptomatic improvement at relate to the subsequent in‐session focus on the therapy
12 months post‐treatment. These findings led both studies relationship. Moreover, we investigated how the use of
(Hersoug et al., 2009; Luyten et al., 2010) to suggest that this patient–therapist focus is related to patient‐rated
future research should examine the differential impact of process variables from the same early treatment sessions.
patient characteristics as well as the contribution of Finally, we examined how pre‐treatment patient character-
patient–therapist interactions for building an effective istics that may be related to a greater focus on the
working alliance with these cold/distant patients. To date, therapeutic relationship change over the course of treat-
only a few studies have examined the relation between ment. Since this is the first study of its kind, our
pre‐treatment patient characteristics, specifically with a investigation is more exploratory in nature, although given
greater technical focus on the treatment relationship in the research reviewed above, we anticipated that some
relation to outcome, and these have been primarily limited pre‐treatment relational and personality characteristics
to patient quality of object relations (QOR). may either facilitate or demand a greater focus on the
Although several studies have demonstrated the inter- therapeutic relationship (i.e., cold, detached, hostile, QOR).
action between patient QOR, the exploration of the We also anticipated that such pre‐treatment characteristics
treatment relationship (under the purview of transference specifically related to the amount of in‐session focus on the
interpretations) and outcome, these findings have been patient–therapist relationship early in treatment would

Copyright © 2011 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 19, 187–202 (2012)
190 K. Kuutmann and M. J. Hilsenroth

likely change during the course of therapy if this interven- American Psychiatric Association, 1994; based on the
tion is subsequently to be related with effective outcomes. psychological assessment process described below). All 76
patients in this study received a DSM‐IV axis I diagnosis,
and 42 patients received an axis II disorder (cluster A = 3,
METHOD cluster B = 25, cluster C = 14). In addition, 19 patients were
assessed to have subclinical but prominent axis II features
Participants or traits (cluster A = 4, cluster B = 4, cluster C = 11). Thus,
this sample consisted of primarily mood‐disordered
All the participants in this study (N = 76) were patients patients with relational problems manifested in either axis
admitted to a psychodynamic psychotherapy treatment II personality disorders or subclinical traits/features of
team at a university‐based community outpatient clinic axis II personality disorders.
(Hilsenroth, 2007). Cases were assigned to treatment
practitioners and clinicians in an ecologically valid manner
based on real‐world issues regarding aspects of clinician Therapists
availability, caseload etc. Moreover, patients were accepted
for treatment regardless of disorder or co‐morbidity. In this Clinicians in the study were 26 advanced doctoral
sample of 76 individuals, 55 patients were female, and 21 students (13 men and 13 women) enrolled in an American
were male. The mean age for this sample was 29.68 years Psychological Association‐approved clinical Ph.D.
(standard deviation [SD] = 10.00). Table 1 displays the programme. Each clinician received a minimum of
demographic information as well as the distribution of 3.5 hours of supervision per week (1.5 hours of individual
patients’ primary axes I and II diagnoses for the entire supervision and 2 hours of group supervision) on the
sample in accordance with the Diagnostic and Statistical therapeutic model of assessment (TMA; Finn & Tonsager,
Manual of Mental Disorders, Fourth Edition (DSM‐IV; 1997; Hilsenroth, 2007), clinical interventions, organization
of collaborative feedback, psychodynamic therapy and
review of videotaped case material. Individual and group
Table 1. Demographic information of sample (N = 76) supervisions focused heavily on the review of the
videotaped case material and technical interventions. All
Variable clinicians were trained in psychodynamic psychotherapy
Gender by using guidelines delineated by Book (1998), Luborsky
Male 21 (28%) (1984), McCullough et al. (2003) and Wachtel (1993) as
Female 55 (72%) well as selected readings on psychological assessment,
psychodynamic theory and psychodynamic psychotherapy
Mean age (SD) 29.68 (10.00)
(for a more detailed description of this training process,
Marital status see Hilsenroth, DeFife, Blagys, & Ackerman, 2006).

Single 46 (60.53%)
Married 19 (25.00%) Treatment
Divorced 10 (13.16%)
Widowed 1 (1.36%) Patients first received a psychological evaluation from
the TMA (Finn & Tonsager, 1997; Hilsenroth, 2007) that
Primary axis I diagnosis attempts to optimize the evaluation phase with its
utilization of a multimethod assessment (i.e., interview,
Adjustment disorder 9 (11.84%)
Anxiety disorder 10 (13.16%)
self‐report, performance tasks and free‐response mea-
Eating disorder 3 (3.95%) sures), as well as a heightened focus upon developing
Mood disorder 40 (52.63%) and maintaining empathic connections with patients,
Substance‐related disorder 1 (1.32%) factors contributing to the maintenance of life problems
V‐code relational problems 12 (15.79%) (often relational), collaboration to define individualized
treatment goals and tasks, as well as sharing and exploring
Axis II diagnosis 42 (55.26%)
assessment results with patients. The TMA used in this
Axis II trait/features 19 (31.15%)
study consisted of four steps including three meetings
Pre‐treatment psychiatric severity between the patient and the clinician totalling approxi-
mately 4.5 hours, and one patient appointment to
Mean BSI‐GSI (SD) 1.60 (0.58) complete a battery of self‐report measures. The three
Mean GAF (SD) 60.16 (5.90) meetings included (1) a semi‐structured diagnostic inter-
BSI‐GSI = Brief Symptom Inventory— Global Severity Index. GAF = view (Westen & Muderrisoglu, 2003, 2006); (2) an interview
Global Assessment of Functioning. SD = standard deviation. follow‐up; and (3) a collaborative feedback session. During

