REGULAR ARTICLES

A Method for Analyzing Therapist

Interventions in the Psychotherapy
of Borderline Patients

HAROLD W. KOENIGSBERC, M.D.

OTTO F. KERNBERG, M.D
ANN H. APPELBAUM, M.D.
ThOMAs SMITFI, M.D.

The authors developed a method for studying A s psychotherapy

comparative outcome
research
studies
moves
of broadly
from

the therapist’s use of technique in responding

to specific patient themes during treatment of defined treatments to the study of pro-
cess/outcome relationships in psychothera-
patients with borderline personality disorder.
pies that are carefully delineated, there is an
This method can monitor the use of expres-
increasing need for reliable and clinically rel-
sive and supportive techniques as well as the
evant methods for analyzing therapist inter-
congruence between patients’ theme catego- ventions. A comprehensive system for
ries and the direction of the therapist’s inter- measuring therapist interventions should
ventions. The method was developed to make it possible to study the relationship
monitor adherence to an operationally de- between outcome and specific therapeutic
fined treatment approach for psychodynamic techniques, as well as the effect of the
psychotherapy of borderline patients. Data therapist’s actions upon the emerging thera-
are presented on interrater agreement ob- peutic process; the extent to which the ther-
apist is actually carrying out the prescribed
tained with this method and on its applica-
treatment; and some aspects of the therapist’s
tion to 12 psychotherapy sessions.
technical skill.
Recently, psychotherapy researchers
have advocated the careful operational defi-
nition of treatments under study.’ Such de-
scriptions, codified in the form of treatment
manuals, identify key ingredients in different
forms of therapy and distinguish different
treatments in comparative outcome studies.

Received November 26, 1991; revised August 6, 1992;

accepted September 1, 1992. From the Department of
Psychiatry, Cornell University Medical College and The
New York Hospital, Westchester Division. Address re-
print requests to Dr. Koenigsberg, The New York Hospi-
tal-Cornell Medical Center, Westchester Division, 21
Bhoomingdale Road, White Plains, NY 10605.
Copyright © 1993 American Psychiatric Press, Inc.

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 120 ANALYZING THERAPIST INTERVENTIONS

Treatment manuals have been developed for present initial reliability data, and demon-
short-term therapies such as time-limited strate use of the method to derive a variety of
dynamic psychotherapy,2 interpersonal psy- indices, matrices, and graphic representa-
chotherapy of depression,3 and cognitive psy- tions that may prove useful in studying ther-
chotherapy,4 as well as for longer term apist interventions specifically in relationship
dynamic psychotherapies.5 Although care to patient themes.
must be taken to recognize the reductionism The skillful conduct of psychotherapy is
inherent in treatment manuals, the manuals a function of many other therapist variables
can be used as guides for training therapists in addition to the use of an array of appropri-
and as standards against which therapists’ ately selected, targeted, and timed interven-
adherence to technique can be measured. tions. In fact, the relative importance of
In outcome studies of particular forms of technique versus nonspecific factors has not
psychotherapy, the researcher must confirm been established. Such factors as the
that the treatment delivered to the study sub- therapist’s tactfulness, empathy, and warmth
jects does in fact correspond to the treatment and the ability to recognize thematic pat-
under study. This problem becomes even terns, tolerate and contain affects, and use
more acute in studies of long-term psycho- language clearly and evocatively all contrib-
therapy and psychoanalysis because consider- ute to skill. Our group is developing a sepa-
able drift in technique over time is possible. rate instrument to measure these and other
Our research group is developing meth- aspects of therapeutic skill; presenting that
ods for study of the long-term psychodynamic work is beyond the scope of this report.
psychotherapy of patients with borderline
personality disorder. As part of this study, we I)E V E 1. 0 P \1 F N ‘F

have operationalized an approach to the OF ‘FIlE ME’rlloD

treatment of borderline patients in a treat-
ment manual.6 This treatment derives from Although a number of schemes for coding
the ego psychology-object relations ap- therapists’ interventions have been de-
proach described by Kernberg.7 We have con- scribed in the literature (see Koenigsberg et
ducted 3-month training seminars, based on al.8 for a brief review), they do not meet our
our manual, to train several groups of psychi- need to monitor technical intervention in
atrists and psychologists, advanced psychiat- relationship to specific patient themes.
ric residents, and psychology trainees in the We sought a method for characterizing
treatment approach. These therapists ap- interventions in relationship to patient
plied this approach, under ongoing supervi- themes that would 1) define interventions at
sion by senior therapists, to the treatment of a level of inference that permits reliable mea-
patients who met DSM-III-R criteria for bor- surement, on the one hand, while affording
derline personality disorder. All sessions were a clear linkage to clinically useful constructs;
audio or video recorded. Informed consent 2) incorporate those interventions that are
was obtained for all procedures. most often required in the treatment of bor-
In this report we describe the develop- derline patients; 3) measure the essential fea-
ment of a system for analyzing interventions tures of the technique specified in our
made by therapists in conducting this ther- treatment manual; 4) include a range of
apy. The system is designed to provide a other commonly used interventions so that a
mechanism for the ongoing monitoring of spectrum of treatment approaches could be
adherence to the defined treatment, as well characterized; and 5) provide acceptable
as for quantitative description of the interrater reliabilities.
therapists’ interventions for use in process In previous work8’9 we developed an in-
studies. We will describe the scoring method, strument, the Therapist Verbal Intervention

