This article was downloaded by: [Australian National University]

On: 09 January 2015, At: 03:35

Publisher: Routledge
Informa Ltd Registered in England and Wales Registered Number: 1072954
Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Psychotherapy Research
Publication details, including instructions for authors and
subscription information:
http://www.tandfonline.com/loi/tpsr20

Affective Dyadic Behavior, Core

Conflictual Relationship Themes,
and Success of Treatment
a a a
Thomas Anstadt , Joerg Merten , Burkhard Ullrich &
a
Rainer Krause
a
Department of Clinical Psychology , University of
Saarland , Germany
Published online: 25 Nov 2010.

To cite this article: Thomas Anstadt , Joerg Merten , Burkhard Ullrich & Rainer Krause (1997)
Affective Dyadic Behavior, Core Conflictual Relationship Themes, and Success of Treatment,
Psychotherapy Research, 7:4, 397-417, DOI: 10.1080/10503309712331332103

To link to this article: http://dx.doi.org/10.1080/10503309712331332103

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information
(the “Content”) contained in the publications on our platform. However, Taylor
& Francis, our agents, and our licensors make no representations or warranties
whatsoever as to the accuracy, completeness, or suitability for any purpose of the
Content. Any opinions and views expressed in this publication are the opinions and
views of the authors, and are not the views of or endorsed by Taylor & Francis. The
accuracy of the Content should not be relied upon and should be independently
verified with primary sources of information. Taylor and Francis shall not be liable
for any losses, actions, claims, proceedings, demands, costs, expenses, damages,
and other liabilities whatsoever or howsoever caused arising directly or indirectly in
connection with, in relation to or arising out of the use of the Content.

This article may be used for research, teaching, and private study purposes. Any
substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,
systematic supply, or distribution in any form to anyone is expressly forbidden.
Terms & Conditions of access and use can be found at http://www.tandfonline.com/
page/terms-and-conditions
 Psychotherapy Research 7(4) 397-4 17, 1997

AFFECTIVE DYADIC BEHAVIOR, CORE

CONFLICTUAL RELATIONSHIP THEMES, AND
SUCCESS OF TREATMENT
Thomas Anstadt, Joerg Merten, Burkhard Ullrich, and
Rainer Krause
Department of Clinical Psychology at the University of Saarland,
Germany
Downloaded by [Australian National University] at 03:35 09 January 2015

In 11 brief therapeutic treatments, affective facial behavior of thera-

pists and patients as well as the latter’s Core Conflictual Relationship
Themes (CCRTs) were investigated and related to treatment outcome.
It has been found that compensatory not reciprocal affective facial
behavior of the therapeutic dyad in the first session is indicative of
success. A scale describing reciprocity vs. compensation in facial
behavior correlated significantly positively with self-reports of out-
come and symptom change. Two psychoanalytic treatments, one
with the highest reciprocity and least success rate and one with the
highest success rate and high compensation, were analyzed in detail
according to the temporal development of affect exchange and
narration through the course of the complete treatment. In both
therapies the frequency of narratives were negatively correlated with
the frequency of facial affects of the patient, so that the hypothesis of
a parallel processing of affective facial behavior and narration could
be ruled out. In the successful treatment, the therapist showed those
affects during the narration of the patient which could have been
expected from the latter. A very distinct temporal organization within
the successful treatment including an enactment period, a period of
instability, and a period of consolidation, contrasted with a homog-
enous distribution of affect in the unsuccessful one. The relevance of
these results for a theory of the therapeutic process is discussed.

There is a consensus in current research that mental disturbances can be

understood as, among other things, maladaptive highly stereotypical social
behavior (Dahl, 1988; Grawe, Donati, & Bernauer, 1994; Fiedler, 1994). Addi-
tionally it has been found that specific interaction patterns, such as high
intrusiveness, are of predictive value for relapses, especially with regard to the
open exacerbation of schizophrenia, depression, and mania (Fiedler, Hahlweg,
Krause, & Schulte, 1993). Given this relationship between social relations and
mental disturbances, it might be worth finding out whether the longevity of
these disturbances is related to the patients’ readiness and capacity to uncon-

This study is part of the project Kr 843-4 multi-channel psychotherapy process research funded by
the German Research Community.
Correspondence regarding this article should be addressed to Dr. Rainer Krause, Fachrichtung 6.4
Psychologie, Universitat des Saarlandes, Im Stadwald 66123 Saarbruchen.

397
 398 ANSTADT ET AL.

sciously provoke such repetitive social interactions in their environment. A first

indication for the validity of this conception could be derived from a series of
studies demonstrating a strong preconscious specific impact of patients’ facial
affective behavior on that of healthy lay persons uninformed regarding the
sickness and who remained consciously unaware of the reason for the alteration
of their internal feelings and their affective expressions. (Frisch, Schwab, &
Krause, 1995; Krause, Steimer, Sanger-Alt, & Wagner, 1989). Given this strong
unconscious influence, it might be that one of the underlying curative factors of
all therapeutic treatments might be the therapists’ capacity to understand and
counteract these provoked social scenarios, whereas empathic laymen would
submit themselves to them.
Maladaptive relationship patterns are conceptualized within different theo-
Downloaded by [Australian National University] at 03:35 09 January 2015

retical contexts and under different names. Grawe (1987), following Piaget, talks
about schemata. Within dynamic system theory the term “attractor” is fre-
quently used (Schiepek, 1994). Psychoanalysts have long referred to “repetition
compulsion” and “acting out” (Freud, 1914).
In the last 15 years, a series of heuristics were developed to enable
researchers to measure repetitive maladaptive structures objectively and reli-
ably. Some of them, like the Core Conflictual Relationship Theme (Luborsky,
1977) and the Plan Diagnosis (Weiss, Sampson, Caston, & Silberschatz, 1977),
are predominantly centered around the act of speaking. They derive so called
“narratives” out of the written discourse between the patient and his social
partner, a therapist, other people, or even reports on dreamed interactions.
These transcripts are the database for the statistical constructions of the
maladaptive relationship patterns. Important gains regarding the reliability and
validity of these measures were made in the last years, confirming the basic
notion that there exists a typical basic maladaptive pattern for each patient
(Henry, Strupp, Schacht, & Gaston, 1994). However, the relationship of these
measures to treatment technique and outcome remains unclear. If there are any
results, they are rather puzzling. To provide an example, within the Penn
Psychotherapy Project, the core relationship theme was similar in early and late
sessions of improving and nonimproving patients. The only difference to be
found was that the improvers showed a “greater sense of mastery” of the theme
in the last five sessions of treatment (Luborsky, 1977). One possible explanation
could be that within successful treatments patients learned a better social
enactment of their basic wishes, but instead of measuring the newly developed
process of enactment itself, mental speech related representation was extracted
out of the text called altered “sense of mastery.” Following this logic, Crits-
Christoph, Demorest, and Connally (1990) were forced to distinguish a struc-
tural and a procedural aspect of transference as measured by the CCRT. The
former was defined as the mental representation of relationship patterns, the
latter as a process of perceiving the therapist over the course of the therapy.
However it is difficult to separate perception from representation, and the act of
perception is not necessarily a social procedural rule. Since the concepts are
extracted from only one behavioral channel, the unresolved basic question of
this methodology is how “narratives” extracted out of speech acts of only one
partner of a dyadic discourse can be related to the hardware of the above
mentioned social interaction patterns. Even if speech related measures of
maladaptive structures are valid mental representation of a basic structure, the
question of how they are enacted in the social field remains unsolved. Given
 AFFECTIVE DYADIC BEHAVIOR 399