Copyright © 2011 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 19, 187–202 (2012)
Patient–Therapist Interactions 191

the collaborative feedback session, there was an emphasis patients and therapists immediately after selected sessions
on the prominent interpersonal/intrapersonal themes prior to these review points. Regarding these ratings,
derived from the testing results, the patient–therapist patients were informed both verbally and in writing that
interaction, the factors that contribute to the maintenance their therapist would not have access to their responses on
of life problems as well as the opportunity to explore these any psychotherapy process measure (i.e., alliance, session
new understandings and apply them to their current process etc.). Also, all sessions of these treatments were
problems in living. The patient and the clinician also videotaped and not just the sessions during in which
reviewed a socialization interview, developed by Luborsky reassessment ratings were completed. Patient process and
(1984) on what to expect in psychodynamic psychotherapy, independent technique ratings for this study were col-
and the patient’s and the clinician’s roles during formal lected at the same two points in time within the
treatment; highlighted the relational focus of the therapeutic first 3 months of therapy (post‐TMA assessment), pre-
process that he or she may become aware of the issues that dominantly the third and the ninth sessions. We chose to
were not known before the start of psychotherapy; and use these two early treatment sessions because they are
outlined potential outcomes (both positive and negative) of standard process assessment points in our programmatic
this new insight. Finally, the clinician and the patient study of psychodynamic psychotherapy. In addition, we
worked together to develop treatment goals and negotiate chose to use the average process ratings across these two
an explicit treatment frame (i.e., scheduling session times, early treatment sessions in order to provide greater
frequency of treatment session(s), missed sessions and psychometric stability for the variables under investiga-
payment plan). In all cases, the clinician who carried out tion (as opposed to scores from only a single session). All
the psychological assessment was also the clinician who patients included in the present analyses had attended a
conducted the formal psychotherapy sessions. minimum of nine sessions and had completed, at least,
Individual psychotherapy consisted of once or twice the ninth session reassessment battery. Mean number of
weekly sessions of short‐term psychodynamic psychother- sessions attended by these 76 patients was 29 sessions over
apy organized, aided and informed (but not prescribed) by an average of 9 months. However, the median number of
the technical guidelines delineated in the treatment sessions and length of treatment were somewhat shorter at
manuals detailed above. The key features of the short‐ 21 sessions and 6 months, respectively.
term psychodynamic psychotherapy treatment model
utilized in these sessions included (Blagys & Hilsenroth,
2000) (1) focus on affect and the expression of emotion; (2) Assessment Measures
exploration of attempts to avoid topics or engage in Personality Disorder Index
activities that may hinder the progress of therapy; (3) The Personality Disorder Index (PDI) is a dimensional
identification of patterns in actions, thoughts, feelings, classification of personality pathology (0‐2) that simply
experiences and relationships; (4) emphasis on past provides a numerical equivalent for the presence of a
experiences; (5) focus on interpersonal experiences; (6) personality disorder (2), the presence of subclinical features
emphasis on the therapeutic relationship; and (7) (1) and no personality disorder (0; Hilsenroth et al., 2000),
exploration of wishes, dreams or fantasies. In addition based on the DSM‐IV axis II diagnosis (derived from the
to these areas of treatment focus, relational patterns, case TMA process). The dimension of subclinical features
presentations and symptoms were conceptualized in the accounts for the presence of personality dysfunction that
context of cyclical patterns (Book, 1998; Luborsky, 1984; meets some but not all full diagnostic criteria for a given
McCullough et al., 2003; Wachtel, 1993). Also, the model axis II disorder. Hilsenroth et al. (2000) found that the PDI
of intervention by Safran and Muran (2000) was used for was associated with clinician‐rated global distress, global
treatment ruptures and for their repair as they occurred social and occupational functioning and global relational
in the therapeutic relationship. Treatment was open ended functioning. Further details of the PDI methodology and
in length rather than of a fixed duration. Whenever a procedures utilized in this study are described more fully
termination date was set, this became a frequent area of elsewhere (Peters, Hilsenroth, Eudell‐Simmons, Blagys, &
intervention as issues related to the termination were often Handler, 2006). The PDI ratings used in the study
linked to key interpersonal, affective and thought patterns demonstrated an excellent level of inter‐rater reliability
prominent in that patient’s treatment. (intraclass correlation coefficient [intraclass correlation
Treatment goals were first explored during the assess- coefficient ICC 1,2] = 0.92; Peters et al., 2006).
ment feedback session, and a formal treatment plan was
reviewed with each patient early in the course of
psychotherapy that was subsequently reviewed at regular Social Cognition and Object Relations Scale
intervals for changes, additions or deletions. Reassessment The Social Cognition and Object Relations Scale
of patient functioning on a standard battery of outcome (SCORS) (D. Westen, Harvard University Medical School,
measures as well as process ratings were completed by unpublished manuscript, 1995; Hilsenroth, M., Stein, M.,

Copyright © 2011 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 19, 187–202 (2012)
192 K. Kuutmann and M. J. Hilsenroth