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KOENIGSBERG ETJIL. 121

Inventory (TVII), for categorizing interven- tion, then, between specifically supportive
tions used in the psychotherapy of borderline techniques and the supportive effect of ex-
patients. Sixteen specific interventions were pressive techniques, avoiding the former
included, encompassing techniques required while recognizing the latter.
in psychodynamic psychotherapy as well as in The TVII was designed to measure the
supportive psychotherapy of borderline degree to which the interventions described
patients. We were able to demonstrate accept- have been employed in each session, in order
able interrater reliabilities with the instru- to provide a measure of adherence and a
ment and to generate significantly different means for discriminating expressive from
intervention profiles for sessions of dynamic supportive therapy.
and supportive psychotherapy using the in- Because our treatment model specifies a
strument. hierarchy of priorities for addressing behav-
The form of psychodynamic psychother- ioral and verbal themes that emerge in the
apy for borderline patients that our group is sessions, the TVII needed to be broadened to
studying calls primarily for use of the core assess interventions directed to theme areas.
techniques of expressive psychotherapy: clar- The hierarchy of thematic priority is deter-
ification, confrontation, and interpretation. mined by the immediate need to address
The treatment is conducted within a frame borderline patients’ severely self-destructive
designed to protect it from the patient’s act- behavior and the threat to disrupt the treat-
ing out. The frame is constructed during the ment altogether. Thus themes that suggest an
first few sessions by means of a verbal treat- impending threat to the integrity of the treat-
ment contract. Because of the borderline ment must be identified and addressed im-
patient’s poor impulse control and prone- mediately. They range from threats of suicide
ness to acting out, the therapist may periodi- or homicide, through plans to quit treat-
cally need to reinforce the initial contract or ment, dishonest communication, and
to set limits during the treatment. Whenever breaches of the treatment contract, to various
possible, the therapist deals with acting out forms of acting out. Such themes are partic-
or threats to the treatment by means of con- ularly common in the psychotherapy of pa-
frontation and interpretation, rather than by tients with borderline personality disorder
limit setting. When limit setting is employed, because these patients are subject to poor
the patient’s role in making it necessary is impulse control and use primitive defenses
examined as soon as possible, and interpreta- that involve actions in the interpersonal
tive-rather than supportive-interventions realm. The therapist must address these
are used to restore the therapist to the posi- major resistances first to ensure that the treat-
tion of technical neutrality. ment is not disrupted. Systematic focus on
Although specifically supportive tech- these resistance themes, or action resistances,
niques such as suggestion, praise, dissuasion, will lead to stabilization of the treatment and
sympathy, and intervention in the patient’s the more consistent emergence of verbalized
life are not included in this approach, the transference and other affect-laden themes.
treatment may nevertheless be experienced Frequently, borderline patients present
at times as supportive by the patient. Such more than one action resistance in a given
treatment features as the reliability of ses- session; for this reason, it is useful for the
sions, the therapist’s ability to tolerate and therapist to follow a principle of priorities that
contain intense affects, the structure of the determines which theme to address first. Our
contract and the treatment frame, and the treatment manual lists common behavioral
work of organizing and seeking to make sense or verbal themes in order of the immediacy
of the patient’s experience may contribute to of their potential to threaten the treatment
this sense of support. We make the distinc- (Table 1). The therapist should address them

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122 ANALYZING THERAPIST INTERVENTIONS

in descending order of priority. Resistance, of focused upon in the early phase, except in a
course, is expected and may appear in the metaphorical, atemporal mode.
transference, in acting out of affect-laden The principle of priorities requires that
themes, and in various interferences with free certain themes be addressed during the ses-
association. Resistance confined to these do- sion, but it does not specify when in the
mains is characteristic in the treatment of session they are addressed. Often the thera-
patients with a neurotic structure. Borderline pist will allow time for a theme to develop or
patients, in addition, mobilize primitive de- will address other themes first; the therapist
fenses within the treatment that often involve uses his or her clinical judgment to deter-
actions against self or others (acting out in mine the timing of interventions within the
session or outside) or threats of such actions. session. The treatment manual requires, how-
As such they pose more immediate threats to ever, that the theme with highest priority be
the treatment process itself. addressed by the end of the session. There is
The first seven thematic categories re- a deviation from technique if a lower priority
flect these forms of severe resistance. If these theme is addressed without dealing with the
action resistances are promptly and consis- higher priority theme. For example, if an
tently addressed, the focus of the sessions will acute suicidal intention (high-priority
gradually shift to the verbal communication theme) is not responded to by a correspond-
of transference and other affect-laden mate- ing therapist intervention, and the therapist
rial. Clinical experience with borderline pa- instead deals with non-affect-laden con-
tients has shown that exploration of genetic scious material (low-priority theme), that is a
antecedents is not useful until their uncon- deviation from optimal technique.
scious repetition in the here and now has
been worked through. Because this occurs in A M F ‘F Il 0 1) F 0 II

the advanced phase of the treatment, uncon- ANALYZING ThERAPIST

scious childhood material is generally not INFER VENTIONS

TABLE 1. Hierarchy of thematic priority We developed a system to enable raters to