Luborsky’s strange result, it could be that the major improvements within the
process of successful psychotherapies are not to be found in the field of mental
representations of a maladaptive relationship pattern, but in the improved
enactment of basic wishes being part of the mental representation pattern. This
alteration would interrupt the vicious circle created in the social field.
Empirical research on the relation between textbound measures of relation-
ship patterns and the enactment is scarce. Some authors “solved” the problem
through the application of a “clinical” algorithm, stating that the act of narration
would “paraphrase” the current relationship (Argelander, 1979; Gill, 1982).
This assumption requires that the ongoing enactment is synchronously, and
usually unconsciously, depicted in the verbal content, so that in some way there
is a more-or-less direct homology between the content of the narrative and the
Downloaded by [Australian National University] at 03:35 09 January 2015

enactment. If this were true, the therapist could bring about change even in the
field of enactment, by changing the mental representations through speech acts,
mainly in the form of interpretation of the transference situation. Freud, at the
beginning of his psychotherapeutic career, was very much in favor of such a
“speaking cure” because he wanted ta reduce “the highly unfavourable tenden-
cies of the patients to replace, in the course of treatment, verbally communi-
cated memories through ‘acting out’ ”(Freud, 1914). This kind of behavior was
considered to be a form of resistance. It is, in our term, the enactment or, in
those of Crits-Christoph et al. (1990), the procedural part of the relationship
pattern. For several reasons, the “clinical algorithms” proposed by Argelander,
Gill, or Freud, are not only invalid, but also an obstacle to a better understanding
of the therapeutic process and its improvement.
1) From a systemic point of view it is logically impossible to change
structural aspects of relationship patterns without having previously altered the
procedural aspects, since, by definition, the procedure reenacts and reconfirms
the structure as long as it is active.
2) It has been shown empirically that transferential interpretation, based on
the assumption of a “paraphrasing” of the maladaptive relationship in the act of
the narration, are experienced as accusatory by the patients and lead to
defensive maneuvers like silence and poor outcome (Henry, Strupp, Schacht, &
Gaston, 1994; Thoma & Kachele, 1992).
3) The handling of the enactment as resistance is unfavorable for the
treatment process because affects and, especially, affective memories are tied to
the enactment of the relationship pattern in the session much more than to the
act of narration per se, which can be steered cognitively, leading to treatment
induced defenses like ‘‘intellectualization.’’
For these reasons, different authors argue that it is more adequate to regard
the predominantly cognitively steered ‘‘remembering via narration” and the
affective one via enacting or acting out, as two necessary forms of actualization
of the past within the present (Laplanche & Pontalis, 1972). However, this
attempt to integrate leaves the questions open as to how these two processes
could be related to one another within the therapeutic process. According to
Thoma and Kachele (1992) the “enactment” should precede the remembering
within the course of treatment. The patient would first, as in all other important
social situations, try to enact unconscious wishes and plans in the therapeutic
situation. He or she would apply the procedural rules of his or her relationship
pattern. Depending on the reaction of the therapist in that phase, the procedural
rule would not work, leading to the necessity to change the mental and internal
 400 ANSTADT ET AL.

representation of the relationship pattern. The patient and his social setting
would fall into a state of instability, followed by a positive or negative
reorganization. Part of the reorganization process could be trials of new
enactments within and outside of the therapeutic situation, and recollections of
how and why such enactments may have failed in the past.
If these arguments are valid, one of the questions regarding therapeutic
technique and process research consists in finding out how successful therapists
counteract the procedural rules of their patients. Within that context, it might be
helpful to compare successful therapists’ reactions to the enactment with those
of empathic laymen interacting with people with the same problems. As we have
already mentioned, our research group showed that naive laymen usually
reacted very intensively but unconsciously to patients affective facial enactment.
Downloaded by [Australian National University] at 03:35 09 January 2015

The procedural rules they applied usually followed a model of “reciprocity” on

the affective and “compensation” on the narrative side. For example, un-
knowing healthy partners of schizophrenic patients, reduced their affect expres-
sion to the very low level of their partners (Krause, Steimer, Singer-Alt, &
Wagner, 1989) and took over the discussion and speech role thereby compen-
sating for the assumed incapability of the patients to solve problems (Villenave-
Cremer, Kettner, & Krause, 1989; Merten, 1996). The unknowing healthy
partners of patients suffering from functional back pain with a clear neurotic
origin adopted their facial affect upward to the high but contradictory level of
the patients and usually handed over the speech process more or less to the
patients’ neurotic themes (Schwab & Krause, 1994). This “empathic” attitude
probably stabilizes the patients’ maladaptive schemata by following the proce-
dural rules of the enactment. However, we still do not have a sufficient
understanding of the process of enactment.
Becker-Beck (1999, for example, extracted five different conceptualiza-
tions of reciprocity and compensation. Possible conceptualizations of comple-
mentarity were even more abundant. Confining the discussion to exchange
processes in the facial affective behavior of two persons talking to one another,
the signalling of a submissive fear affect by one of them might be answered by
the other with the same affect, a consoling affective attitude like smiling and
distress, by anger or contempt or no affect at all. The first one is usually called
symmetric and reciprocal. In the second case the smile can be conceived as
compensating the negative affect. Anger, disgust, and consoling can be under-
stood as complementary behavior. Some fear patterns provoke aggressive, some
contemptuous, and some helping behavior depending on the context of the
affect signalling and the internal state of the dyad. One of the contexts is, of
course, the spoken discourse. Attempts of authors like Benjamin (1984), Leary
(1957), and Plutchik (1980) to develop a logical system of the interrelations of
affects are valuable for research, but not yet for the practitioner. On a clinical
level, reciprocity is usually defined as the exchange of more or less similar forms
of behavior, whereas complementarity of action requires qualitatively distinct
but somehow fitting forms of behavioral answers. The exact question of what
this fitting response might be has to be resolved anew in each clinical case. There
is however well-established clinical knowledge about emotional scripts like
affect reversal (laughter instead of horror-doomsday humor), affect equivalents
(physiological arousal instead of experiencing), affect exchange (erotization of
fear and anger thrill and sadism) to mention just some examples (Balint, 1959;
Fenichel, 1946). Adding speech content we find things like cynicism, positive
 AFFECTIVE DYADIC BEHAVIOR 401

verbal statements with a negative affective signal in the face and or voice. It is
evident that for making the decision which behavior might be answered
complementarily, reciprocally, or remain unanswered, the clinician cannot rely
on the narration nor on the affective signal alone. He or she has to derive
knowledge about the intentional structure using the complete contextual be-
havior that happens synchronously with affect expression and narration over
the course of time. This is usually done in an abbreviated form using the
therapist’s own feelings and phantasies induced by the patient’s behavior as a
tool of measurement.
We have tried to investigate whether outcome of therapeutic treatments can
be predicted from the quality of affect exchange at the beginning of the
treatment, and how these affect exchange processes are related to the relation-
Downloaded by [Australian National University] at 03:35 09 January 2015

ship patterns derived from the written text. One assumption was that reciprocal
affective behavior on the side of the therapist would be equivalent to an
empathic layman who is drawn into the “scenarios” of the patient, which would
then lead to an unfavorable outcome, whereas compensatory affective reactions
should be related to good outcome. The second assumption was that comple-
mentary affective reactions on the side of the therapist would mirror the object’s
negative reactions, as derived out of the narratives. The third was centered
around the primacy of the enactment in all therapies followed by a phase of
instability and with a subsequent restructuring.

HYPOTHESES

Departing from models and empirical findings concerning the quality of the
therapeutic relationship and the change processes that are necessary for a
successful treatment, the following relations between dyadic facial affective
behavior, narrations, phase structures within treatment, and therapeutic out-
come are hypothesized.
1. Reciprocity of facial affective behavior between therapist and patient in
the first session should be related to poor, compensation to good outcome.
2. The affective facial reaction of a successful therapist should not repeat the
affective reactions of objects in the social scenarios, as they are most frequently
reported in the narrations of the patient.
3. Successful treatments should be characterized by a temporal succession
involving affective facial enactment in the first part of treatment. This serves to
test whether the therapist is prone to repeat the structure through the applica-
tion of the procedural part of the relationship pattern. Within successful
treatments, a marked phase of instability, measurable in all channels (altered
affective enactment, and alteration of the narratives), which is then followed by
a more cognitively steered phase of reorganization (no more affective enact-
ment, changes in the narratives) should be an indicator of structural change.