& Pinsker, J. (2007). Social Cognition and Object supervisor (a licensed Ph.D. clinical psychologist). Further
Relations Scale: Global Rating Method (SCORS‐G). details of the SCORS methodology and procedures utilized
Unpublished manuscript. The Derner Institute of Ad- in this study are described more fully elsewhere (Peters
vanced Psychological Studies, Adelphi University, Garden et al., 2006). The SCORS variables used in the study
City, NY.) is a narrative‐based, global–dimensional object demonstrated good to excellent levels of inter‐rater
relations measure designed to assess a variety of dynamic reliability (ICC 1,2 = 0.61–0.83; Peters et al., 2006).
personality features beyond the overt presentation of the
patient. The SCORS consists of eight clinician‐rated
Inventory of Interpersonal Problems Circumplex Scales
variables that examine the affective and cognitive aspects
(Alden, Wiggins, & Pincus, 1990; Horowitz, Alden,
of an individual’s object relations (Hilsenroth, Stein &
Wiggins, & Pincus, 2000)
Pinsker, 2007). Each of the eight SCORS variables is
The Inventory of Interpersonal Problems Circumplex
scored on a seven‐point anchored rating scale where
Scales (IIP‐C) is a 64‐item inventory of distressing
lower scores (e.g., 1 or 2) indicate greater pathology and
interpersonal behaviours that the respondent identifies as
higher scores (e.g., 6 or 7) indicate greater psychological
‘hard to do’ (i.e., behavioural inhibitions) or ‘does too
health. Complexity of representations (complexity) as-
much’ (i.e., behavioural excesses) on a 0 (not at all) to 4
sesses the richness of a patient’s representations of the self
(extremely) Likert scale. Items were derived from verbatim
and others and the ability to integrate both positive and
transcripts of patients’ psychotherapy intake interviews.
negative attributes of the self and others. Affective quality
Subsequent analyses identified the current version, which
of representations (affect) assesses a patient’s positive
conforms to the interpersonal circumplex, through the
and/or negative expectations from others in relationships
covariation among the eight IIP‐C octant scales. These
and how the patient describes relationships. Emotional
eight scales can be represented pictorially as a circle such
investment in relationships (relationships) identifies the
that attributes adjacent to one another have more similarity
patient’s level of commitment and emotional sharing in
and that those across from one another have opposite
relationships. Emotional investment in values and moral
qualities. Counterclockwise from the top of the circle,
standards (morals) distinguishes between patients who
these subscales included (1) domineering/controlling
show no remorse for selfish actions and those who think
(i.e., being too controlling or manipulative in interpersonal
about moral questions in genuinely compassionate and
interactions); (2) vindictive/self‐centred (i.e., being
thoughtful ways. Understanding of social causality
frequently egocentric and hostile in dealing with
(causality) assesses how well a patient understands
others); (3) cold/distant (i.e., having minimal feelings
why people do what they do. Experience and manage-
of affection for and little connection with other people);
ment of aggressive impulses (aggression) assesses a
(4) socially inhibited/avoidant (i.e., being socially avoid-
patient’s degree and quality of expressed aggression. The
ant and anxious and having difficulty approaching
self‐esteem variable assesses the affective quality of self‐
others); (5) non‐assertive (i.e., having difficulty in expres-
representation. Identity and coherence of self (identity)
sing one’s needs to others); (6) overly accommodating/
assesses a patient’s level of identity integration and goal‐
exploitable (i. e., being gullible and easily taken
directed behaviour. Ford and colleagues (1997) have
advantage of by people); (7) self‐sacrificing/overly
previously used a composite object relations score as a
nurturant (i.e., being excessively selfless, generous,
variable. We have also adopted this procedure by summing
trusting, caring and permissive in dealing with others);
each of the eight SCORS variables and by dividing by 8 to
and (8) intrusive/needy (i.e., imposing one’s needs and
produce a single seven‐point object relations composite
having difficulty in respecting the personal boundaries of
score (SCORS‐C).
other people). The IIP‐C has well‐documented reliability
Independent SCORS ratings were based on the patient’s
and validity (Horowitz et al., 2000) with subscale alpha
level of relational functioning at the time of evaluation (i.e.,
coefficients ranging from 0.76 to 0.88 and test–retest
semi‐structured interview and feedback) and across the
reliabilities ranging from 0.58 to 0.84 (total r = 0.79).
first two sessions of psychotherapy (when available), as
well as from two sessions at the end of treatment (within last
10% of sessions attended). That is, the SCORS variables Session Evaluation Questionnaire
were dimensionally scored based on relational episodes The Session Evaluation Questionnaire (SEQ) is a
and self‐statements verbally expressed during the course of measure of in‐session psychotherapy process that consists
the treatment sessions. External raters then independently of 24 bipolar adjective scales rated from a score of 1 to 7
rated the SCORS variables for each participant immediately by the patient. It is separated into two sections, each
after viewing the videotapes. External raters in this study consisting of 12 bipolar scales. The first section of the
consisted of the same pool of Ph.D. graduate clinicians measure exemplifies two dominant in‐session evaluation
trained in the SCORS rating system (none provided video indices identified as depth and smoothness. Adjective
ratings for their own patients) or in some cases, the study scales in the second section exemplify two dominant

Copyright © 2011 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 19, 187–202 (2012)
Patient–Therapist Interactions 193