1. Suicide or homicide threats.
simultaneously score 1) patient themes
2. Overt threats to treatment continuity (e.g., financial within the session, 2) the type of intervention
difficulties, plans to leave town, requests to decrease used by the therapist, and 3) the thematic
session frequency).
area toward which the intervention was di-
3. Dishonesty or deliberate withholding in sessions
rected. Intervention type was rated using the
(e.g., lying to the therapist, refusing to discuss
certain subjects, silences occupying most of 16 TVII intervention categories as defined in
the sessions). the TVII scoring manual plus an “other” cat-
4. Contract breaches (e.g., failure to meet with an egory. Thematic areas were rated using the
auxiliary therapist when agreed upon, failure to take
prescribed medication).
categories of patient behavioral or verbal
5. In-session acting out (e.g., abusing office furnishings, focus specified in the treatment manual, in-
refusing to leave at end of session, shouting). cluding a category for childhood material
6. Between-session acting out. and an “other” category.
7. Nonaffective or trivial themes. Within the broad categories of transfer-
8. Transference manifestations.
ence references, other affect-laden themes,
a. Verbal references to therapist.
and childhood material, a multiplicity of pa-
b. “Acting in” (e.g., positioning body in overtly
seductive manner, looking away from the
tient-specific subthemes emerge. It is these
therapist). themes that reflect the uniqueness of the
c. As inferred by therapist (e.g., references to other patient and that provide raw material for the
doctors).
therapist’s mutative interventions. Our rat-
9. Nontransferential affect-laden material.
ing system does not attempt to identify spe-

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KOENIGSBERG ETJ4L. 123

cific subthemes; it would be extremely diffi- change, or one episode might extend over
cult to generate a set of categories that would more than one exchange. Although such an
do justice to the diversity of possible sub- approach might add to the reliability in rating
themes, and technical adherence to our treat- interventions and intervention directions, it
ment approach can be assessed with the adds to the complexity of the rating process.
broader categories. The extent to which the We therefore chose the simpler segmentation
therapist can correctly identify subthemes approach for our initial reliability studies,
and respond to them is a sensitive reflection with the plan to explore other segmentation
of the skill of the therapist. This is a variable schemes should that be necessary to achieve
that we measure with an instrument to be acceptable reliability.
reported elsewhere. The Core Conflictual Re- For each segment, the rater scores the
lationship Theme (CCRT) method of most clinically prominent patient theme, the
Luborsky and colleagues’#{176} affords a possible type of therapist intervention, and the the-
approach to identifying the subthemes. Our matic area toward which the therapist di-
research group is currently exploring its ap- rected the intervention. The direction of
plication to sessions with borderline patients. therapist intervention is rated on the basis of
The sessions are scored for patient theme the manifest content of the therapist’s re-
areas, therapist intervention types, and the marks; it is relatively straightforward to score
direction of therapist interventions (see Ta- each intervention in this way. It is more diffi-
bles 2,3, and 4, respectively). For this purpose cult to assign a thematic category to the pre-
the session is segmented into units consisting ceding block of patient material because
of a block of the patient’s speech and the important session themes may emerge grad-
ensuing comment by the therapist. Alterna- ually over the space of several units. A theme
tive segmentation approaches were consid- may be strongly established in a session yet
ered, including the use of a separate set of not appear in the manifest content of a spe-
raters to divide the therapist’s speech into cific block of patient material. For this reason,
intervention episodes characterized by a single the raters read the session transcript in se-
intervention directed toward a single theme quence from the beginning, indicating at the
area. Several such episodes might be con- point of each intervention the patient theme
tained in a single patient/therapist ex- that was strongest during the preceding block

TABLE 2. Interrater agreement of two raters for patient action/verbal themes

Total Number Category

Patient Theme of Endorsements Kappa

1. Suicidal or homicidal threats 0 -

2. Threat to treatment continuity 8 0.23

3. Dishonesty/withholding 0
4. Breach of contract 78 1.00*
5. In-session acting out 6 -0.02
6. Outside acting out 2
7. Trivialization 2
8. Transference related 131 0.84*
9. Other affect-laden themes 78 0.83*
10. Childhood material 33 0,83*
11. Other 6 0.32

Note: Values shown are total endorsements by two raters on 172 intervention units from transcripts of three
sessions, each with a different patient and therapisL Kappa is given only for categories with 5 or more
endorsements.
*P< 0.01.

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 124 ANALYZING Ti JERAPIST INTERVENTIONS

of patient material. The raters are encour- data below suggesting that this is a feasible
aged to rate patient themes within the overall approach.
context of the session, drawing upon their In our early work with this method, raters
clinical judgment. The extent to which expe- frequently disagreed between the “transfer-
rienced psychotherapist raters may achieve ence” and “other affect-laden themes” cate-
interrater reliability with this method is an gories. This is because references to others in
empirical question. We will present reliability the session may be implicit transference ref-

TABLES. Interrater agreement of two raters for type of intervention

Total Number of Category

Intervention 1)’pe Endorsements Kappa
1. Informs4 7 0.76”
2. Clarifies 209 0.73”
3. Reinforces contract4 8 0.27
4. Accepts, suggests4 9 0.38””
5. Dissuades, prohibits4 0
6. Sets limits” 0
7. Offers sympathy4 3
8. Expresses hopefulness4 0
9. Confronts 65 0.60”
10. Intervenes in patient’s life4 0
11. Explains deviation from neutrality 0
12. Stresses reality aspects of patient-
therapist relation4 2
13. Interprets 26 0.67”
14. Directs focus from therapist” 0
15. Reveals self4 2
16. Accepts help from patienta 0
17. Other 3 -0.01

G Note: Values shown are total endorsements by two raters on 172 intervention units from transcripts of three
sessions, each with a different patient and therapist. Kappa is given only for categories with 5 or more
endorsements.
aSupportive intervention,
“P< 0.15; ““P< 0.05.

