Open door review



Therapists’ professional and personal characteristics as predictors of working alliance and outcome in psychotherapy

Knekt, P., Laaksonen, M., Härkänen, T., Maljanen, T., Heinonen, E., Virtala, E., & Lindfors, O. (2012). The Helsinki Psychotherapy Study: effectiveness, sufficiency, and suitability of short- and long-term psychotherapy. In R. A. Levy, S. Ablon & H. Kächele (Eds.), Psychodynamic Psychotherapy Research. Evidence-Based Practice and Practice-Based Evidence (pp. 71-94). Totowa,NJ: Humana Press.

Heinonen, E., Lindfors, O., Laaksonen, M. & Knekt, P. (2012). Therapists’ professional and personal characteristics as predictors of outcome in short- and long-term psychotherapy. Journal of Affective Disorder, 138, 301-312.

Heinonen, E., Knekt, P., & Lindfors, O. (2014). Therapists’ professional and personal characteristics as predictors of outcome in long-term psychodynamic psychotherapy and psychoanalysis. European Psychiatry, 29, 265-274.


This study investigates therapists’ professional and personal characteristics and identity as predictors of the therapist-patient working relationships, the psychotherapy process, and patient therapy outcomes in two short-term and two long-term therapies (Knekt et al. 2012). Both quantitative and qualitative methods will be used to meet these aims. The study is based on a cohort design and the data is coming from the Helsinki Psychotherapy study. The participants are 367 outpatients from psychiatric services in the Helsinki region having long-standing depressive or anxiety disorder causing work dysfunction. Patients with psychotic disorder, severe personality disorder, adjustment disorder, bipolar disorder or substance abuse were excluded. Solution-focused therapy included 12 and short-term psychodynamic psychotherapy 20 therapy sessions, both therapies lasting about half a year. The long-term therapies were open-ended, psychodynamic psychotherapy lasting about 3 years with about 240 sessions and psychoanalysis lasting about 5 years, with about 650 sessions. Treatments were provided by 71 volunteering psychotherapists who had an average of 9 years work experience in the short-term and over 15 years in the long-term therapies. The patient outcome assessment covers different measures of psychiatric symptoms and recovery, need for treatment, work ability, personality functioning, social functioning, and lifestyle. These outcome measures are administered longitudinally: prior to start of treatment and at 14 pre-chosen time points during a 10-follow-up from start of treatment. Working alliance was rated by both patient and therapist at the third therapy session, and 9 times during a 5-year follow-up. Information on the psychotherapy process is collected four times during the follow-up.

Original contributions have been published (Heinonen et al. 2012, 2013, 2014) from this sub-study and one study is ongoing (see cited our homepage).


The results of this study may have implications improving the quality and flexibility of therapist training programs and supervision, and help in accommodating clinicians’ personal qualities with therapy models for optimizing effective training, learning, and therapy practice.


Dr. Paul Knekt

National Institute for Health and Welfare, P.O. Box 30, 00271 Helsinki



Stockholm Outcome of Psychotherapy and Psychoanalysis Project (STOPPP): Therapeutic identity

Sandell, R., Carlsson, J., Schubert, J., Broberg, J., Lazar, A., & Grant, J. (2004). Therapist attitudes and patient outcomes: I. Development and validation of the therapeutic attitudes scales (tasc-2). Psychotherapy Research, 14, 469-484. doi: 10.1093/ptr/kph039
Sandell, R., Lazar, A., Grant, J., Carlsson, J., Schubert, J., & Broberg, J. (2006). Therapist attitudes and patient outcomes. III. A latent class analysis of therapists. Psychology and Psychotherapy: Theory, Research and Practice, 79, 629-647.
Sandell, R., Lazar, A., Grant, J., Carlsson, J., Schubert, J., & Broberg, J. (2007). Therapist attitudes and patient outcomes: II. Therapist attitudes influence change during treatment. Psychotherapy Research, 17, 201-211.

Brief Summary

The therapist has been found a most important factor determining therapy outcome, even in manualized treatments. The Therapeutic Identity (ThId) questionnaire was developed in the Stockholm Outcome of Psychotherapy and Psychoanalysis Project (STOPPP; Sandell et al., 2000; Sandell et al., 2004) with the aim to evaluate therapists’ professional background and experience, their therapeutic attitudes and style, as well as the private theories and meta-theoretical assumptions. The Therapeutic Attitudes Scales (TASC) is the part of the questionnaire that concerns therapists’ therapeutic values and beliefs. The ThId has versions in English, German, Spanish, and Portuguese.