post‐session mood indices identified as positivity and Westen, Novotny, & Thompson‐Brenner, 2004). We have
arousal (Stiles, 1980; Stiles & Snow, 1984; Stiles et al., recently reported (Hilsenroth et al., 2005) on the excellent
2004). For the current sample, the mean patient SEQ inter‐rater reliability and internal consistency of the
ratings from the two sessions were as follows: depth = 5.6 CPPS, as well as significant results on six separate
(SD = 0.75), smoothness = 4.8 (SD = 0.99), positivity = 4.9 validity analyses conducted across several different
(SD = 0.95) and arousal = 3.9 (SD = 0.87). contexts and samples. The CPPS data we utilized in the
current study were derived from this recent report, have
followed procedures detailed there, and were rated by
Combined Alliance Short Form—Patient Version
trained external raters who have demonstrated the ability to
The Combined Alliance Short Form—Patient Version
rate these individual techniques in a good (ICC 0.60–0.74;
(CASF‐P) is a measure for assessing patient‐rated alliance.
Fleiss, 1981) to excellent range (ICC 0.75; Fleiss, 1981). In
It consists of 20 items rated on a seven‐point Likert‐type
addition, all Spearman–Brown corrected mean ICCs for the
scale consisting of 1 (never), 2 (rarely), 3 (occasionally),
individual CPPS‐PI and CPPS‐CB techniques were also
4 (sometimes), 5 (often), 6 (very often) and 7 (always) and
in the excellent range (and thus may be examined
is rated by the patient. The psychometric properties,
individually) as were the ICCs for the CPPS‐PI and
reliability and validity of this measure are provided in the
CPPS‐CB scale scores. In regard to independent clinical
original article by Hatcher and Barends (1996). An
ratings of in‐session focus on the patient–therapist
examination of the internal consistency of this measure
relationship used in this study, we used the CPPS item
has demonstrated a total scale coefficient alpha of 0.93
no. 7, ‘The therapist focuses discussion on the relationship
(R. L. Hatcher, personal communication, 1997) as well as a
between the therapist and patient’. Specifically, for the
coefficient alpha of 0.91 for the total scale using a subset of
sessions used in the study, three different sets of inter‐rater
the current participants (Ackerman, Hilsenroth, Baity, &
reliability were calculated for this item; all of which were in
Blagys, 2000). For the current sample, the mean CASF‐P
the excellent range of inter‐rater reliability (≥0.75; Fleiss,
rating was 6.2 (S.D. = .60) for the two early treatment
1981), representing ICC (2,1) values of 0.91 (Hilsenroth
et al., 2005), 0.88 (Stein et al., 2010) and 0.90 (unique to
the current study). For the current sample, the average
Comparative Psychotherapy Process Scale CPPS‐PI item no. 7 across the two early treatment sessions
The Comparative Psychotherapy Process Scale (CPPS) was 2.4 (SD = 1.4) in the ‘somewhat characteristic’ to
is based upon the findings of two empirical reviews of the ‘characteristic’ range, representing low to moderate levels
comparative psychotherapy process literature (Blagys & of occurrence. In addition, for the current sample, the mean
Hilsenroth, 2000, 2002). It is a brief descriptive measure CPPS‐PI scale score for the rated sessions was 3.43
designed to assess therapist activity and techniques used (SD = 0.69), and the mean CPPS‐CB scale score was 1.17
and occurring during the therapeutic hour. Based on these (SD = 0.41), representing a significant level of adherence to a
reviews, a list of interventions was developed from the psychodynamic treatment model (degrees of freedom
empirical literature that represents characteristic features [df] = 75, t = 25.8, p < 0.0001, d = 4.0).
of psychodynamic–interpersonal (PI; defined broadly to
include psychodynamic, psychodynamic–interpersonal
and interpersonal therapies) and cognitive–behavioural
(CB; defined broadly to include cognitive, cognitive–
behavioural and behavioural therapies) treatments. The Pre‐Treatment Patient Characteristics
measure consists of 20 randomly ordered techniques rated
on a seven‐point Likert scale ranging from 0 (not at all The PDI exhibited a significant positive relationship with
characteristic), 2 (somewhat characteristic), 4 (characteristic), patient–therapist relationship focus (N = 76, r = 0.27,
to 6 (extremely characteristic). The CPPS may be completed p = 0.02), indicating that greater personality pathology
by a patient, a therapist or an external rater. Ten statements was related to more focus on the therapeutic relationship
are characteristic of PI interventions, and 10 statements are during early treatment sessions. In relation to this, Table 2
characteristic of CB interventions. These interventions can reports the Pearson correlation coefficients and the level of
then be organized into two scales: one measuring PI features significance for the relationship between focus on
(CPPS‐PI) and one measuring CB features (CPPS‐CB). the patient–therapist relationship early in treatment
The reliability and clinical validity of the CPPS has (predominantly the third and the ninth sessions) and patient
been well established (Hilsenroth, Ackerman, & Blagys, pre‐treatment interpersonal problems (n = 71). We found
2001; Hilsenroth, Ackerman, Blagys, Baity, & Mooney, that the patient’s pre‐treatment IIP total score had a
2003; Hilsenroth, Blagys, Ackerman, Bonge, & Blais, 2005; significant positive relationship to the therapist’s focus on
Hilsenroth et al., 2006; Hilsenroth, DeFife, Blake & the patient–therapist relationship early in treatment
Cromer, 2007; Thompson‐Brenner & Westen, 2005; (r = 0.32, p = 0.006). There was also a significant correlation

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194 K. Kuutmann and M. J. Hilsenroth