METHOD

In a research project, funded by the German Research Community, 11 brief

therapies utilizing different theoretical orientations (psychoanalytic, cognitive-
behavioural, client-centered) each lasting 15 sessions were investigated. The
 402 ANSTADT ET AL.

participating therapists were required to have at least 150 cases, more than 5
years experience, and training responsibilities within their field. They were free
to choose those patients with whom they thought they could work under
research conditions. There were no constraints concerning the diagnoses or
symptomatology. In fact they chose very severely disturbed people who had
been in treatment before with little success.
All treatments were completely videotaped in a split-screen technique with
the patient on one and the therapist on the other side of the screen. The
dialogues were completely transcribed according to the rules of the Ulmer Text
Bank (Mergenthaler, 1986).
Outcome was calculated using ratings of outcome, individual goal attain-
ment scales for each patient, helpfulness, and treatment satisfaction ratings from
Downloaded by [Australian National University] at 03:35 09 January 2015

both patient and therapist after the 15th session. Additionally, changes in the
scores of the Freiburger Beschwerdenliste (FBL, Fahrenberg, 1975), a list of
complaints which was completed by the patient before and at the end of
treatment, was used.
In table 1 the different measures of outcome are depicted. The 11 therapies
were rank ordered according to the combined outcome measure. The correla-
tion between the outcome ranking of patient and therapist was r = .58 (p = .08)
that between the outcome rating of the therapist and the FBL change score r =
.68 (p = .032). The correlation between the self-report on outcome of the
patient and the FBL change score was r = 0.24 (p = 0.49). There was a higher
consistency between the therapists rating and the change of the FBL filled out by
the patient. In three cases the therapists were much more critical than their
patients, only in one was it the other way around. So, the therapists, not the
patients ranking, fitted to the FBL change scores. This does not imply that the
patients’ ranking is “false” since there was a very substantial correlation (r =
+ .84, p = 0.002) between patients’ outcome ratings and the change scores of
their affective facial expression from negative to positive from the first to the
fifteenth session.

Table I . Outcome-Measures of the I 1 Therapies

Therapy Nr. change
ranking Patient’s Therapist’s scores FBL
(combined) orientation ranking ranking (raw-scores)
1 C.B. 1.5 1 47
2 P.A 3.5 2 34
3 C.C.T 6.5 3 38
4 C.C.T 6.5 4.5 31
5 C.B. 1.5< 6.5 - 13
6 P.A. 6.5 4.5 19
7 D.1.T 3.5< 8 - 25
8 P.A 6.5< 11 -5
9 D.1.T 9 6.5 - 27
10 C.B. 10 9.5 -5
P.A. % 9.5 %

C.B. cognitive behavioral

P.A. psychoanalytic
C.C.T client centered therapy
D.I.T. Dynamic intended (An east German version of an insight oriented uncovering treatment)
 AFFECTIVE DYADIC BEHAVIOR 403

AFFECTIVE EXCHANGE
The affective part of the nonverbal interaction between patient and thera-
pist was investigated using facial affective expressions of both interacting
partners. The measurement was done with the Emotional Facial Action Coding
System EMFACS, developed by Friesen & Ekman (1984) baSed on FACS (Ekman
& Friesen, 1978). In departing from FACS which registers comprehensively all
facial activities, EMFACS is reduced to patterns which are potentially relevant to
affect.
Using a dictionary (Friesen & Ekman, 1984; Wagner, 1986) these events are
related to the affective categories genuine (felt) happiness, ingenuine happiness,
anger, contempt, disgust, fear, sadness, and surprise. These are referred to as
primary affects. The dictionary is very restricted, and an interpretation is only
Downloaded by [Australian National University] at 03:35 09 January 2015

given if the coded facial activity fits exactly with the configurations listed in the
dictionary.
In addition, “blends” and “masks” can be inferred from the raw scoring of
facial events. Blends are innervations of two of the above-mentioned primary
affects from the anhedonic spectrum emitted at the same time. Masks are
patterns during which an expression of happiness or surprise is used to cover up
a previously existing negative expression. In addition, we calculated the sum of
all negative affects as well as the sum of all positive affects.
Frijda (1986) and Krause (1990) have argued that each affect has an
underlying cognitive structure which follows the rules of a proposition. There is
a subject, an object, and a desired interaction between both. In showing the
affect signal, the subject indicates which interaction is desired. For example,
anger implies the wish that the object would go away; fear indicates the subject’s
wish to flee. By use of this propositional structure we can relate the subject’s
wish, and the object’s reactions of the pervasive narrative structure, to the affect
shown in the face of both protagonists. The measurement of facial affect does
not necessarily allow inferences to be made about the experiencing of feelings.
First of all, there are display rules through which affect is simulated as a
conventional emblematic sign. Secondly, most of the shown affect is not
internally monitored. As we have shown elsewhere (Krause, Steimer-Krause,
Merten, & Ullrich, 1996; Merten, 1996), the affective sign has no built-in
information concerning the object of the proposition to which it is intended to
be attached. It can indicate the emotional state of the sender, the feeling of the
sender about the object of the narrative, and it might be a commentary regarding
the interaction. Therefore, shown contempt might indicate that the sender is
contemptuous of himself, of the object, of a common third person being talked
about, or of the interaction partner, which puts us in need of information
regarding context in order to reduce the ambiguity of the signal.
To investigate the temporal organization of the facial affective behavior
within a session and to identify possible changes in the phase structure between
successive sessions, the following measures describing the temporal organiza-
tion of facial affective behavior have been developed. They have already proved
to be useful in the prediction of the emotional experience within therapeutic as
well as everyday life interactions (Merten, 1996; Merten et al., 1996).
At = distance between two consecutive innervations of facial affective
events
 404 ANSTADT ET AL.

u(At) = standard deviation of the distance At within one session

Atrel = relativated distance, on the assumption of an equal distribution of all
affects over the therapeutic session. These relative distances are indepen-
dent of the amount of facial affectivity
u(Atre,) = standard deviation of the relative distances between 2 consecutive
innervations

The standard deviations of At and Atreldepend on the non-homogeneity of the

distribution of facial activities over the period of observation. A completely
homogeneous temporal distribution of facial activities through the observation
period would result in an equal distribution of variance 0.
Downloaded by [Australian National University] at 03:35 09 January 2015

NARRATION

Using the transcripts, we extracted repetitive relationship episodes, fol-

lowing Luborsky’s (1977) method. Luborsky’s measuring instrument (the
CCRT-Core Conflictual Relationship Theme) claims to be a formalized version
of the clinician’s intuition, a sort of operationalization of the nuclei of the
transference “clichC. Changes in the CCRT are frequently considered as valid
”

measurements of basic change. The CCRT relies heavily on the psychoanalytic

notion of conflict, extracting characteristic wishes of the patients and objects, as
well the subject’s reactions to these wishes. The raters mark those passages
during which the patients produce a narrative about an interaction with other
persons (“relationship-episodes”: RE). In a second step the following compo-
nents are determined:

1. The wish the patient generates vis-3-vis the interaction partner (W-
Component)
2. The reaction of object generates regarding the wish (RO-component)
3. The reaction the subject generates (RS-component).

According to Luborsky (1977) 10 episodes are needed to formulate a CCRT

which is representative for the person. Finally, the CCRT is comprised of the
most frequent components, which represent what is called a pervasive structure.

RESULTS

RECIPROCAL VS. COMPENSATORY AFFECT EXCHANGE AND

THERAPEUTIC OUTCOME

In general, facial expression during the first session is highly variable

between subjects. So, for example, we find a male borderline patient with 8 2 %
of his affects being disgust, and a female agoraphobic patient with 82% felt
happiness. Among the therapists, we find a psychoanalytically oriented male
with 86% of his affects being felt happiness. Two male therapists of the
cognitive behavioral orientation showed more than 50% contempt in the first
session.
Using a dyadic combination of the first session’s facial affect of both
partners, we developed a reciprocity vs. compensation scale of facial affect
 AFFECTIVE DYADIC BEHAVIOR 405

exchange called ‘‘dyadiclead-affect. First we defined the individual lead-affect

”

of a protagonist as the most frequent primary affect out of all affects displayed
by this person. If the lead-affect was either anger, contempt, disgust, fear, or
sadness they were considered as negative, if it was felt happiness, which is not
social smiling but genuine joy or surprise, it was considered as positive.
Reciprocity was assumed if the lead-affects of both protagonists were either
positive or negative. They were considered as compensatory if one was negative
and the other positive. Since there are two forms of reciprocity, one in a
negative and one in a positive version, we rank ordered the two according to the
following logic: Dyads in which both partners show genuine happiness as the
lead-affect, despite the severity of the situation and the symptomatology, do not
enter emotionally into the field. Both take on a defensive attitude and the
Downloaded by [Australian National University] at 03:35 09 January 2015