TABLE 4. Interrater agreement of two raters for direction of intervention

Total Number of Category

Intervention Direction Endorsements Kappa

1. Suicidal or homicidal threats 0 -

2. Threat to treatment continuity 9 0.20

3. Dishonesty/withholding 0
1.00*
4. Breach of contract 78
5. In-session acting out 7 0.27
6. Outside acting out 0
7. Trivialization
8. Transference related 128 0.85*
9. Other affect-laden themes 77 0.88”
10. Childhood material 28 0.84”
11. Other 11 0.44

.+ Note: Values shown are total endorsements by two raters on 172 intervention units from transcripts of three
sessions, each with a different patient and therapist. Kappa is given only for categories with 5 or more
endorsements.
*P<0.01.

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KOENIGSBERG ET14L. 125

erences (see Gill and Hoffman” for a discus- nique. Two constructs that are useful for
sion of this issue from a methodological per- monitoring adherence are 1) the relative use
spective). To deal with this complication, we of expressive versus supportive interventions
developed the following guidelines for scor- and 2) the therapist’s technical response to
ing material as a transference reference. All specific themes. A simple computer routine
explicit references to the therapist and any organizes the individual segment scores to
affect-laden references to the treatment itself form the indices and arrays of interest. These
are scored as transference references. Spe- measures are designed to be used by the
cific behaviors directed toward the therapist research team to find lapses in adherence
that are commented upon by patient or ther- and by the therapist and his supervisor to
apist are also scored in this category. Finally, identify the technical deviations. They are
to allow for what are often clinically import- intended to supplement, but not supplant,
ant implicit transference references, a refer- process supervision; therapist and supervisor
ence to someone other than the therapist is receive a printout of the arrays and indices
scored as a transference reference if two con- for selected sessions and may consider this
ditions prevail: 1) the patient had made an information during their discussion.
explicit transference reference elsewhere in The intervention array (Figure 1) dis-
the session, and 2) parallels between the rela- plays at a glance the themes that emerged in
tionship with the other and that with the the patient material and the specific therapist
therapist are strong in the clinical judgment interventions directed toward each theme.
of the rater. Using these scoring guidelines, By inspection, one can identify areas that
we obtained acceptable interrater reliabilities were not addressed or tendencies to use spe-
in the transference category. cific techniques to address certain themes.
When a specific block of patient speech The first horizontal row, “Patient Content
preceding an intervention is too brief to per- Present,” shows the number of times a block
mit identification of a theme, the previous of patient speech was classified in each the-
theme rating is carried over into that block. matic area. Below this is a two-dimensional
If the rater has difficulty deciding between matrix representing the therapist’s interven-
two or more theme categories for a specific tions. Reading across the row for each inter-
unit, the theme highest in the hierarchy of vention type reveals the number of times it
priority is scored for that unit. This approach was directed toward each patient theme area.
is conservative, ensuring sensitivity to in- Reading down the column for each theme
stances of therapists failing to address high- area reveals the interventions used by the
priority themes. therapist to address that area.
Zeros in an entire column below a non-
PROFILING TIlE zero patient theme score indicate a theme
TECHNICAl, CONDECT OF that was not addressed. Because failure to
‘F Fl E S E S S I C) N address a high-priority thematic area reflects
poor adherence to technique and is there-
Because it is the pattern of individual interven- fore important to identify, the computer pro-
tions that characterizes the therapist’s tech- gram automatically carries out a scan and
nique within a session and reflects flags all thematic areas present in the session
adherence, the individual segment ratings that were not addressed by the therapist. The
are aggregated to generate indices and matri- program also sums up the number of expres-
ces that characterize the technical conduct of sive and supportive interventions and indi-
the session. These constructs can be used cates the percentage of total interventions in
both to monitor adherence and to provide each category. Too high a percentage of sup-
the therapist with specific feedback on tech- portive interventions would reflect deviation

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126 ANALYZING THERAPIST INTERVENTIONS

from the manualized treatment. frequency with which the therapist addresses
To explore whether a high correspon- his or her interventions toward the thematic
dence between patient content area in a seg- area contained in the patient’s most recent
ment and the focus of the therapist’s statement. The elements in this matrix corre-
intervention in that segment is a useful pro- spond to the categories of patient theme and
cess or skill measure, we constructed a pa- of therapist intervention direction for each
tient-therapist congruence matrix (Figure 2). scored segment. The numbers along the di-
This matrix provides information about the agonal of the matrix indicate instances when

FIGURE 1. Session adherence analysis matrix.

04-26-1989
23:45:45
PATIENT: 003
SESSION NO.: 44
INTERVENTION RATER: HWK

FOR THIS SESSION: THE THERAPIST MADE A TOTAL OF 71 INTERVENTIONS.

