Profiles of Adherence and Flexibility in Psychodynamic Psychotherapy: A Cluster Analysis

Abstract

We used cluster analysis, a mixed dimensional-categorical design (Ward, 1963), to provide profiles of technique adherence and flexibility in psychodynamic therapy toexamine the relationship between such profiles and outcome. A 4-cluster solutionrepresenting a 2 × 2 categorical model was predicted. Forty-six outpatients wereconsecutively enrolled in individual psychodynamic psychotherapy and received aDSM–IV Axis I diagnosis of a depressive spectrum disorder. Patients were assessedpre and posttreatment through self-report of depressive symptoms. Treatment wasvideotaped, two early sessions were independently rated for use of PI (psychodynamicinterpersonal)and CB (cognitive–behavioral) techniques with excellent interraterreliability (ICC >.75). Mean technique ratings were calculated per case. A hierarchicalcluster analysis was used and surprisingly produced a 3-cluster solution: (1) Adherentand Minimally Flexible, (2) Somewhat Adherent and Somewhat Flexible, and (3)Adherent and Somewhat Flexible. While all clusters demonstrated improvement insymptoms, it appears that psychodynamic therapists who incorporate CB techniquesshould be mindful of doing so at the expense of their primary modality. Minimallytechnique-flexible therapists seem to cluster as a group that is focused on adherence andnot necessarily limited in overall technique use and engagement. However, adherentand somewhat flexible therapists appear to have significantly higher rates (85%) ofclinically significant change compared to either less flexible or less adherent therapists(45% and 38%, respectively). Further research is needed to establish consistent clustersof adherence/flexibility and clarify how much of the relationship between adherence,flexibility, and outcome can be accounted for by other treatment factors, such astherapist engagement