discourse does not go beyond this. This version received the ranking 3. If both
were negatively reciprocal, according to their lead-affects, they are at least in a
problem area, but since the risk exists, that the patient may run away if the
therapist confirms the enactment, we gave the ranking 2. Compensatory lead-
affects (+/ - ) got the ranking 1.
This ranking correlates (r = - .70, p = .03) with the combined outcome
measure of patient and therapist, and r = - .65 (p = 0.04) with the combined
ranking scale including the change scores in the FBL. In addition the percentage
of the therapist’s lead-affect as part of his or her affective repertoire in the first
session correlates significantly negatively (r = - .66, p = .03) with the thera-
pist’s own rating of outcome after the fifteenth session. So the first hypothesis
about the disadvantages of a reciprocal affective reaction on the side of the
therapist at least in the first session was clearly confirmed.
The two psychoanalytic therapies with the best and the worst rankings were
selected for further analysis of the hypotheses two and three. The therapy of Mr.
H, with the second-best outcome, ended as planned after 15 sessions. Therapy A,
the third worst, was ended after a few additional sessions. Neither therapist nor
patient A were satisfied with the result (Ranking 8 in table 1). Positive facial
affective expressions of the patient gradually went down.
Mr. H was a 55-year-old married artist, who attended with his wife because
of sexual relationship problems and severe alcohol and working problems. They
agreed that the man should be treated. Previously he had been treated as an
inpatient for depression. He was diagnosed as a “histrionic personality disor-
der” according to the DSM 111-R.
Miss A suffered from a severe anxiety disorder with panic attacks. She had
previously been treated with behavior therapeutic techniques, and was addition-
ally under medication. According to the DSM 111-R she was classified as a case of
“mixed personality disorder.”
In both cases the therapists were very experienced psychoanalysts, who had
training responsibilities for young candidates, as well as having more than 150
cases and 20 years of experience.
The distribution of affect, in the first hour of the two therapies is the
following:
Within the first session Miss A had 169 facial affective events, 104 being
primary affects. Her therapist had 117 facial affective events, 42 being primary
affects and 58 social smiles. On 66 occasions the patient showed felt happiness,
15 times sadness, 12 times fear, 7 times contempt, 4 times anger, no disgust, and
no surprise. The relative frequency of felt happiness, within the therapist
 406 ANSTADT ET AL.

repertoire was 82% of the primary affects. So, from the overt behavior dyad A
seemed to manifest a very happy and reciprocal dyad at the beginning or, in our
terms, with a monotonous positive lead-affect and reciprocity.
Patient H showed 134 facial affective events in the first hour, 61 being
primary affects. The remainder were social smiles and much speech-related
illustrators, something Miss A didn’t show at all. The therapist had 79 facial
affective events, 64 being primary affects, 8 illustrators, and 1 1 social smiles.
The patient had an almost equal distribution of anger, disgust, and felt happi-
ness. The therapist’s disgust reaction outweighed that of the patient, and his
own felt happiness reaction. The therapist showed no fear and no sadness but
much surprise. This depicts a compensatory dyad, since the high amount of felt
happiness on the side of the patient clearly dominates over the negative
Downloaded by [Australian National University] at 03:35 09 January 2015

emotions, whereas the therapist is predominantly negative.

Table 2 shows the primary affects of patients and therapists across all 15
treatment sessions. Both patients can be characterized by specific longitudinal
affective patterns across the sessions. There are significant differences between
them over the complete course of treatment with regard to joy, anger, disgust,
fear, sadness, and surprise. Whereas Miss A can be described as a joy, fear,
sadness type with a nearly complete absence of surprise, anger, and disgust, Mr.
H, in contrast, is an anger, disgust, joy type without omissions in the spectrum
of affects.
Both therapists produced very low values for fear and sadness. In that
respect they are very different from the patients. Mr. H’s therapist was 12 times
more frequently surprise than Miss A’s therapist. If we disregard that, there are
no significant differences in the average frequencies between the therapists over
all the sessions.

NARRATIVES

The CCRT was applied to all treatment sessions of both cases being
discussed. Tables 3 and 4 depict the number of relationship episodes the patients
generated through the complete course of treatment. This is a complete list of
the number of narratives about interactions with other people.
The female patient A’s most frequent wish is for “help and support” (20),
the second “to make a good impression” (16), the third “others should not

Ta&le2. Average Frequencies of Primary Affects, Patient A and ff and Their

Therapists
Patient happy (felt) anger contempt disgust fear sadness surprise
A 53.9 (19.6) 2.7 (2.2) 6.53 (2.5) 0.53 (0.9) 7.8 (5.4) 7.3 (3.8) 0.4 (0.8)
H

Therapist
20.9 (10.6) 12.4 ( 5 )
**
4.6 (4.5) 6.5 ( 3 . 5 )
.*
4.4 (3)
*
2 (2.2)
.* ..
5.3 (3.4)

A 45.2 (19) 5.3 (4.9) 2.8 (2.9) 12.9 (5.5) 0.1 (0.3) 0.3 (0.6) 0.5 (0.6)
H 34.4 (21.2) 6.1 (6.1) 3.4 (2.2) 14.5 (8.7) 0.1 (0.2) 0.2 (0.4) 6.0(9.1)
I
n.s. n.s. n.s. n.s. n.s. n.s.
Average frequencies (Standard deviations).
*,**Levelsof significance for t-tests comparing patient A and H, as well as therapists.
* * p c .001, ‘p < .05, two-tailed testing.
 AFFECTIVE DYADIC BEHAVIOR 407

Table 3. Frequencies of Relationship-Episodes (Narratives), Wishes and RO ’s, Case A

Sessions

CaseA 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 C
RE’S 4 3 4 8 7 4 4 8 3 9 6 3 4 5 7 79

w-1 3 1 1 4 1 1 3 3 2 1 2 0
w-2 4 1 1 4 2 4 16
w-3 1 1 1 1 3 1 1 9
W-N 6 2 8 10 7 3 5 9 3 9 10 5 3 5 7 92

R0-1 1 3 2 1 1 1 1 3 2 3 18
R0-2 3 2 2 2 2 3 2 2 18
Downloaded by [Australian National University] at 03:35 09 January 2015

RO-3 3 1 2 1 1 1 1 3 13
RO-N 7 3 11 11 10 9 6 7 1 13 9 3 4 12 10 116
Legend
RE’S: total frequency of relationship-episodes(narratives)
W-1: support and help
W-2: to make a good impression
W-3: others should not intervene
WJ: total frequency of wishes in the narratives
R0-1: others dramatize
R0-2: others are not honest
RO-3: others laugh about me
RO-N: total frequency of RO’s

intervene” (9), and finally that they should be open and honest. The object
reactions are that the others dramatize, are not honest, and are laughing at her.
Table 4 depicts high variability of the frequencies of relationship episodes,
over the sessions, in therapy H. There are sessions with as many as 20 narratives
and others with nearly none. The three most frequent wishes of patient H are “I
want to resist exploitation” (34), followed by “I want to be brilliant and to be
admired” (30), and “I want closeness and mutuality” (28). The most frequent
reactions of the objects are negative, and vary between exploitation and
destruction on the one hand, to ignoring and devaluating on the other. Linking
the patient’s narration to affect expression we might expect several production
rules. One would be that the patient’s facial affective behavior would be tied in
with the wish element of his narrative. For example, generating facial distress
when talking about the wish to get help or anger when talking about the wish to
defend himself against exploitation. The other would be that the affects would
be tied to the object’s reactions as told in the stories. This linkage could either
mimic or comment affectively on the action of the object and finally they might
be linked to his narrations about his own reaction to the object’s reaction, again
either mimicking or commenting on his own reaction. Finally, the expressed
affect could have nothing to do at all with the narration, commenting on instead
the state of the relationship. On the side of the therapists, we can assume similar
patterns, such as the therapists’ reflecting affectively the narration of patients
wishes, the objects’ reactions, or the subjects’ reactions to the objects’ reaction.
A simple hypothesis, related to a successful enactment of the production rules in
Case H during treatment, would be that the therapist would act facially
aggressive, contemptuous or disgustful vis-2-vis the patient’s wishes to be
 408 ANSTADT ET AL.