NUMBER OF EXPRESSIVE INTERVENTIONS =48 PERCENT = 67.6

NUMBER OF SUPPORTIVE INTERVENTIONS =22 PERCENT =31.0

NUMBER OF NEUTRAL INTERVENTIONS = 1 PERCENT = 1.4

SESSION INTERVENTION MATRIX

2 3 4 5 6 7 8 9 10
Suicide Threat Lying Contract Acting Acting Trivial Transf Affect Childhood
Homicide to or Breach In Out Laden Material
Threats Conty Withld

Patient
Content 1 0 0 0 0 0 0 70 0 0
Present

1.InformsO 0 0 0 0 0 0 17 0 0
2.ClariflesO 0 0 0 0 0 0 21 0 0
3.ContractsO 0 0 0 0 0 0 0 0 0
4.AcceptsO 0 0 0 0 0 0 5 0 0

5.Prohibits0 0 0 0 0 0 0 0 0 0

6.Limits 0 0 0 0 0 0 0 0 0 0

7.Sympathy0 0 0 0 0 0 0 0 0 0

8.Hopefulo 0 0 0 0 0 0 0 0 0

9. Confront 0 1 0 0 0 0 0 19 0 0

10.Intvene 0 0 0 0 0 0 0 0 0 0
l1.Expl/DevO 0 0 0 0 0 0 0 0 0

12.Reality 0 0 0 0 0 0 0 0 0 0
13.Interpreto 2 0 0 0 0 0 4 0 0
14.Away 0 0 0 0 0 0 0 0 0 0
I5.Reveals 0 0 0 0 0 0 0 0 0 0
16.Acpthelp 0 0 0 0 0 0 0 0 0 0
17.Other 0 0 0 0 0 0 0 1 0 0
>>> The following content areas present in session were unaddressed by the therapisL
AREA No. 1

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KOENIGSBERG ETAL. 127

the therapist’s intervention is directed at the would have zero entries in all columns except
same theme area that appeared in the the tenth. We will present some preliminary
patient’s speech block in that unit. Therapists findings using this matrix below.
who are closely tracking the patient would
presumably often make interventions falling I N ‘F F H H A ‘F E R H E I. I A B I L I 1’ V

on this diagonal. At other times, a therapist

might direct an intervention toward a theme Six psychoanalysts and psychotherapists,
present earlier in the session or a theme to each with at least 15 years of clinical experi-
which the therapist seeks to draw the patient’s ence, applied the scoring categories to tran-
attention. Such interventions would appear scripts of sessions as part of the process of
as off-diagonal elements in the matrix. developing the scoring method. Discussions
The patient-therapist congruence matrix of scoring discrepancies were used to refine
may be useful for identifying interesting pro- scoring guidelines. All sessions were selected
cess developments in the sessions. One hy- from twice-a-week psychotherapies of pa-
pothesis to be explored, for example, is tients with borderline personality disorder.
whether more skillful therapists have higher Care was taken to include sessions conducted
percentages of on-diagonal rather than off- by less experienced therapists because inter-
diagonal interventions. The matrix will also ventions by less experienced therapists were
identify situations in which a therapist consis- usually less crisp and represented a greater
tently addresses a certain patient theme by scoring challenge.
avoiding it or by shifting to a specific alterna- Once the basic guidelines had been de-
tive theme in the next response. If, for exam- veloped, two raters from the original group
ple, a therapist responded to suicidal themes (O.F.K and H.W.K.) rated six additional ses-
by directing interventions only toward child- sions using these guidelines and a discussion-
hood material, the first row of the matrix consensus method to refine their reliability

FIGURE 2. Patient.therapist theme congruence matrix for Patient 44, Session 10.

Intervention Direction

.
. .5
S S
.3 0

u . s
.1
g
. .5

- 4 Cf) ‘ W) O C

1.Suicide/Homicide 38 0 0 0 0 0 0 0 0 0 0

2.ContinuityThreat 0 0 0 0 0 0 0 0 0 0 0
3.Dishonesty 0 0 0 0 0 0 0 0 0 0 0
4.ContractBreach 0 0 0 0 0 0 0 0 0 0 0
5.Actingin 0 0 0 0 2 0 0 0 0 0 0
Patient 6.Actingout 0 0 0 0 0 0 0 0 0 0 0

Theme 7.Trivialization 0 0 0 0 0 0 0 0 0 0 0
8.Transference 0 0 0 0 0 0 022 0 0 0
9.AffectLaden 0 0 0 0 0 0 4 5 0 0 0
l0.Childhood 0 0 0 0 0 0 0 0 0 0 0
11. Other 0 0 0 0 0 0 0 0 0 0 0

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128 ANALYZING THERAPIST INTERVENTIONS