Using the TASC in a national sample the Stockholm group (Sandell et al., 2000; Sandell et al., 2004) was able to identify four clusters of therapists. These were interpreted primarily on the basis of their associations with variables related to the therapists’ training. One was a cognitive/behavioural cluster, which scored high in adjustment, supportiveness and kindness, and another one consisting of therapists with classic psychoanalytic attitudes, which scored low on these variables and high on neutrality and insight. The two remaining clusters were interpreted as consisting of therapists with more eclectic attitudes, high on scales where the cognitive/behavioral cluster was high but also high on scales where the psychoanalytic cluster was high. Considering their profiles across the TASC scales one of them was interpreted as a psychodynamic cluster, generally closer to the psychoanalytic cluster, whereas the other reflected a more cognitive perspective, with a profile closer to the cognitive/behavioural cluster. In subsequent studies the TASC has been found significantly to correlate with patients’ outcome in psychodynamic therapy and psychoanalysis.


Prof. Rolf Sandell, Stockholm


The therapeutic attitude: Negotiating a “dark continent”

Klug, G., Henrich, G., Kächele, H., Sandell, R. & Huber, D. (2008). Die Therapeutenvariable: immer noch ein dunkler Kontinent? [The therapist variable: is it still an unknown factor?] Psychotherapeut, 53, 83-91.


There is broad consensus in the scientific community that the therapist matters. The therapeutic attitude, conceived as the therapist’s personal backdrop against which the therapeutic process is unfolding during treatment, is a salient curative factor. The present study aimed at further elucidating the therapeutic attitude. In order to more subtly differentiate the person of the “healer“, psychoanalysts, psychodynamic psychotherapists, and cognitive-behavioral therapists were investigated. We hypothesized that there are significant differences between therapists of different therapeutic orientations according to their differential training and technique.

The Therapeutic Attitude Questionnaire (ThAt), the German translation of the Therapeutic Identity Questionnaire, developed by Sandell and co-workers, was applied to explore the therapist variable. The questionnaire comprises therapists’ demographics, academic and professional training, professional experience, personal therapy or training analysis and therapist’s theoretical orientation. Therapist’s attitude is captured by items of therapist’s belief in curative factors, individual technique and basic assumptions, condensed into the Therapeutic Attitudes Scales (TASC): Adaptation, Insight, Kindness, Neutrality, Supportiveness, Self-doubt, Irrationality, Artistry and Pessimism. Furthermore, therapists described in free-text format their strengths, limitations, aims and difficulties in therapy.

We investigated a total sample of 451 psychotherapists: 208 psychoanalysts, 81 psychodynamic psychotherapists and 162 cognitive-behavioral therapists; response rate was 52 %.

The central finding of the ANOVA for TASC variables was that adaptation and insight differentiate the groups in the theoretically expected way: cognitive-behavioral therapists believed that the patient’s adaptation to the environment is the most essential curative factor, whereas psychoanalysts believed that insight into problems is the most essential curative factor; psychodynamic psychotherapists took an intermediate stance. CHAID analysis of the TASC variables showed that adaptation contributes the most to the therapists’ differentiation. Thus, we concluded that psychoanalysts, psychodynamic and cognitive-behavioral therapists work in empirically distinguishable ways and as theoretically expected.


This study is limited because it does not address the therapist’s effectiveness as a correlation with the outcome of the therapy is lacking.


Dr. Günther Klug

Department for Psychosomatic Medicine and Psychotherapy of the Technische Universität, München


Studying psychotherapy process with the PQS: Therapists’ techniques in psychoanalysis and short-term and long-term psychoanalytic psychotherapy: are they different?

Seybert, C., Desmet, M., Erhardt, I., Hörz, S., Mertens, W., Ablon, S.,  Levy, R., Kächele, H. (2010). Therapists techniques in psychoanalysis and short-term and long-term psychoanalytic therapy: Are they different? Journal of the American Psychoanalytic Association, 59(3) (3), 592-602. 


Therapeutic techniques represent a significant part of the therapist’s contribution to the therapeutic process.

This study compares the therapeutic techniques used in recorded sessions of 13 psychoanalyses, 15 long-term (LTDP) and 30 short-term (STDP) psychodynamic psychotherapies. Two hundred two therapeutic sessions were analyzed with the Psychotherapy Process Q-Set (PQS; Jones, 2000). In regards to the techniques defined and presented in the research literature, we identified 25 suitable PQS items among the total 100 items from the PQS. These therapeutic techniques are compared among the PA, LTDP and STDP samples and at different points in time of the therapeutic process. The correlation of each sample with the PQS analytic prototype (Ablon & Jones 1998) identifies therapeutic techniques characteristic for psychoanalytic oriented therapies. The study addresses three questions: (1) whether there are differences between PA, LTPD, and STPD at the level of therapeutic technique, (2) whether PA and LTPD show more resemblance to the PQS psychoanalytic prototype than STPD, and (3) whether interpretation (among other tech­niques) differs between STPD and LTPD.