Table 4. Frequencies of Relationship-Episodes (Narratives), Wishes and RO’s, Case

H
Sessions
CaseH 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 C

RE’s 9 11 -* 16 10 20 3 6 8 5 15 9 8 7 137

w-1 1 - 6 4 3 5 3 2 2 1 2 1 2 2 3 4
w-2 6 1 - 5 7 5 4 1 1 30
w-3 5 - 3 5 2 5 1 1 3 3 28
W J 12 12 - 20 13 12 23 4 6 10 5 18 9 11 8 163

R0-1 2 1 10 3 3 7 2 2 2 4 2 4 1 2 4 5
R0-2 1 3 3 4 2 6 2 2 1 2 1 1 2 3 0
Downloaded by [Australian National University] at 03:35 09 January 2015

R0-3 3 3 2 6 7 1 1 4 1 1 1 3 0
R O N 14 18 22 13 18 32 6 8 9 6 19 12 10 10 197
*The third session did not take place.
Legend
RE’s: total frequency of relationship-episodes(narratives)
W-1: to defend against exploitation
W-2: to be brilliant and to be admired
W-3: closeness and mutuality
WJ: total frequency of wishes in the narratives
R0-1: others exploit me and treat me like they want to
RO-2: others are aggressive and destructive
R0-3: others are devaluing me and my work
R O N : total frequency of RO’s

admired. The wish for defense against exploitation allows no such simple
hypothesis. For case A, such simple predictions are more difficult because there
seems to exist a built-in conflict between the wish for support and help and the
aversion against other peoples’ intervention. From the side of object reaction, a
reenactment through the therapist, associated with bad outcome, could consist
of dramatizing, being dishonest, and laughing at the patient. All these reactions
can be partially measured facially by including different contexts, such as speech
and gaze patterns (Merten, 1996).
Usually an affect expression with mutual gaze pattern is indicative for the
state of the relationship. If the speaker produces the affect and looks away it is
frequently indicative for an element of the narration. However the linkage of
elements of the narration are often very difficult to unravel. For example,
Patient H talks about the alleged “homosexuality” of his brother, attributed to
the latter by his mother, thereby somehow quoting his mother by saying “that
this is very, very bad!” nodding his head, raising his voice, and making an
intense disgust expression while looking at the therapist. It is impossible to
clarify at the moment whether he “identified” with his mother as the aggressor
or is producing a caricature of her, or perhaps is he full of disgust vis-2-vis the
therapist and is hiding it behind the affective quotation. In addition Merten
(1996) has shown that the linkage of facial affect, speech, and gaze is specifically
altered if patients suffering from schizophrenia are engaged in the dyadic
discourse. Because we have to expect complicated relations, we will start with
a very simple measure which will gradually become more and more sophisti-
cated.
 AFFECTIVE DYADIC BEHAVIOR 409

THE LINKAGE OF AFFECT AND NARRATION

How these affective and narrated relationships are related to the diagnosis is
not the topic of this article, but it is not very difficult to relate the wish to be
admired to a histrionic personality disorder. On the enactment side, a propor-
tion of 165 facial events, with only 64 being affects, could be indicative for a
false affect syndrome. For the patient with the anxiety disorder, it is not as easy
to speculate. However since about 65% of these patients suffer from a comorbid
secondary diagnosis on axis I1 of the DSM 111-R as “dependent personalities,” the
wishes for help and to make a good impression could be related to this sort of
personality structure. The procedural rule for the enactment could be contained
in the generation of either felt or unfelt happiness. However the latter would be
Downloaded by [Australian National University] at 03:35 09 January 2015

related to being dishonest, something she despised as an object reaction.

Departing from the assumption of a “homology” of affective enactment and
narration, we first compared the frequency of narratives with the frequency of
facial affective displays. We found a significant negative correlation of r = - .27
(Kendall’s Tau, p = .04). When calculating the correlations separately for each
therapy, they remain negative (r = - .31 in case A, r = - .20 in case H). Because
of the small number of instances, they do not attain significance. This result
contradicts the relations found in the investigation of everyday life interactions
where speech and facial activity in general and affect in the true sense of the
word are positively correlated. In psychotherapies the coupling of word and
affect is obviously different from phenomena found in everyday dialogues. We
have already seen that psychotherapists show much less facial affect than their
patients, with nearly no fear and sadness. This holds true for all of the 1 1
therapists we investigated. A second reasonable assumption, for which we will
give empirical support later is, that the therapists rather seldom produce affect
while speaking in comparison to laypeople in everyday life. They would instead
shift affect expression to the process of listening as a form of emotional
mirroring. In any case, the hypothesis of direct homology of the act of narration
and affective enactment is not valid.
If we relate facial expressions, narratives, and phase structure to therapeutic
outcome, we see that in the successful treatment H, a clear-cut phase distribution
concerning the narratives can be found, whereas in the unsuccessful case A, the
null hypothesis of an equal distribution of the number of narratives over the
sessions cannot be rejected (~’(14,N = 79) = 1 1 , 17). The relationship episodes
in case H are unequally distributed (~’(13,N = 153) = 27, 6l;p < .05), with an
augmentation up to the 7th hour, and a reduction, particularly for the wish to be
admired, from the 8th hour on.
In addition, the temporal organization of Mr. H’s therapist’s facial behavior,
within the therapy sessions shows two clear-cut phases. There is a very high
variance until the 7th hour, after which it is more evenly distributed across the
sessions (U Wilcoxon rank sum W test: U = 8,O; W = 61, P = 0.04). This means
that in the first half of the treatment the therapist shows an interaction style
which can be characterized as follows: In the first half or two-thirds of these
sessions, he didn’t talk very much, listened attentively without displaying much
affect, and made only brief statements. In the second part of these sessions he
attempted to intervene with much facial affect but was not very successful due
to the patient’s tendency to produce very elaborate monologues.
Additionally, there are significant differences in the temporal structures of
 4 10 ANSTADT ET AL.

affect expression between the subjects’ sigma (.(ATre,), F = 4.298, P = .013;

.(At,,), F = 5.095, P = 0.006). Analysis of contrasts shows that Mr. H’s
therapist had the highest values while his patient had the lowest (Merten et al.,
1996).
Based on the observation that in this therapy the wish “to be admired” is
very frequent in the first half with a climax in the sessions 6 and 7 ( 1 2 times) and
zero values in the 4 consecutive sessions, we can presume that the phase
structure might be related to a production rule tied to the enactment of
phantasies about grandiosity somehow breaking down within the 7th session.
This might have to do with the difference in the temporal distribution of affect
expression of the therapist with a major change in the same session. Whether
this is true, can only be answered through a methodology linking specific
Downloaded by [Australian National University] at 03:35 09 January 2015

elements of narratives and facial affect in a more detailed way.

Table 5 shows the significant intercorrelations between the wishes, the
object reactions, and the affects of both interaction partners throughout the
entire course of treatment.
Since the tables are based on 4 matrices with 9 x 12 cells (108), 5 significant
coefficients could be expected by chance (5 %). The number of coefficients in 3
matrices is within the realm of chance. It is only in the correlation matrix
involving the facial values of Mr. H’s therapist and the CCRT values of Mr. H that
we find 1 1 significant coefficients. Therefore, we can assume a better than
chance relation between the narrations of the patient and the affect of his
therapist. For the patient, we find only one significant negative correlation of r
= -.59 between his displayed genuine joy and his description of being
exploited through the past and present-day partners. There is no correlation
between the facial affect of the therapist and the wish “to defend against
exploitation. However, there are prominent correlations between the fre-
”

quency of the wish “to be admired,” but contrary to the hypothesis, it is

positively correlated with the negative affect expressions of the therapist
(contempt, r = 0.59; disgust, r = 0.70).