with each other. themes. The frequently employed interven-

Following this period of training, the two tion types, “informs,” “clarifies,” “confronts,”
raters independently rated 172 intervention and “interprets,” could be identified with
units from transcripts of three sessions in good interrater agreement. Agreement was
order to establish interrater reliabilities. The inadequate for the categories “accepts, sug-
sessions rated were the 10th, 18th, and 30th gests” and “reinforces contract.”
sessions from three different treatments con-
ducted by three different therapists. To pro- ASSESSING ADIIEREN:E
vide a more stringent test, sessions of less
experienced therapists were used. One application of this method is to detect
In terrater agreements were calculated deviations from the technique specified in
using the category kappa statistic.’2”’ This the treatment manual. The manual specifies
measures the degree to which judges achieve three principles for the conduct of the treat-
above-chance agreement in assigning items ment: 1) action resistance themes must be
to categories. We calculated the kappa values addressed in any session in which they ap-
for each of the 11 patient theme categories, pear; 2) expressive rather than supportive
the 17 intervention type categories, and the interventions should be employed; and 3)
11 intervention direction categories. The during the early phase of treatment the ther-
agreements for the two raters are displayed in apist should rarely direct interventions to-
Tables 2, 3, and 4, respectively. The number ward unconscious childhood material, but
of times each category was endorsed by either should concentrate predominantly on the
judge is specified in the tables. Kappas are unconscious meaning in the here and now.6
indicated only for those categories having at These principles must be translated into
least 5 endorsements. Several theme and in- operational adherence criteria for research
tervention categories did not appear in the use. To formulate these criteria, we examine
sessions rated. This is because the 172 ratings the extent to which the principles are fol-
derive from only three sessions; sessions con- lowed over a range of sessions, including
ducted by more experienced therapists, by thosejudged by clinicians to be adherent and
therapists untrained in the manual, or by nonadherent. Cutoff scores may be selected
therapists conducting other types of treat- that best distinguish adherent from non-
ment would be expected to include addi- adherent sessions. We report here on such an
tional interventions. Further work is called exploratory analysis with 12 sessions.
for to apply the system to a wider range of Twelve psychotherapy sessions con-
sessions. ducted by 10 therapists ranging in experience
Because the individual category kappas and training from a psychoanalyst with over
may be affected by differing base rates among 30 years of experience to senior residents and
the categories, we also calculated kappas for psychology interns were rated by one of the
each scale taken as a whole. These kappa authors (H.W.K).
values were 0.83, 0.62, and 0.83, for patient For each session a number of indices
theme, therapist intervention, and interven- were generated, including the percentage of
tion direction, respectively. total interventions that were expressive
Interrater agreement for identifying pa- rather than supportive and the fraction that
tient themes was acceptable, with the excep- were clarifications, confrontations, and inter-
tion of two less frequently encountered pretations. In Table 3, supportive interven-
themes: threats to continuity and in-session tions are indicated by superscript a’s; all other
acting out. The interrater agreements for di- interventions are classified as expressive tech-
rection of the therapist’s intervention were niques.
comparable to those for identifying patient The distribution of scores of these mdi-

VOLUME 2 NUMBER
#{149} 2 SPRING
#{149} 1993
KOENIGSBERG ETAL. 129

ces for the 12 sessions is displayed in Figure These observations suggest that one cri-
3. The percentage of expressive interventions terion for nonadherence could be a percent-
ranged uniformly from 68% to 98% among age of expressive interventions below
the 12 sessions, except for an outlier at 43%. 50-60%. A second criterion for nonadher-
Review of the transcript of the outlier session ence could be the presence of an Un-
indicated a marked departure from the man- addressed action resistance in the session. A
ual. The session had been conducted by a third criterion could be the use of confronta-
junior therapist who was rotating out of the tion or interpretation directed toward child-
clinic and was planning to transfer the pa- hood material during the first 2 years of the
tient. During this session the therapist of- treatment (the period under study in our
fered the patient the names of four therapists project). However, the examination of tech-
to see for consultation, with the patient com- nique profiles for a larger number of sessions
plaining vehemently about the poor quality independently rated by experienced clini-
of each of the therapist’s referrals. The ther- cians as adherent or nonadherent is needed
apist appeared to have deviated from an ex- to establish the operational criteria.
pressive toward a supportive approach in the
face of his plan to transfer the patient. OilIER I N DICES
Inspection of Figure 3 reveals a uniform
distribution of the indices for clarifications, To determine whether the percentage of on-
confrontations, and interpretations, with no diagonal interventions had clinical relevance
clear outliers. This suggests that in the con- for the session, we examined the distribution
duct of psychodynamic psychotherapy for of this index over the 12 sessions rated. This
borderline patients there is a wide range of
variation from session to session in the fre- FIGURES. Distributi on of se lected session indices.
quency with which these techniques are em-
ployed. Our experience in supervising
100
therapists in the project, however, suggests
that two factors may influence the relative use lf#{149} #{149} +
of these interventions: 1) interpretations are 90 $
#{149}
made less frequently in early sessions and 2) $ S
80 S S
confrontation and interpretation are used S

more frequently by the more experienced S

70 #{149}
therapists. We suspect that the observed uni- 0
form distribution in the use of these interven- ‘ S

60
tions may be an artifact resulting from the S
C
sample of 12 sessions, which contains a mix
50
of early and late sessions and junior and se-
5

nior therapists. This work needs to be ex- ‘5 5

40 S 5

tended to larger numbers of sessions and 8

S S
stratified by therapist experience level and a. 30 5
#{149} S
phase of treatment.
S
The 12 sessions were examined for flags 20 1 .
S
indicating that essential patient themes had
#{149} #{163} #{149}
not been addressed. Among the sessions, 10 S #{149}
S
three had unaddressed action resistances. In S

S #{149}
two cases these were suicidal threats and in ss 4
aa, Cocb*ni Wpmt on
one case outside acting out. These sessions *#{149} .-.-- Them

would violate our adherence criteria.

JOURNAL OF PSYCHOTHERAPY PRACTICE AND RESEARCH

130 ANALYZING THERAPIST INTERVENTIONS

index is an indicator of the extent to which within the session in which the patient theme
the therapist’s interventions closely track the fell into one of the action resistance catego-
patient’s theme areas. The distribution of ries. The distribution of these values is also
scores is displayed in Figure 3. The scores displayed in Figure 3. They are distributed
were uniformly distributed over the range over the range of 0% to 81%.
from 72% to 95%, except for one outlier at
40%. The outlier session was the same session GRAPIIIC DISPLAY OF

that was described above as an outjier in the SESSION TlIElATIc

percentage of expressive interventions E V 0 I. 1 T I 0 N

index. Examination of the transcript reveals

that the low level of tracking in this session is The raw data gathered in rating the session
accounted for by the therapist’s never ad- transcripts may also be plotted to display the
dressing transference themes. These themes evolution of themes over time within the ses-
related to the patient’s anger at the therapist sion and in relation to the therapist’s inter-
for planning to transfer her. ventions. Figure 4 exemplifies this method of
We also constructed an index of defen- graphic display. For each segment in se-
sive themes, which is the percentage of units quence, we plot the session theme along a

FIGURE 4. Thematic profile, Patient 44, Session 10. In figures 4-7, where no arrow appears,
the intervention was a clarification.