Table 2. Relationship between patient pre‐treatment Outcome

interpersonal problems with early treatment (third and ninth
sessions) focus on the patient–therapist relationship (n = 71)
Since both the extant research literature and our results
In‐session focus on indicated the figural nature of patients exhibiting a cold/
patient–therapist relationship distant interpersonal style and low self‐esteem (Beretta
et al., 2005; Hersoug et al., 2002; Hersoug et al., 2009;
IIP total score r = 0.32; p = 0.006 Saunders, 2001) in regard to therapeutic relationship, we
IIP subscale
Dominance r = 0.06; p = 0.60
sought to examine these patient pre‐treatment character-
Vindictive r = 0.28; p = 0.02 istics further in relation to outcome. First, we examined the
Cold r = 0.35; p = 0.002 amount of change on the SCORS self‐esteem ratings for 73
Socially inhibited r = 0.29; p = 0.02 patients in the sample pre‐treatment and post‐treatment
Non‐assertive r = 0.23; p = 0.05 (M = 2.9, SD = 0.68; M = 3.9, SD = 0.86, respectively), and
Overly accommodating r = 0.20; p = 0.09 these patients demonstrated a significant large‐effect
Self‐sacrificing r = 0.06; p = 0.61
increase on the independent clinical ratings of self‐esteem
Intrusive r = 0.07; p = 0.55
over treatment (n = 73, df = 72, t = 9.17, p < 0.0001, d = 1.29,
IIP = Inventory of Interpersonal Problems. Positive correlations reflect g = 1.28, r = 0.54). We also observed a significant relation-
relationships in which a greater degree of interpersonal problems was ship between the degree of early treatment focus on the
related to more in‐session focus on the patient–therapist relationship.
therapeutic relationship and amount of post‐treatment
change on the self‐esteem variable (n = 73, r = 0.30, p = 0.01).
between the three IIP subscales cold (r = 0.35, p = 0.002), Likewise, we examined the amount of change on the
socially inhibited (r = 0.29, p = 0.02) and vindictive (r = 0.28, IIP cold/distant subscale over the course of treatment.
p = 0.02) with the focus on patient–therapist relationship Although initially in the project, we did not attain post‐
variable. treatment IIPs for all patients, as this was not a post‐
When looking at the relationship between focus on the treatment measure in the beginning of the programme.
patient–therapist relationship early in treatment and However, a comparison of patients who completed post‐
patient dynamic personality features (N = 76), we found treatment IIPs versus those who did not at the end
that focus on the patient–therapist relationship early in of therapy revealed no significant difference on pre‐
treatment was only significantly related to one SCORS treatment IIP total score or the cold/distant subscale
variable, self‐esteem (N = 76, r = −0.26, p = 0.02). The (F = 0.45, p = 0.50; F = 1.23, p = 0.27, respectively). In our
SCORS composite score was not significantly related sample, we had 43 patients who completed both pre‐
(r = −0.10, p = 0.38) to greater focus on patient–therapist treatment and post‐treatment IIPs. Again, these patients
relationship, and all other SCORS variables were also demonstrated a significant decrease on the IIP cold/
found to be non‐significant (p > 0.10). These negative distant subscale over their course of psychotherapy (n = 43,
correlations indicate lower scores (i.e., greater problems or pre‐treatment: M = 1.12, 2 SD = 0.78, post‐treatment:
psychopathology; here, in regard to problems in self‐esteem M = 0.88, SD = 0.66, df = 42, t = −2.2, p = 0.03, d = 0.34,
regulation) on the SCORS with higher scores (i.e., more) on g = 0.33, r = 0.16). In addition, we found a significant
the patient–therapist relationship focus variable. relationship between the degree of focus on the therapeutic
relationship in these early sessions with subsequent
Psychotherapy Process amount of change over the course of treatment in cold/
distant subscale values (n = 43, r = 0.32, p = 0.04).
We examined the relationship between the therapist’s focus Finally, given that previous research has demonstrated
on the patient–therapist relationship with measures of an interaction between pre‐treatment level of object
psychotherapy process from the same two early treatment relations and focus on the therapeutic relationship with
sessions. In these analyses, we found no relationship outcome (i.e., Connolly et al., 1999; Høglend, 1993;
(n = 75, r < 0.04, p > 0.70) with any of the four patient‐rated Høglend et al., 2006; Ogrodniczuk et al., 1999; Piper
SEQ variables (depth, smoothness, positivity and arousal) et al., 1991), we examined the overall level of object
and focus on the treatment relationship. In addition, we relating in relation to the amount of patient–therapist
examined the relationship between patient‐rated alliance focus with subsequent change on the IIP cold/distant
with the amount of patient–therapist focus in these subscale by using hierarchical regression. Prior to
sessions and found a non‐significant relationship (n = 75, conducting this analysis, both the SCORS‐C and the
r = −0.17, p = 0.14). These findings indicate that greater technique variables were centred in order to facilitate
focus on the therapeutic relationship has little relation on
how patients rated in‐session process but indicated slightly
lower, albeit non‐significant, levels of patient‐rated alliance 2
Note that our pre‐treatment IIP cold/distant subscale mean is
during these same early treatment sessions. virtually identical to that of Hersoug et al. (2009).

Copyright © 2011 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 19, 187–202 (2012)
Patient–Therapist Interactions 195

interpretation and to reduce multicollinearity between the findings make sense in the theoretical frame of short‐term
predictor variables (Aiken & West, 1991). In Table 3, we relational oriented dynamic therapy where greater inter-
present the ability of both these variables (QOR and personal problems are assumed to manifest not only
therapeutic technique) as well as their interaction to outside the therapy room but also in the therapeutic
predict change in IIP cold/distant scores over treatment. relationship and where exploring the patient–therapist
Patient pre‐treatment QOR was entered as the first step in interaction is considered to be an important way to
the model, predicting change in IIP cold/distant scores, intervene (Book, 1998; Luborsky, 1984; McCullough
and was found to have a positive, albeit non‐significant, et al., 2003; Safran & Muran, 2000; Strupp & Binder,
relationship with outcome, accounting for 6% of the 1984; Wachtel, 1993, 2008). It is important to note that the
change observed across treatment. When the amount of therapists in our study, graduate trainees, were actively
early treatment focus on the patient–therapist relationship supervised according these specific models of treatment
was added to the model in the second step, this was by using videotape. Thus, when working with patients
significant and positively related to change in IIP cold/ who exhibit greater personality pathology, a cold/distant
distant scores (p = 0.04), independent of level of object interpersonal style or low self‐esteem, the therapists were
representations, as was the model containing both encouraged to explore both implicit and explicit manifes-
variables (R = 0.39, R2 = 0.15) and the increase in explained tations of these issues that occurred during the session.
variance in outcome (9%). In the final model, the third That is, our results demonstrate that therapists in this
step, we found that both the early session therapist focus study were doing what they were trained to do according
on the treatment relationship and the interaction of this to the treatment model being supervised. Therefore, our
therapist activity with patient level of object representa- findings may not be generalized to treatment as usual;
tions were unique and significant predictors of change in however, they do provide some evaluation of this
IIP cold/distant scores (p = 0.004 and p = 0.01, respective- treatment model on subsequent patient change.
ly). The addition of this interaction variable contributed Surprisingly, this greater focus on the therapeutic
significant predictive power to the full model (R = 0.53, relationship was not related to other patient rated process
R2 = 0.29), explaining an additional 14% of the variance in variables during these sessions, including the therapeutic
outcome on the IIP cold/distant subscale.3 First, this alliance. One might expect that a greater focus on the
indicates that, in general, for all patients in the study, a patient–therapist interaction and how the quality of the
greater focus on the patient–therapist relationship early in relationship is perceived to be related, either positively or
the treatment demonstrated more improvement in cold/ negatively, and therefore, our lack of significance with
distant interpersonal problems. Second, independent of other process variables is surprising to us. The largest
the first effect, those patients with higher levels of object relationship we found among these process variables was
representations benefited even more significantly from a between a focus on the patient–therapist relationship and
focus on the therapy relationship in their cold/distant alliance. Although non‐significant, patients rated the
interpersonal problems over treatment. That is, a greater alliance slightly lower during the same sessions where
focus on the in‐session therapeutic relationship helped there was a greater focus on the therapeutic relationship.
improve patient scores on the IIP cold/distant subscale in This might lead one to believe that the use of this
general, and for those patients with less impaired object technique in treatment results in a negative view of the
relations, this patient–therapist focus helped improve alliance among patients, but the examination of broad
these scores even more. outcomes in our study reveals otherwise (for a review, see
Hilsenroth, 2007). Conversely, this may be an example of
therapists addressing issues in the relationship that in the
DISCUSSION moment are not positively associated with alliance (i.e.,
rupture) but nonetheless may contribute to later change, a
In this study, we found that greater levels of pre‐treatment finding that has some precedence in the literature regard-
patient personality pathology and interpersonal problems ing quadratic change in patient alliance across treatment
were positively related to a more here‐and‐now focus on (Hilsenroth, Peters, & Ackerman, 2004; Kivlighan &
the patient–therapist relationship in early treatment. This Shaughnessy, 2000; Stiles et al., 2004). Moreover, the
was especially true for patients with a cold and withdrawn patient‐rated alliance was very high for our sample, with
interpersonal style or those with low self‐esteem. These a mean over 6 on a seven‐point scale. So, rather than
describing these patients as rating the alliance poorly, it
would be more accurate to describe the negative correla-
Using the more statistically conservative reliable change index score tions in these sessions as being related ‘adequate’ or ‘good’
for the IIP cold/distant scale that adjusts pretest scores for regression
to the mean and measurement error (Jacobson & Truax, 1991; Speer, levels of patient alliance (i.e., a score of 4 or 5 on a seven‐
1992), we again found a significant interaction model; R = 0.50, point scale) rather than ‘very good’, or ‘excellent’ (a score of
R2 = 0.26, p = 0.009. 6 or 7). This is an important point to keep in mind regarding