Table 5. Intercorrelations Between Facial Expressions and CCRT

W-1 W-2 W-3 WJ RE’S R0-1 R0-2 RO-3 R O N C

facial expression Case H

therapist H
contempt .59* .52 .58’ .43 .57’
disgust .70 * .60
happy felt .40 - .63* -.42 11
interpreted - .49
patient H
happy felt .59* 1
Case A
therapist A
contempt .56
sadness - .50 .5O
surprise - .51
patient A
disgust - .49 .54
sadness .56* - .51
happy felt - .47
(Kendall’s r: p < 0.05; p’ < 0.01; 2-tailed)
Legend see table 3 and 4
 AFFECTIVE DYADIC BEHAVIOR 411

We hypothesized that this would occur only in unsuccessful courses of

treatment. However, these results could have at least a partial alternative
explanation because the same behavioral pattern of the therapist also correlates
quite substantially with the narrations about the reactions of the significant
others, i.e., “others devaluate me and ignore me and my work” (r = 0.43 for
contempt and r = 0.60 for disgust). Due to the structure of the narrations, these
two elements probably occur quite frequently together, at least in the first seven
sessions and emotional reactions of the therapist could imply an affective
empathetic commentary on the described actions of the objects. Since this wish
and the corresponding object reactions are dramatically reduced in the second
section of the treatment, it is likely that the relations are due to the phase
structure of the treatment. In fact, the facial affective signals of the therapist’s
Downloaded by [Australian National University] at 03:35 09 January 2015

disgust and contempt in the second half of the treatment occur 58 times less than
in the first part (177 vs. 119). Since the displayed genuine joy of the therapist
correlates negatively with the frequency of narration about aggressive object
reactions, another indicator for an empathic reaction is likely. To test this
hypothesis in a more detailed way, in 8 of the 15 hours gaze and speech context
of the therapist’s anger, contempt, disgust, and genuine happiness expressions
were registered and set into relation to the patient’s rating of his affective
experience during the sessions and the presumed experience of his therapist as
measured after the session with the Differential Emotion Scale (DAS, Merten &
Krause, 1993). Depending on two types of speech content “no one” or “other
people” correlations were completely different. In the latter case the correlation
+
between self rating happiness and facial contempt was r = .76 in the former
it was r = - .84. Under the condition “no one” the patient rated the therapist
as angry if he showed contempt (+ .76). Facial disgust of the therapist accom-
panying discourse on object reactions was related to patient’s experience of joy,
if no other object was talked about with unhappiness. If three forms of text
contents and the therapist’s frequency of expressed anger, contempt, disgust,
happiness were compared, the following pattern showed up. In the “no object”
verbal context, anger, contempt, and disgust expression was 15% below, and
happiness 15% above the expected amount. During the topic of women
(basically his mother, wife, and some female “psychotherapists”), happiness
was 12% under; and anger, contempt, and disgust were 12, 15, and 8%over the
expected level. Mutual gaze patterns were accompanied with 18%augmentation
of happiness and a 13% lowering of disgust of the therapist. If only the therapist
looked, the distribution was as expected. If no one looked there was a 10%
reduction of genuine happiness. If only the patient looked, a 12% augmentation
of disgust and a 9% reduction in happiness expressions were to be found.
Nobody looking is often accompanied by silence, mutual gaze by a rather
context-free confirmation of the relationship usually located within speaker
turns. If only the patient looks, usually the therapist speaks. In that situation,
disgust increases. He usually made comments or interpretations about the
function and significance of his female introject-like partners, who were at-
tacking and exploiting the patient’s creativity in a grotesque way. Therefore, the
negative affect usually did not signify a disliking for the patient, but rather
reflected the therapist’s commentary on the content of the relationship epi-
sodes, especially on what the “story teller” is experiencing through his objects.
In that case, the therapist would be acting as a “container” (Bion, 1967), and in
doing so, would take over a very important function for the patient by
 412 ANSTADT ET AL.

expressing the patient’s implied rejection. In turn, this reveals to the patient
affects that he himself was not capable of generating during the interactions.
However such an interpretation is not sufficient. The disgust and contempt
expression in the therapists’ face sometimes repeated the devaluation of the
objects. Following the maladaptive schema, the patient, through his (at times)
grotesque gesticulations, which the therapist had characterized as a “Punch and
Judy show,” had reenacted the same devaluation he had spoken about in his
narratives. Following his CCRT, the patient was usually unable to enact the wish
for admiration vis-2-vis the important objects in his reality and phantasy. The
reactions of the objects were not admiration, but devaluation.
The therapist had in fact organized his treatment around the patient’s
compulsive need to make narcissistically depleted women shine (a term the
Downloaded by [Australian National University] at 03:35 09 January 2015

patient had used) through grandiose artistic productions. This of course, did not
fulfill their purpose, and led to harsh critique and devaluation which ended up
in the standard reproach of his wife, that he only made music to sexually attract
young women. In the 7th hour the therapist had asked, whether the patient
“really need this kind of circus?” To this confrontation the patient answered, for
the first time, with a real emotional movement, “obviously,” and in doing so, he
realized that he had replicated this pattern. These two interpretations of the
results are not mutually exclusive because it is quite evident that the patient had
seduced the therapist, with at least partial success, into engaging in the historical
pattern. In fact, the correlations between the wishes of the patient and the
expression of the therapist are substantially higher than those between the
narrated object reactions and the therapist’s expression. Perhaps a therapist can
understand the relationship o€feredby the patient in treatment only if he himself
experiences the emotional consequences after having enacted them. In the
commentary that Mr. H’s therapist had to give after each session, he was often
concerned, in the first half of the treatment, that he might be overwhelmed
through his own feelings of contempt in response to the patient’s ridiculous
behavior. The patient was deeply influenced by the content-free contempt
expression, as was shown by the two above mentioned correlation coefficients
(T = - 3 4 , self-rating happiness, T = .76, object-rating anger). Although
content-free contempt and disgust expression was very seldom and far below
the expected, it did happen, and was of severe influence. On the other hand, the
patient was able to impress the therapist in a very positive way, as the extremely
high surprise expression and surprise self-rating of the therapist showed. He was
indeed a fascinating personality for the therapist.
In the unsuccessful case A, the relationship between narrated episodes and
the facial expression of the therapist are in general much lower and do not go
beyond the values we expected by chance. Since there is no relation at all
between the narrated object reactions and the therapist’s facial expression it is
hard to believe that the shown contempt and sadness is a commentary on the
actions of the objects. Additionally, the facial affective behavior of the patient
provides no commentary to her own narrations about object reactions. There is
only one correlation between the patient’s disgust reactions and the narrated
behavior of the objects “to dramatize.” Both patient and therapist were engaged
in extensive mutual smiling, which allowed them to establish a positive relation-
ship despite the fact that the therapist had declared the patient’s behavior to be
a “smiling mask,” and had identified the missing aggression as an essential
problem. However, both patient and therapist were quite happy, and the
 AFFECTIVE DYADIC BEHAVIOR 413

therapist experienced less guilt when enacting this kind of interactive defense
(Merten et al., 1996). In that respect, Miss A did give the good impression that
she thought she would need to keep the relationship going. At the same time she
acted dishonestly, something she had despised as an object reaction. All this was
of course at least preconscious and not under control through the patient. The
therapist had declared the patient to have a “fragile ego,” and in following this
diagnostic assumption he stabilized this pattern. However, as a result, the
treatment was becoming cognitively and affectively very boring, which could be
inferred from the complete absence of surprise reactions in both protagonists. In
addition, patient A, in responses to self-report questionnaires, never declared
any surprise. Without surprise reactions we do not have substantial indications
that there are new insights, either on the side of the patient or on the side of the
Downloaded by [Australian National University] at 03:35 09 January 2015

therapist. Related to our initial hypothesis, the therapist did indeed not drama-
tize, but he was not honest about the patient and the constant happiness
expression was experienced by the patient as being not taken seriously some-
thing she feared as an object reaction. As to the wish, she got more support and
help than she needed, but at the same time, the therapist made too many
interventions within his affective enactment.