THEMATIC
I II SR Is I
AREA Patient: 044 C CCCCC lPlies 3$ NI Ic I PS
Session: No. 10 I 11111 1111111111 II II
Suicide Therapist: 11

Continuity Threat 2

Lying 3 Key to Interventions

Blank #{149} Clarifies
Contract Breach 4
C #{149} Confronts
D = Directs focus away from therapist
Acting-in 5
H = Expresses hope
I = Interprets
Acting-out 6
In = Informs
P Prohbts ordiscourages
Trivializing 7
I c
#{149}

R = Reinforces contract
Transference 8 S Suggests or accepts
SR = Reveals about self
Affect Laden 9 111L #{149}
UncertaiMnaudSe

Childhood 10

Other 11

I I I I I I

10 20 30 40 50 60 70

Intervention No.

VO1.UME 2. NUMBER 2. SPRING 1993

KOENI;SBER; ET1L. 131

nominally defined y-axis. The therapist’s in- therapy. This was followed by a shift by the
terventions in each segment are superim- patient to the transference theme. The ther-
posed as labeled arrows. (To make the display apist employed a number of clarifying inter-
easier to read, we adopt the convention that ventions that led to the patient reporting that
when no arrow is present in a given segment, she experienced the therapist as probing her
the intervention is a clarification). Such a for “some kind of right answer.” Following
graphic display might be an effective tool for this transference reference and a reminder
identifying changes in the process of sessions by the therapist that the patient should talk
over time. about her feelings regardless of her fantasy of
Figure 4 represents an early session in the therapist’s response, the patient began to
which the patient began by reporting that she speak of her suicidal feelings. As this theme
had little to say and then lapsed into silent continued through the remainder of the ses-
periods (classified as acting out in session). sion, the therapist made a series of confron-
As the therapist confronted this, the patient tations and interpretations and then began
began to speak of a feeling that she was going introducing supportive interventions as the
nowhere in life (category 9). The therapist session drew to a close.
made a number of confrontations suggesting Figures 5-7 represent the 25th, 37th, and
that the patient had similar feelings about her 72nd sessions, respectively, in an ongoing

FIGURE 5. Thematic profile, Patient 12, Session 25.

THEMATIC

AREA Key to Interventions

Patient: 012
Blank Clarifies
#{149}
Session: No.25
Suicide 1
C Confronts Therapist: 70
D = Directs focus away from therapist
Continuity Threat 2
H = Expresses hope
I = Interprets
Lying 3
In = Informs
P = ProhSiits or discourages
Contract Breach 4
R = Reinforces contract
Acting-in 5 S = Suggests or accepts
SR= Reveals aboutself
Acting-out 6 ? = UncertaiMnaude

Trivializing 7

Transference 8

Affect Laden 9

Childhood

Other 11

10 20 30 40 50 60 70

Intervention No.

JOURNAL OF PSYCHOTHERAPY PRACTICE AND RESEARCH

132 ANALYZING TI IERAPIST INTERVENTIONS

treatment. Inspection of the three figures ces and matrices that reflect key session tech-
indicates a trend for the latest session to have nique and process features has been defined.
fewer action resistances present and for the Individual unit ratings may also be displayed
patient to spend more time focusing on trans- graphically to depict the emergence of
ference feelings. This is the progression that themes sequentially during sessions.
is desired as the treatment continues over Our method is perhaps most similar in
time. perspective to that of Gill and Hoffman” for
rating the therapists’ interventions that ad-
D IS C I S S I0 N dress the patient’s experience of the relation-
ship to the therapist. Their approach, like
We have developed a method of scoring tran- ours, attempts to relate therapist interven-
scripts of psychotherapy sessions for major tions to the area addressed. They include
session themes, form of therapist interven- categories for interventions to clarify the
tions, and thematic direction of intervention. transference, to interpret the here and now
Two experienced therapists have been able to of the transference, and to make interpretive
obtain acceptable interrater agreements in links between transference themes and extra-
scoring commonly appearing themes and in- transferential experiences. Their system is,
tervention types and directions. A set of mdi- however, more narrowly focused than ours.

FIGURE 6. Thematic profile, Patient 12, Session 37.

THEMATIC

AREA

Suicide Patient: 012

Session: No.37
Continuity Threat 2 . IL. Therapist: 70

Lying 3

Contract Breach 4

Acting-in 5 (ICICI . Key to Interventions

Blank = Clarifies
Acting-out 6

Trivializing 7
.LL.L_i Is
____ Is
C1*1TCLLL
II,
C
D
H
-

=
Confronts
Directs focus away from therapist
Expresses hope
I = Interprets
Transference 8
In = Informs
P ProhSits or discourages
Affect Laden 9
#{149}

R = Reinforces contract

Childhood io S = Suggests or accepts

SR Reveals about self
? Uncertainflnaudfole
Other 11 #{149}

L Sets hmits
#{149}

I I
10 20 30 40

Intervention No.