Copyright © 2011 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 19, 187–202 (2012)
196 K. Kuutmann and M. J. Hilsenroth

Table 3. Hierarchical regression analysis of patient level of object representations and in‐session focus on the therapeutic relationship
predicting change in IIP cold/distant scores over treatment (n = 43)

Parameter β Standard Error β Standard β t p R R2 ΔR2

Step 1 (F = 2.7; df = 1, 41) 0.25 0.06

Intercept 0.29 0.11 2.6 0.01

SCORS‐C 0.43 0.26 0.25 1.6 0.11

Step 2 (F = 3.5; df = 2, 40) 0.39* 0.15 0.09*

Intercept 0.28 0.11 2.6 0.01

SCORS‐C 0.38 0.25 0.22 1.5 0.14
Focus on the therapeutic relationship 0.16 0.08 0.30 2.0 0.04

Step 3 (F = 5.2; df = 3, 39) 0.53*** 0.29 0.14**

Intercept 0.24 0.10 2.3 0.02

SCORS‐C 0.25 0.24 0.15 1.1 0.30
Focus on the therapeutic relationship 0.24 0.08 0.44 3.0 0.004

SCORS‐C × Focus on the therapeutic relationship 0.53 0.19 0.40 2.7 0.01

*p < 0.05. **p ≤ 0.01. ***p < 0.005.

SCORS‐C = Social Cognition and Object Relation Scale—Composite. SCORS‐C × Focus on therapeutic relationship = interaction effect of the Social
Cognition and Object Relation Scale—Composite and Focus on the therapeutic relationship.

the findings of our study and one we shall return to later. Although prior research has suggested that patients
Finally, since these data were reported from early sessions, with a cold and detached interpersonal style may initially
it is not possible to draw any conclusions for how this report lower alliance and are experienced by therapists as
technique may have affected process variables later in more challenging to work with, many of these same
treatment. authors have advocated for the importance of openly
Our outcome analyses showed that for the two patient exploring interactions within the therapeutic relationship
pre‐treatment characteristics that were most related to in a supportive and empathic manner (Beretta et al., 2005;
early session focus on the therapeutic relationship, self‐ Hersoug et al., 2002; Hersoug et al., 2009; Luyten et al.,
esteem and cold/distant interpersonal style, both demon- 2010; Saunders, 2001). Such sentiment is best summarized
strated a significant change over the course of treatment. In by Hersoug and colleagues (2009, p. 179) who stated that
addition, the amount of change in these specific patient ‘When working with patients who have a cold/detached
characteristics was significantly related with a greater interpersonal style therapists should attend to early signs
focus on the patient–therapist interactions that occurred in of negative response and look for potential ways to
these early sessions. This means that the pre‐treatment improve the alliance. If negative response occurred, the
patient characteristics subsequently related to early session therapist may address the problem of the alliance in order
focus on patient–therapist interactions later demonstrated to repair the alliance rupture…. Patients who are more
change over the course of therapy that was related to the distant or disconnected may represent a challenge early in
use of more of this same intervention. Also, given prior therapy, but their potential for improvement of the
research (Saunders, 2001), it is reasonable to suspect that alliance through long‐term treatment should not be
these two personality variables, self‐esteem and cold/ underestimated’. Our findings support and extend prior
distant interpersonal style, may have some relationship to research that in‐session focus on the therapeutic relation-
one another in the change process, and in fact, we found ship is an effective way to address and work with patients
this to be true in our data (Δself‐esteem and Δcold/ exhibiting relational problems (Colli & Lingiardi, 2009;
distant n = 43, r = 0.26, p = 0.09). That is, as self‐esteem Constantino et al., 2008; Bennett et al., 2006; Muran et al.,
improves, one might expect a more engaged–involved 2009; Safran et al., 2005). These results are also consistent
relational stance, or conversely, as patients become more with emerging data that suggest an in‐session focus on
adaptively engaged with others (including the therapist), the therapeutic relationship is most effective when the
their self‐esteem improves. Future research should alliance has been found to be high (Ryum, Stiles,
attempt to further explore the relationship between Svartberg, & McCullough, 2010; Schut et al., 2005).
changes in patient self‐esteem and interpersonal/social The role that patient levels of QOR played in the change
functioning. of cold/distant interpersonal problems over treatment was