Overall more similarities than differences could be found within these samples.

The most significant differences regarding therapeutic techniques, identified through t tests, were found on seven techniques. For example, psychoanalysts were observed to be more empathic toward their patients than were STDP therapists. No significant differences could be found between PA and LTDP therapists.

All three samples achieved a correlation of .50 or higher with the PQS psychoanalytic prototype. When correlating only the technique items of the samples and the PQS prototype, the technique items of the STDP sample achieve the highest correla­tion of .76 followed by the correlation of .70 for the LTDP sample and .58 for the PA sample.


Despite limitations regarding sample size and heteroge­neity the results  indicate little dimensional differentiation in the techniques used in PA, LTDP, and STPD. In accounting for these differences, the length of treatment was more important than the lying down vs. face-to-face distinction.


Dr. Carolina Seybert

International Psychoanalytic University Berlin


Therapist variables and patient outcome

Berghout, C., & Zevalkink, J. (2011). Therapist variables and patient outcome after psychoanalysis and psychoanalytic psychotherapy. Journal of the American Psychoanalytic Association, 59, 577-583.


Evidence from studies that have focused on the effects of therapist variables on treatment outcome suggests that a moderate amount of variance in patient outcomes is attributable to therapist differences, regardless of the type of treatment practiced. In the literature, researchers have considered gender of the therapist, therapists' experience and training, therapists' treatment attitudes, and self-reported attachment style to be relevant therapist variables (e.g., Beutler et al. 2004). In the present study, we investigated whether these therapist variables are related to patient outcome in a group of patients after psychoanalysis and a group of patients after psychoanalytic psychotherapy.

The patient sample (N = 97) originated from a project, with participants from four mental health care organizations in the Netherlands, designed to study the effectiveness of long-term psychoanalytic treatment. For the present study, we focused on patients who had ended long-term psychoanalytic treatment. One group of patients had received psychoanalysis (PA; n = 40); the other group had received psychoanalytic psychotherapy (PP; n = 57). Patient outcome was assessed by using the three outcome factors that were found in the PCA factor analyses: General distress, Introversion, and Disadaptation and disorganization (see Berghout, Zevalkink, and de Jong 2010).

All therapists (N=53) in the project were licensed clinicians (psychiatrist-psychotherapists or psychologist-psychotherapists)


Prof. Caspar C. Berghout

Department of Research and Quality Assurance, Netherlands Psychoanalytic Institute, PO; Box 7031, 1007 JA Amsterdam



To become a psychotherapist – a clinical challenge for students and a pedagogic challenge for teachers

Ögren, M.L., Bertling, U., Boalt-Boëthius, S., Werbart, A., Hau, S. (2012). Professional development and psychotherapy supervision. Nordic Psychology, 64, 3, 147-149.
Hau, S., Jacobsson, G., Lindgren, T. (2012).  Rites of passage – novice students’ experience of becoming psychotherapists. Nordic Psychology, 64, 3, 46-56.


Postgraduate psychotherapy education combines teaching of theoretical knowledge, applied clinical experience as well as clinical practice under supervision. In an ongoing naturalistic study, the interplay between learning declarative and procedural knowledge and the development of a professional identity as a psychotherapist are investigated.


Two educational programs, both located at the Department of Psychology, Stockholm university, are evaluated: A postgraduate psychotherapy education program and the psychotherapeutic training taught during the later part of the MSc Psychology education program. Much of the skills formed during the training concerns acquiring a procedural clinical knowledge. At the same time the process of developing a psychotherapeutic identity is very much linked to the capacity to form working alliances with patients, supervisors, and teachers. However, these complex interactive processes have to be studied systematically in order to improve the effectiveness of education programs. The processes of learning procedural knowledge and the communicative aspects of the education are investigated by means of interviews, questionnaires, student written summing-ups after psychotherapies and performance measures. Students, supervisors, teachers, and patients are studied before, during and after the educational programs. Conclusions can be drawn on how to further develop the education for becoming a competent psycho-therapist by comparing the groups at two different levels of education program.