VOLUME 2 #{149}
NUMBER SPRING
2 #{149} 1993
KOENIGSBERG ETAL. 133

They dichotomize theme areas into transfer- ple, that raters other than the two tested here
ence or external themes, and interventions can use the system reliably. The level of clini-
into clarifications or interpretations. cal skill necessary for raters can be explored
In preliminary studies of 12 psychother- by examining interrater agreements of
apy sessions of the treatments of 10 different judges with varying levels of experience and
patients, we have identified percentage of training. Finally, measurement of a larger
expressive interventions and percentage of number of sessions, independently judged
on-diagonal interventions as indices that may for adherence and skill, is needed to confirm
prove useful in assessing therapist adherence the suggestion from our preliminary data
to our manual and an aspect of therapist skill. that the percentages of expressive interven-
We have also demonstrated the feasibility of tions and diagonal interventions are useful
a system to flag sessions in which high-priority indices and to establish reasonable cutoff
themes have been unaddressed by the thera- scores for them. The other indices and arrays
pist. Thus, we offer an approach to identify- presented require further trials to determine
ing sessions that fall below a standard of whether they are useful descriptors of tech-
adherence to technique. This process pro- nique in process studies.
vides a mechanism to correct deviations from
technique. In addition, our system appears to The authors thank John Clarkin, M.D., Steven
offer promise as a method for tracking inter- Bauer, M.D., Arthur Carr, Ph.D., Paulina
vention-related process variables in sessions. Kernberg, M.D., Lawrence Rockland, M.D.,
Additional work is needed to confirm Michael Sel.zer, M.D., and Frank Yeomans, M.D.,
and extend the preliminary findings re- for their assistance.
ported here. We need to confirm, for exam- This work was supported in part by a grant from

FIGURE 7. Thematic profile, Patient 12, Session 72.

THEMATIC
AREA
Ksy to Interventions
Suicide Blsnk - P #{149}Prohbts or discourages
C Confronts
#{149} R = Rsinlorcss contract Patient: 012
Continuity Threat 0-Directs focus away from foerepist
Session: No.72
S = Suggssts oraxspts
Therapist: 70
H #{149}
Exprsssss hops SR Rsvsals tout
#{149} self
Lying I-- #{149}
UnosrtisMnsjdIe
In Informs
#{149}

ContractBreach

Acting-in

Acting-out 6

Trivializing 7

Transference

Affect Laden

Childhood

Other 11
I
10 20 30 60 70 80 90

InterventionNo.

JOURNAL OF PSYCHOTHERAPY PRACTICE AND RESEARCH

134 ANALYZING TUIERAPIST INTERVENTIONS

the Fund for Psychoanalytic Research of the Amer- tion 36th Congress, Special Half-Day Programme
ican Psychoanalytic Association. on Empirical Research in Psychoanalysis and Psy-
An abbreviated version of this article was pre- chotherapy, Rome, Italy,July 1989.
sented at the International PsychoanalyticAssocia-

R F F F R F N C F

1. Luborsky L. DeRubeis RJ: The use of psychotherapy psychotherapy of borderline patients. J Nerv Ment
treatment manuals: a small revolution in psychother- Dis 1985; 173:424-431
apy research style. Clin Psychology Rev 4:5-14, 1984 9. Koenigsberg HW, Kernberg OF, Rockland L, et al:
2. Strupp HH, BenderJL: Psychotherapy in a New Key: Developing an instrument for characterizing tech-
A Guide to Time-Limited Dynamic Psychotherapy. niques in studies of the psychotherapy of borderline
New York, Basic Books, 1984 patients, in Psychoanalytic Process Research Strate-
3. Klerman GL, Weissman MM, Rounsaville BJ, et at: gies, edited by DahI H, Kaechele H, Thom#{227} H. New
Interpersonal Psychotherapy of Depression. New York, Springer-Verlag, 1988, pp 147-162
York, Basic Books, 1984 10. Crits-Christoph P. Luborsky L, Dahl L, et al: Clini-
4. Beck AT, Rush A, Shaw B, et at: Cognitive Therapy of cians can agree in assessing relationship patterns in
Depression: A Treatment Manual. New York, psychotherapy: the Core Confuictual Relationship
Guilford, 1979 Theme method. Arch Gen Psychiatry 1988; 45:1001-
5. Luborsky L: Principles of Psychoanalytic Psychother- 1004
apy: A Manual for Supportive/Expressive Treatment. 11. Gill MM, Hoffman IZ: A method for studying the
New York, Basic Books, 1984 analysis of aspects of the patient’s experience of the
6. Kernberg OF, SeIzer M, Koenigsberg HW, et at: Psy- relationship in psychoanalysis and psychotherapy. J
chodynamic Psychotherapy of Borderline Patients. Am Psychoanal Assoc 1982; 30:137-167
New York, Basic Books, 1989 12. FIeissJL: Measuring nominal scale agreement among
7. Kernberg OF: Borderline Conditions and Pathologi- many raters. Psychol Bull 1971; 76:378-382
cal Narcissism. New York, Aronson, 1975 13. Tinsley HFA, Weiss DJ: Interrater reliability and
8. Koenigsberg HW, Kernberg OF, Haas G, et al: Devel- agreement of subjectivejudgments.Journal of Coun-
opment of a scale for measuring techniques in the seling Psychology 1975; 22:358-376

VOLUME 2 #{149}
NUMBER 2 #{149}
SPRING 1993