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Patient–Therapist Interactions 197

also of some interest. Informed by past research in this area, clinicians in this study viewed the therapeutic relationship
we examined the effect of patient QOR and found that as an arena where more adaptive relating is first practised
there was an interaction effect with greater early treatment and explored. Therefore, the adaptive relational changes in
focus on the patient–therapist relationship on subsequent this context, no matter how small, were underlined and
changes in cold/distant patient interpersonal problems. supported (e.g., ‘I think it’s important to point out that you
Our findings were consistent with the findings in studies were just able to express this issue in here with me, what do
by Connolly et al. (1999), Ogrodniczuk et al. (1999), as well you think helps to do that in here as opposed to your other
as Høglend and colleagues (Høglend et al., 2006; Høglend relationships’ and ‘What do you think has changed the
et al., 2007; Høglend et al., 2008) who similarly reported most in our relationship that allows you to say that to me
that patients with high levels of QOR benefited from a now as opposed to in the past’). Likewise, clinicians
greater in‐session patient–therapist relationship focus (i.e., affirmed, validated and supported patient’s involvement
transference interpretations). It is also important to note the or experience in the therapeutic relationship (e.g., ‘Given
similarity between the low to moderate levels of interven- your history it only seems reasonable that you’d be cautious
tions within the patient–therapist relationship in those in allowing yourself to become emotionally open with me, a
studies (i.e., 1–4; see also Ryum et al., 2010; Schut et al., man’ and ‘Recognizing the reasons for that caution, I feel
2005) and the current investigation (i.e., 1–3). In addition, privileged you’re sharing those feelings with me now’).
our results are consistent with prior research demonstrat- Furthermore, clinicians in this study would often
ing a relationship between high QOR and outcome in sustain this focus on the therapeutic relationship with
interpretive therapy (Piper, Joyce, McCallum, & Azim, follow‐up inquiry of patient’s experience of this in‐session
1998; Piper, McCallum, Joyce, Rosie, & Ogrodniczuk, 2001) process (e.g., ‘What’s it like to share that out loud, in here
as well as the accuracy of transference interpretations and with me’, ‘What’s it like to hear me say that’ and ‘How
outcome for patients with high QOR (Piper, Joyce, does it feel to tell me about having accomplished this’).
McCallum, & Azim, 1993). This exploration of in‐session affective experience about
Although we have discussed our findings in relation the therapeutic relationship also extended to the clinicians
to the rupture–repair and transference interpretation (e.g., ‘As I listen to the story you just told me I also feel a
research, we also believe it is important to clarify the deep sense of hopelessness and despair’) as well as
applied clinical implications from our study. Primarily, observing the ‘emotional temperature’ in the therapeutic
we want to point out that the focus on the therapeutic space (e.g., ‘It seems like something has changed in the
relationship variable used in this study was much broader room the last minutes between us. Things have become
than the two specific areas of research interest discussed more quiet and it feels like we are more distant from each
above, the rupture–repair process and transference inter- other than we were earlier’ and ‘As you were speaking
pretations. In fact, what would classically be understood as about that it seems like the room has filled with joy and
a transference interpretation (i.e., an explicit link between a excitement’). Such interventions sharing the in‐session
historic caretaker, therapist and internal dynamic compo- affective experience of clinicians have been described as
nents) occurred very rarely in this study. Again, our ‘self‐involving’ statements and very often lead to further
definition of this focus on the therapeutic relationship exploration of the therapeutic relationship (McCarthy,
entails any in‐session discussion of the patient–therapist 1982; Reynolds & Fischer, 1983; Teyber & McClure, 2000).
interaction, regardless of whether these were interpretive In relation to that, therapists helped patients recognize
or not, i.e., any observations, clarifications, explorations or and explore emotional experiences in the relationship that
questions about the therapeutic relationship. For instance, might have been avoided or gone unrecognized (e.g., ‘You
although therapists would often interpret or explore how seemed to become tearful just now when I noticed the
interpersonal and affective themes covered during session positive things you’ve accomplished, can we try to
might play out in the therapeutic relationship (e.g., ‘You understand that more together’, ‘It seems right now that
know we’ve talked a lot about the issue of. . . today, and I it’s easier to describe others feelings for you than the way I
wonder how that might play out in here between the two of might feel for you’). In sum, this range of interventions
us’ and ‘How do you understand that issue in regard to our under the purview of in‐session therapeutic interactions
relationship’), they would also frequently encourage are all used to help create an adaptive, observing,
perspective taking in this relationship and about the affectively engaged relational interaction that might
therapy (e.g., ‘How do you imagine I feel after hearing provide a template for patients to apply to other
your story’, ‘What do you imagine I might be thinking relationships in their lives. We believe this is an essential
about you’, ‘That certainly makes sense, but I wonder if clinical contribution of this paper; that is, beyond its
there could be any other reason why I might do that other place in the rupture–repair process or when used more
than just being upset with you’ and ‘I wonder if you can specifically in transference interpretations, a broad
imagine any other way I might feel’). It is also important range of interventions that bring greater focus on what
that, rather than just a place to repeat prior behaviour, is happening within the ‘here‐and‐now’ in‐session