DISCUSSION

Our data has confirmed that the facial affective reaction of a therapist to his or
her patient at the beginning of treatment is a good predictor of outcome and
process of short-term psychotherapies, disregarding the theoretical orientation
of the treatment, at least with very experienced psychotherapists. Reciprocal
affective reaction is indicative of poor outcome, especially in the version of
mutual felt happiness displays. This kind of affective behavior is probably the
consequence of a mutual defense pattern centered around affective denial of the
problems the patient is offering. Reciprocal affective action, in the anhedonic
spectrum, is better but not very favorable either. It does not seem to reflect a
defense structure, but the “empathic reactions” of layman. If a patient generates
facial disgust every half minute and does not smile at all, like the borderline
patient mentioned above, it is difficult to compensate this behavior by smiling.
The therapist of this patient fought very hard, but the majority of his minimal
facial affect, was contempt reflecting his countertransference feelings. He was
aware of these feelings but not of his facial leakage. The patient’s most important
wish in the CCRT was, of course, to be loved.
Compensating affective reactions are indicative of good progress: if the
patient is denying his or her negative affects through facial affective happiness,
the compensatory reaction is negative affect; if he or she shows anger, con-
tempt, disgust, fear, sadness, the compensatory reaction is felt happiness or
surprise. The facial affect is hard to control and usually not monitored internally
either by the patient or the therapist, in that respect it is un- or preconscious.
This raises the question whether one of the important benefits of the couch
setting is that the facial affective signaling is short circuited, shutting down a
very important stabilizing production rule for the enactment of the maladaptive
relationship pattern. The other question is whether therapists should more
closely observe, in their training, their habitual and specific affective behavior.
 414 ANSTADT ET AL.

Most of the ongoing psychoanalytic training procedures, with the focus on

narrations and privacy, are not very suitable for this purpose.
Second, a homology between the structural and the procedural parts of
maladaptive relationship patterns cannot be expected. This is certain if we
consider the frequency of both kinds of events across the complete treatment,
taking the sessions as units of analysis. The significant negative correlation
between both streams of behavior is more supportive of an antagonistic
relationship between procedural and structural parts of relationship patterns.
The patient A, who wants to be autonomous, has an affective production rule
fostering dependency. The patient H, who wants to make creative works of art,
has a production rule making him the clown. The patient who wants to be loved
opens the relationship with a bombardment of disgust.
Downloaded by [Australian National University] at 03:35 09 January 2015

In the successful treatment, substantial relations between the narrated

episodes of the patient and the facial affective behavior of the therapist could be
found. A closer inspection revealed that the therapist produced those affects that
the patient did not tell nor display in the narrated episodes, but which could be
expected as adequate emotional responses. Understanding the interactive pro-
cess in such a way leads to the conclusion that the missing production rules are
first reenacted and reexperienced by the therapist and are then handed over to
the patient. This confirms Bion’s ideas about the container function of the
therapist (Bion, 1967). He is however a reacting container, offering behaviorally
new production rules to the patient.
In the successful treatment, we find a clear-cut phase structure. However,
the segmentation into a period of enacting followed by a period of working
through, is not appropriate to the complexity of the processes. In the first
segment the patient does tell a lot of narratives. He is however, incapable of
emotionally understanding them and generating appropriate production rules.
By the feeling evoked in the therapist and handed back to the patient, a point is
reached at which the whole situation must be organized anew. Then, in case H,
the wish “to be admired” can be reappraised or other coping strategies can be
developed in order to derive different subject and object reactions. In the
unsuccessful treatment, we do not find any phase structure, which may be due
to the fact that the narrations do not provoke the missing affects in the therapist,
and so they cannot be handed back to the patient. The patient could have been
aggressive, but in her attempts she was afraid of being left alone. The absence of
aggression was not reflected by the therapist. We do know why this happened,
but that would require explaining the complex patterns of countertransference
and the anxieties the therapist was drawn into partially through the patient and
partially through the project.
The presented results have to be understood as preliminary. It is extremely
time consuming to analyze facial behavior, so we have not yet been able to
generalize our results over all therapies. Therefore, the following warnings and
comments are necessary.
1) Since we used measures that were in part aggregated across the whole
session, the correlations do not reflect the diachronic relationship between the
process of narration and the affective acting out of the protagonists within the
session. However, as we analyzed the microlevel of narratives and facial
expressions in case H, a factual relationship between a commenting facial
behavior of the therapist to the narration of the patient has been found.
2) We do not have enough empirical support in order to generalize these
results over all psychoanalytic brief therapies. We analyzed two extreme cases
 AFFECTIVE DYADIC BEHAVIOR 415

indicating success and failure, in treatments conducted by two very experienced

therapists. We assume, of course, that inexperienced therapists make other
mistakes, especially through the usage of incorrect techniques.
3 ) We do not yet know whether these observations and their possible
relation to outcome show up in treatments with therapists of other theoretical
orientations, such as cognitive behavioral or client-centered. In a series of
further studies we hope to find answers to these questions.

REFERENCES

Argelander, H. (1979). Die kognitive Organisa- M.: Fischer.

tion psychischen Geschehens [The cognitive Friesen, W. V., & Ekman, P. (1984). EMPACS-7
organization of mental processes]. Stutt- Emotional facial action coding system. Un-
Downloaded by [Australian National University] at 03:35 09 January 2015

gart: Klett-Cotta. published manuscript,

Balint, M. (1959). Thrilk and regressions. Lon-
don: Hogarth Press.
Becker-Beck, U. (1995). Soziale Interaktion in
Gruppen: Struktur- und Prozessanalyse[So-
cial interaction in groups: An analysis of
structure andprocess]. Saarbriichen: Univer-
sitat des Saarlandes, Habilitationsschrift .
Benjamin, L. S. (1984). Principles of prediction
using structural analysis of social behavior.
In: R. A. Zucker, J. Aronoff, & A. I. Rabin
(eds.), Personality and the prediction of
behavior. Orlando: Academic Press.
Bion, W. (1967). Second thoughts: Selected pa-
pers on psychoanalysis. London: Heine-
mann.
Crits-Christoph, P., Demorest, A , , & Connolly,
M. B. (1990). Quantitative assessment of in-
terpersonal themes over the course of psy-
chotherapy. Psychotherapy, 27, 5 13-52 1.
Dahl, H. (1988). Introduction. In: H. Dahl, H.
Kachele, & H. Thoma (eds.). Psychoanalytic
process research strategies. Berlin, Heidel-
berg, New York: Springer-Verlag.
Ekman, P., & Friesen, W. (1978). Pacialaction
coding system. Palo Alto: Consulting Psy-
chologist Press.
Fahrenberg, J. (1975). Die Freiburger Beschwer-
denliste FBL [The Freiburg list of com-
plaints]. Zeitschrift fur Klinische Psycholo-
gie, 4, 79-100.
Fenichel, 0. (1946). Thepsychoanalytic theory
of neurosis. London: Routledge.
Fiedler, P., Hahlweg, K., Krause, K., & Schulte,
D. (1994). Klinisch psychologische Interak-
tionsforschung, soziale Einflussnahme und
Selbstregulation [Clinical psychological in-
teraction research, social influence and self
regulation]. Heidelberg: Antrag auf Einrich-
tung eines DFG-Schwerpunktes.
Fiedler, P . (1994). Personlichkeitsstorungen
[Personality disorders]. Weinheim: Beltz.
Freud, S. (1914). Erinnern, Weiderholen, Dur-
charbeiten [Remembering, repetition and
working through]. Stutienausgabe Ergan-
zungsband. Behandlungstechnik Frankfurt/
Frijda, N. H. (1986). The emotions. Cambridge:
Cambridge University Press.
Frisch, I., Schwab, F., & Krause, R. (1995).
Affektives Ausdrucksverhalten gesunder und
an Colitis erkrankter mannlicher und wei-
blicher Erwachsener [Expressive behavior of
male and female healthy subjects suffering
from colitis ulcerosa]. Zeitschrift fiir Kli-
nische Psychologie, 24, 230-238.
Gill, M. M. (1982). Analysis of transference.
New York: International Universities Press.
Grawe, K.(1987). Psychotherapie als Entwick-
lungsstiulation von Schemata. In: Caspar, F.
(Hrsg)., Problemanalyse in der Psychothera-
pie. Bestandsaufnahme und Perspektiven
[Psychotherapy as stimulation for the devel-
opment of schemata]. Tubingen: DGVT-
Verlag.
Grawe, K., Donati, R., & Bernauer, F. (1994).
Psychotherapie im Wandel [Psychotherapy
in change]. Gottingen: Hogrefe.
Henry, W. P., Strupp, H. H., Schacht, Th.E., &
Gaston, L. (1994). Psychodynamic ap-
proaches. In: Bergin, A. E., Garfield, S. L.
(eds.). Handbook of psychotherapy and be-
havior change. 4ih ed. New York: Wiley.
Horowitz, M. J. (1991). Person schemas and
maladaptive interpersonal patterns. Chi-
cago & London: University of Chicago Press.
Krause, R. (1990). Psychodynamik der Emo-
tionsstorungen [the psychodynamic of emo-
tional disorders]. In K. R. Scherer (ed.).
Enzyklopadie der Psychologie, Bd. CfIVl3.
Gottingen: Hogrefe.
Krause, R., Steimer, E., Sanger-Alt, C., &
Wagner, G. (1989). Facial expression of
schizophrenic patients and their interaction
partners. Psychiatry, 52, 1-12.
Krause, R., Steimer-Krause, E., Merten, J., &
Ullrich, B. (1997). Dyadic interaction regula-
tion, emotion and psychopathology. In:
William F. Flack &James Laird (eds.). Emo-
tions and psychopathology: Theory and Re-
search. New York and London: Oxford Uni-
versity.
 416 ANSTADT ET AL.