Stephan Hau, Prof. PhD

Department of Psychology, Stockholm University

Gunnel Jacobsson, PhD

Department of Psychology, Stockholm University

Development of an adherence-scale for differentiation between psychodynamic psychotherapy and psychoanalysis

Huber, D., Henrich, G., Gastner, J., & Klug, G. (2012). The Munich Psychotherapy Study: Must all have prizes? In R. Levy, S. Ablon & H. Kächele (Eds.), Psychodynamic Psychotherapy Research (pp. 51-69). Totowa, NJ: Humana Press.


The aim is to provide an adherence scale of high discriminant ability for differentiation between the psychoanalytic pole and the psychodynamic pole of psychotherapeutic technique. In this study, the psychoanalytic pole is represented by psychoanalytic psychotherapy and the psychodynamic pole by psychodynamic psychotherapy according to the nomenclature of German guidelines for psychotherapy. The assessment of treatment integrity is an essential quality criterion for outcome and process outcome studies. Adherence to a treatment manual in RCTs as well as in effectiveness studies is viewed as a strategy to assure internal, statistical and construct validity. The problem of differentiation between the psychoanalytic pole and the psychodynamic pole follows from the broad overlap between them, both in theoretical conceptualizations and practical implementation. Therefore, the scale development is performed in a bilateral way by integrating both a theoretical and an empirical approach.

The development of the adherence instrument is embedded in a theoretical and empirical framework by applying the literature about psychodynamic versus psychoanalytic techniques and by also applying real-world therapy sessions. Audiotaped psychodynamic and psychoanalytic therapy sessions are sampled from the Munich Psychotherapy Study (MPS; Huber, Henrich, Clarkin, & Klug, 2013; Huber, Zimmermann, Henrich, & Klug, 2012) within which unmanualized treatment conditions (psychodynamic psychotherapy, psychoanalytic psychotherapy, cognitive-behavioral therapy) were compared.

First step was an extensive literature research which provides the ground for item formulation. In total 36 items were formulated reflecting therapist’s techniques and attitudes prototypical either for psychodynamic psychotherapy or for psychoanalytic psychotherapy (e.g. “Therapist encourages to free association” or “Therapist intervenes supportive [commending, approving, and advising]”). These items are to be regarded as dimensional in the sense of “rather psychodynamic” or “rather psychoanalytic” and not as categorical.

In a second step a group discussion was performed to discuss the discriminating power of all items. Six experts (three female and three male training analysts) participated in the discussion. Three chair-men focused the discussion to extract those items which presumably present prototypical therapist’s technique or attitude of one of the therapeutic approaches and furthermore can discriminate between them reliably. The discussion resulted in 22 items, 11 presented the psychodynamic pole and 11 presented the psychoanalytic pole.

In a third step “expert therapy sessions” were selected. Twelve blinded experts (seven training analysts and five training psychodynamic therapists) after having carefully listened to audiotaped therapy sessions, rated whether it was a psychoanalytic or a psychodynamic session. Sessions were sampled from the middle part of the treatment. We choose two consecutive sessions to enhance assessment of aspects of the treatment process itself. Thus, five middle part sequences of psychodynamic and five psychoanalytic psychotherapy middle part sequences were rated. Each sequence was listened to and assessed by varying pairs of expert raters. Sessions are defined as “expert therapy sessions” if the two raters and the therapy label of the MPS were identical.

The forth step involves a structured expert rating by applying the 22 items to the “expert therapy sessions”. A further group of about 9-12 experts (psychodynamic therapists and psychoanalysts with 5 years clinical experience at least) will be divided into six varying rater groups (three raters in each group). Ratings are based on three psychodynamic and three psychoanalytic “expert therapy sessions” (middle part sequences). Each expert listened to one or more sequences of “expert therapy sessions” and assessed each item of the therapist’s attitudes and interventions on a 4-point rating scale (0 = “not at all characteristic” to 3 = “extremely characteristic”). The most consensually rated items, both within raters’ groups and within treatment approach, are the most discriminative items and are appropriate for the adherence measure.


To date an empirically robust adherence measure to discriminate between psychodynamic psychotherapy and psychoanalytic psychotherapy is still lacking. The majority of the currently used adherence scales are suitable for discriminating cognitive-behavioral and psychodynamic approaches but fail to provide reliably discrimination between different psychoanalytic approaches. Because of an increasing interest in effectiveness studies of high external validity of unmanualized long-term treatments, the measurement of adherence is of major importance for psychotherapy research of high scientific standard.


Melanie Ratzek, Dr. Dipl.-Psych.

Evangelisches Zentralinstitut für Familienberatung Berlin
Auguststraße 80
10117 Berlin