Copyright © 2011 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 19, 187–202 (2012)
198 K. Kuutmann and M. J. Hilsenroth

patient–therapist relationship can be an important other; and (4) expression of positive feeling and support for
aspect of effective treatment. the other (Hess, 2002). Pertinent to our discussion of these
Although the treatment provided to the current sample distance‐decreasing attachment strategies, research from
was a supportive–expressive, affect‐focused and relationally the attachment theory literature has found that greater
oriented form of psychodynamic therapy (Luborsky, attachment avoidance is related to deficits in interpersonal
1984; McCullough et al., 2003; Safran & Muran, 2000; interest, involvement, empathy, helping behaviour and
Wachtel, 1993, 2008), we recognize that many of the empathic accuracy (i.e., the ability to accurately identify the
techniques focusing on the in‐session patient–therapist internal thoughts and feelings of other people), as well as
relationship listed above would also be consistent with greater use of strategies that increase psychological,
other forms of psychodynamic and even some cognitive‐ emotional and physical distance from others (Burnette,
behavioural treatments as well (Bateman & Fonagy, 2004; Davis, Green, Worthington, & Bradfield, 2009; Izhaki‐Costi
Clarkin, Yeomans, & Kernberg, 1999; Gunderson, & Schul, 2010; Joireman, Needham, & Cummings, 2001;
2001; Kohlenberg & Tsai, 1991; Linehan, 1993; Tsai et al., Mikulincer & Shaver, 2005; Pietromonaco, Rook, & Lewis,
2008; Young, 1999). In particular, other psychodynamic 1992; Shaver, Schachner, & Mikulincer, 2005; Simpson,
approaches such as mentalization‐based treatment Ickes, & Grich, 1999; Wayment, 2006; Zaki, Bolger, &
(Bateman & Fonagy, 2004) and transference‐focused Ochsner, 2008). As such, these patients may find them-
psychotherapy (TFP; Clarkin et al., 1999) that specifically selves in a paradoxical cycle of deepening alienation
promotes complex perspective taking regarding the self whereby they keep themselves safe from interpersonal
and others (i.e., mentalization) as well as an exploration rejection and pain by avoiding or distancing themselves
of the patient–therapist relationship (i.e., transference). from others, but in doing so foreclose the opportunity to
However, it is also important to note in regard to our gain more adaptive relational skills and experiences that
findings that the exploration of the in‐session patient– would allow for deeper and more fulfilling interpersonal
therapist relationship was conducted within a milieu of relationships (Carvallo & Gabriel, 2006; Collins, Cooper,
supportive techniques, where patients felt high levels of Albino, & Allard, 2002; Gallo, Smith, & Ruiz, 2003;
trust and connection with their therapist as well as a Mallinckrodt, 2000; Mallinckrodt & Wei, 2005; Mikulincer
collaborative sense of the goals and tasks of their treatment et al., 1998; Shaver et al., 2005). Therefore, the need for more
(i.e., mean patient‐rated alliance score over 6 on a seven‐ adaptive (i.e., corrective) relational experiences with the
point scale). Therefore, although some of the in‐session therapist may be particularly true for patients with a cold/
patient–therapist relationship techniques detailed here may distant relational style. In sum, consistent with the work of
be consistent with TFP, the larger treatment in which this Hess (2002), Hill (2004), Wachtel (1993, 2008), McCullough
occurred was not as the use of supportive techniques is and colleagues (2003) as well as Safran and Muran (2000),
clearly prohibited in TFP (Clarkin et al., 1999). Like we would suggest that perhaps, the most curative aspect of
Gabbard and Horowitz (2009), we believe that such ‘here‐and‐now’ in‐session processing of the therapeutic
prohibition represents a false dichotomy of practice that relationship, rather than links to symbolic or genetic
appears inconsistent with the available data on the associations, is the opportunity for an examined in vivo
optimal use of techniques exploring the patient–therapist emotional–relational interaction that can provide a much
relationship. Consistent with the findings presented here, needed template for more adaptive attachment strategies
this appears to be a low to moderate number (1–4) of and interpersonal functioning.
interventions per session examining the patient–therapist Despite being one of the first studies to explore the
relationship, in the context of a strong therapeutic alliance, specific relationship between patient pre‐treatment inter-
within a larger treatment that allows for an optimal personal characteristics and a subsequent focus on
responsiveness of both supportive and expressive in‐session patient–therapist interactions, our examination
technical components (see Bateman & Fonagy, 2004; of these issues have some potential limitations that should
Hilsenroth & Slavin, 2008; Høglend & Gabbard, in press; be addressed. Some limitations of the current study were
McMain et al., 2009; Ryum et al., 2010; Schut et al., 2005). that the patient sample primarily had mild to moderate
Also note the consistency between several of the levels of distress and impairments in functioning, as well
interventions described above and the provision of an as being treated by graduate trainees. Future research is
actively supportive milieu, as well as the rupture‐and‐ necessary on more severe samples with more experienced
repair model by Safran and Muran (2000), with attachment therapists to extend the implications of the present
theory‐based strategies for decreasing psychological/ findings. In addition, the lack of an experimental design
emotional distance from others. These distance‐decreasing (i.e., random assignment, wait list control or alternative
attachment strategies include (1) acknowledging or con- treatment) does not allow us to conclusively rule out the
sidering the other’s message; (2) showing an intention or potential impact of common factors on our observed
willingness to share information with the other; (3) treatment‐related effects. Also, the lack of follow‐up data
perception of similarity or shared experience with the prevents us from knowing the stability of the changes

Copyright © 2011 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 19, 187–202 (2012)
Patient–Therapist Interactions 199

obtained with this kind of intervention. These limitations Burnette, J.L., Davis, D.E., Green, J.D., Worthington, E.L., &
notwithstanding, this study is the first to examine the Bradfield, E. (2009). Insecure attachment and depressive
symptoms: The mediating role of rumination, empathy, and
relationship of these patient characteristics with work in
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Personality, 70, 965–1008.
Patrick Luyten, Chris Muran, Jesse Owen, Jeremy Safran, Connolly, M.B., Crits‐Christoph, P., Shappell, S., Barber, J.P.,
Lisa Wallner Samstag and Paul Wachtel for their helpful Luborsky, L., & Shaffer, C. (1999). Relation of transference
comments and suggestions on an earlier version of this interpretations to outcome in the early sessions of brief
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