Laplanche, J., & Pontalis, J. B. (1972). Das
Vokabular der Psychoanalyse [The vocalbu-
lary of psychoanalysis]. Frankfurt/M.:
Suhrkamp.
Leary, T. (1957). Interpersonal diagnosis of
personality. New York: Ronald.
Luborsky, L. (1977). Measuring a pervasive psy-
chic structure in psychotherapy: The core
conflictual relationship theme. In: N.
Freedman & S. Grand (eds.). Communica-
tion structures and psychic structures. New
York: Plenum Press.
Mergenthaler, E. (1986). Die Ulmer Textbank
[The ulm textbank]. Entwurf und Realisie-
rung eines Textbankverwaltungssystems als
Downloaded by [Australian National University] at 03:35 09 January 2015
therapy-noch einmal. In: A. E. Bergin & s.
L. Garfield (eds.). Handbook of Psycho-
therapy and Behavior Change. 4th ed. New
York: Wiley.
Schwab, F., & Krause, R. (1994). h e r das
Verhaltnis von korperlichen und mentalen
emotionalen Ablaufen bei verschiedenen
psychosomatischen Krankheitsbildern. [the
relation of mental and physiological emo-
tional processes in the case of psychosomatic
disorders] Zeitschrift fur Psychotherapie,
Psychosomatik, Medizinische Psychologie,
44, 308-315.
Schiepek, G. (1994). Der systemwissenscha-
fliche Ansatz in der Klinischen Psychologie.

Beitrag der angwandten Informatik zur [Systems-theory in clinical psychology]

Forschung in der Psychoanalyse. Berlin:
Springer.
Merten, J., & Krause, R. (1993). DAS (Differen-
tielle Affekt Skala). Arbeiten der Fachrich-
tung Psychologie [DAS Differential Emotion
Scale]. Saarbrucken: Universitat des Saar-
landes.
Merten, J. (1996). Affekte und die Regulation
nonverbalen, interaktiven Verhaltens.
Strukturelle Aspekte des mimisch-affektiven
Verbaltensund die Integratfon von Affekten
in Regulationsmodelle. [Emotions and the
regulation of nonverbal, interactive be-
havior] Bern: Peter Lang.
Merten, J., Ullrich, B., Anstadt, T., Krause, R., &
Buchheim, P. (1996). Emotional experi-
encing and facial expression in the psycho-
therapeutic-process and its relation to treat-
ment outcome. A pilot-study. Psychotherapy
Research, 6(3).
Plutchik, R. (1980). Emotion: A psychoevolu-
tionary synthesis. New York: Harper &
Row.
Orlinsky, D. E., Grawe, K., & Parks, B. K.
(1994). Process and outcome in psycho-
Zeitschrip fiir Klinische Psychologie, 23(2),
77-92.
Villenave-Cremer, S., Kettner, M., & Krause, R.
(1989). Verbale Interaktion von Schizoph-
renen und ihren Gesprachspartnern [Verbal
interaction of schizophrenic patients and
their healthy partners]. Zeitschrifr fur Kli-
nische Psychologie und Psychotherapie, 3 7,
401-421.
Thoma, H., & Kachele, H. (1992). Psychoana-
lytic practice, Vol. 2 Clinical studies. Berlin:
Springer-Verlag.
Wagner, G. (1986). Entwicklung eines automa-
tisierten Verfahrens zur Affektinterpretation
[Development of an automatic procedure to
interpret facial-affective behavior]. Diplo-
marbeit an der Fachrichtung Psychologie der
Universitat des Saarlandes, Saarbriicken.
Weiss, J., Sampson, H., Caston, J., & Silbers-
chatz, G. (eds.). (1977). Research on the
psychoanalytic process. San Francisco, Psy-
chotherapy research group, Department of
psychiatry, Mount Zion Hospital and Medical
Center.

Zusammenfassung
Im Rahmen von 1 1 Kurzzeitpsychotherapien wurden der emotionale Gesichtsausdruck der Thera-
peuten und Patienten sowie deren zentrale Beziehungskonfliktthemen untersucht und zum Behand-
lungserfolg in Beziehung gesetzt wird. Es zeigte sich, dass ein kompensatorischer, nicht ein
reziproker Gesichtsausdruck in der therapeutischen Dyade der ersten Sitzung den Behandlungserfolg
indiziert . Eine Skala, die die Reziprozitat versus Kompensation im mimischen Verhalten beschreibt,
korrelierte signifiiant positiv mit Selbstbeschreibungen des Therapieergebnisses und symptomati-
schen Veranderungen. Zwei psychoanalytische Behandlungen, die eine mit der hochsten Rezipro-
zitat und dem geringsten Erfolg, die eine mit dem grossten Erfolg und einem hohen Mass an
Kompensation, wurden detailliert analysiert im Hinblick auf die zeitliche Entwicklung des Affekt-
austausches und der Narration iiber den gesamten Therapieverlauf. In beiden Therapien war die
Haufigkeit von Narrativen negativ korreliert mit der Haufigkeit von Affekten in der Mimik des
Patienten, so dass die Hypothese eines parallelen Verlaufes affektiven mimischen Verhaltens und der
Narration verworfen werden konnte. In der erfolgreichen Behandlung zeigte der Therapeut
wahrend der Berichte des Patienten jene Affekte, die man eigentlich von letnerem hatte erwarten
konnen. Eine sehr unterschiedliche zeitliche Organisation in der erfolgreichen Therapie, welche eine
Phase der Festlegung, eine Phase der Instabilitat und eine Phase der Konsolidierung umfasste, stand
im Gegensatz zu einer relativ homogenen Verteilung des Affektes in der weniger erfolgreichen
 AFFECTIVE DYADIC BEHAVIOR 4 17

Behandlung. Die Relevanz der Befunde f i r eine Theorie des therapeutischen Prozesses wird
diskutiert .

R6sume
Dans 11 therapies breves, I’expression mimique affective des therapeutes et des patients, ainsi que les
themes relationnels conflictuels centraux ont t t e explores et mis en relation avec I’effet du traitement.
I1 a i t 6 dtmontrk qu’une mimique affective compensatoire et non rkciproque de la dyade therapeutique
lors du premier entretien indique le succis. Une kchelle dkcrivant la rtciprocite, respectivement la
compensation de I’expression mimique etablit une corrklation significativement positive avec les
autodescriptions de I’effet et la modification des symptbmes. Deux traitements psychanalytiques, l’un
avec la plus grande reciprociti et le moins de succis, I’autre avec le plus grand succi.s et un haut niveau
de compensation, ont i t 6 analysts dans les details en fonction du dkveloppement temporel de I’ichange
affectif et de la narration tout au long du traitement. Dam les deux therapies, la frequence des narra-
Downloaded by [Australian National University] at 03:35 09 January 2015

tions ktait corrilee nkgativement avec la frequence des affects dans la mimique du patient, ainsi
I’hypothkse d’un processus parallile de I’expression mimique et de la narration a pu Stre rejetee. Lors
du traitement k succi.s, le therapeute a produit les affects qui auraient pu &re attendus du c8te du
patient. Une organisation temporelle tres distincte dans le traitement h succes, comptant une periode
de performance, une piriode d’instabilite et une periode de consolidation, a contrast6 avec une distri-
bution homogene d’affectsdans le traitement sans succes. L‘importance de ces resultats pour une thtorie
des processus thkrapeutiques est discutee.

Received November 20, 1993

Revision Received July 3, 1995
Accepted January 4, 1996