Academic journal article American Journal of Psychotherapy

Process and Technique Factors Associated with Patient Ratings of Session Safety during Psychodynamic Psychotherapy

Academic journal article American Journal of Psychotherapy

Process and Technique Factors Associated with Patient Ratings of Session Safety during Psychodynamic Psychotherapy

Article excerpt

This study investigates the relationships between patient ratings of in-session safety with psychotherapeutic techniques and process. Ninety-four partici- pants received Short-Term Dynamic Psychotherapy (STDP) at a university- based clinic. Patient experiences of therapeutic process were self-assessed early in treatment using the Session Evaluation Questionnaire (SEQ; Stiles, 1980). Techniques implemented in session were identified using the Com- parative Psychotherapy Process Scale (CPPS: Hilsenroth et al., 2005). Alli- ance was evaluated with the Combined Alliance Short Form-Patient Version (CASF-P; Hatcher and Barends, 1996). Safety significantly correlated with session depth, smoothness, and positivity. Safety was significantly related to the interaction of psychodynamic-interpersonal and cognitive-behavioral techniques, but to neither individual subscale Safety significantly correlated with CASF-P Total, Confident Collaboration, and Bond. Patient experiences of safety are consistent with exploration and depth of session content. Integration of some CB techniques within a psychodynamic model may facilitate a sense of safety. Safety is notably intertwined with the therapeutic relationship.

KEYWORDS: process; psychodynamic psychotherapy; safety; technique; alliance; SEQ; CPPS

PSYCHODYNAMIC PSYCHOTHERAPY AND PATIENT SAFETY

The field of psychotherapy research has established the significance of the therapeutic environment in patient treatment. The cultivation of a safe atmosphere can be viewed as a "gateway" to therapeutic progress. Safety can be conceptualized as an experience of trust and openness to vulner- ability that allows the patient to tolerate greater exploration of affect. Friedlander and colleagues (2006, 2011) define safety within the therapeu- tic system as the patient's understanding of therapy as "a place to take risks, be open, vulnerable, flexible; a sense of comfort and an expectation that new experiences and learning will take place" (Friedlander et al., 2006, p. 216), as well as the client's level of comfort in "exploring conflicts with a therapist and other family members" (Escudero, Friedlander, & Heatherington, 2011, p. 139). It is posited that a patient's feeling of safety in therapy is essential for progress (Weiss et al., 1986; Sandler, 1960, as cited in Foreman, Gibbins, Grienenberger, & Berry, 2000), and that the level of safety is positively correlated with the speed of therapeutic change (Rappaport, 1996). Patients are better able to "work through" when enveloped in safety, which entails developing self-understanding and less defensive functioning through therapeutic investigation (Rappaport, 1996). Ogrodniczuk and colleagues expanded this notion, adding that safety enables exploration of both positive and negative affective experi- ences, and this tolerance can reduce premature termination (Ogrodniczuk, Joyce, & Piper, 2005). Further emphasizing safety's significance, Beck and colleagues (2006) found that lower levels of safety in therapy were asso- ciated with poor treatment outcome (Beck, Friedlander, & Escudero, 2006).

Control-mastery Theory (CMT), which is based on a psychoanalytic model and was developed by the San Francisco Psychotherapy Research Group, is one of the few theories in the literature to discuss the salient issue of patient-experienced session safety as it relates to therapeutic progress. Control-mastery Theory suggests that the patient is motivated to clinically improve only to the degree that his or her sense of safety allows (Rappaport, 1997). This theory implicates that the patient is perpetually searching for safety in the therapeutic environment, and the experience of safety is established through interactions in which the patient tests the therapist. Therapist responses to these tests are key to solidifying a safe atmosphere in which the patient is able to release the maladaptive patterns that have sustained pathologic behaviors and to embrace new ways of living. …

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