Uncovering Interaction Structures in a Brief Psychodynamic Psychotherapy

Desvelando Estruturas de Interação em uma Psicoterapia Psicodinâmica Breve

Descubriendo Estructuras de Interacción en una Psicoterapia Psicodinâmica Breve

Abstract

Interaction structures refers to the repetitive ways of interaction between the patient-therapist dyad over the course of treatment. This construct is operationalized by the repeated application of the Psychotherapy Process Q-Set (PQS) to psychotherapy sessions. Studies in this line of research have so far focused only on long-term treatment. The present study examines whether interaction structures can be detected empirically in short-term psychotherapies. All sessions (N = 31) of a successful case of brief psychodynamic psychotherapy were coded with the Psychotherapy Process Q-Set (PQS). The application of Q type factor analysis procedures with varimax rotation revealed five interaction structures: resistance, alliance, facing depression, expectation of change, and introspection and hearing. The analysis of variation of these structures over the course of the treatment showed that these interactions are nonlinear, may be positively or negatively protruding in different sessions, or be predominant at some treatment phase.

Keywords
brief psychotherapy; psychotherapeutic processes; psychoanalytic psychotherapy

Resumo

Estruturas de interação designam os funcionamentos repetitivos da díade paciente-terapeuta ao longo do tratamento. O constructo é operacionalizado pela aplicação repetida do Psychotherapy Process Q-Set (PQS) às sessões de psicoterapia. Estudos nesta linha de investigação até agora focalizaram somente tratamentos de longa duração. Esta investigação examina se estruturas de interação podem ser detectadas empiricamente em psicoterapias breves. Todas as sessões (N = 31) de um caso bem-sucedido de psicoterapia psicodinâmica breve foram codificadas com o PQS. A aplicação de análise fatorial do tipo Q com rotação varimax revelou cinco estruturas de interação: resistência, aliança, enfrentado a depressão, expectativa de mudança, e introspecção e escuta. A análise da variação destas estruturas ao longo do tratamento mostrou que as mesmas não são lineares, podem estar positiva ou negativamente salientes em diferentes sessões, ou predominar em alguma etapa do tratamento.

Palavras-chave
psicoterapia breve; processos terapêuticos; psicoterapia psicanalítica

Resumen

Estructuras de interacción designan los patrones repetitivos de interacción de la díada cliente-terapeuta durante el tratamento. El constructo se operacionaliza mediante la aplicación repetida del Psychotherapy Process Q-Set (PQS) a las sesiones de psicoterapia. Los estudios esta línea de investigación hasta ahora se centraron sólo en tratamientos de largo plazo. Esta investigación examina si las estructuras de interacción se pueden detectar empíricamente en psicoterapias breves. Todas las sesiones (N = 31) de un caso exitoso de psicoterapia psicodinámica breve se codificaron con el Psychotherapy Process Q-Set (PQS). La aplicación del análisis factorial del tipo Q con rotación varimax reveló cinco estructuras de interacción: resistencia, alianza, enfrentando la depresión, expectativa de cambio, y introspección y escucha. El análisis de la variación de estas estructuras durante el tratamiento mostró que las interacciones no son lineares, pueden ser positiva o negativamente sobresalientes en diferentes sesiones, o predominar en alguna etapa del tratamiento.

Palavras clave
psicoterapia breve; processos terapéuticos; psicoterapia psicoanalítica

Explaining the process of change in psychotherapy is a common challenge for clinicians and researchers. However, in the ambit of psychodynamic psychotherapies, the hiatus between practice and empirical investigation is clear. Psychotherapists and researchers seem to inhabit different universes, there being little synergy between the two fields (Fonagy, 2004; Kernberg, 2015). Although psychoanalytical concepts and treatments have solid empirical support, few psychotherapists are familiar with the studies undertaken in this approach (Shedler, 2010). We believe that researchers must prioritize empirical methods which are capable of capturing the complexity of the phenomena which characterize the therapeutic encounter, such that they may respond to questions relevant to the psychoanalytical clinical practice. In this article, we highlight the potential of the Psychotherapy Process Q-Set (PQS; Jones, 2000) for producing relevant knowledge regarding the therapeutic process in individual cases.

The PQS (Jones, 2000) is Q-sort type instrument which provides quantifiable descriptions of the behaviors and attitudes of the therapist, of the patient, and of the interaction between both in the therapeutic session. This instrument has already been adapted for various languages and has been used for over 25 years to study the therapeutic process in different approaches of psychotherapy. Studies with the PQS follow two distinct, but complementary, lines: that of the prototypes, which adopts a nomothetic perspective for examining the relationship between the adherence of psychotherapies to ideal models (constructed through the responses to the items of the PQS of experts from different theoretical orientations) and the results of the treatment; and that of the interaction structures, which adopts an ideographic perspective for revealing the ways in which the patient and therapist interact over the course of the treatment (Smith-Hansen, Levy, Seybert, Erhardt, & Ablon, 2012).

Interaction structures constitute patterns of interaction of the dyad which occur during psychotherapy, sometimes, without the patient and/or therapist consciously noticing. The concept is part of a model of therapeutic action which seeks to overcome the interpretation/insight versus relationship dichotomy which has, sometimes, divided clinicians and researchers of psychoanalytic orientation. The construct, which integrates other concepts such as that of enactment, intersubjectivity and role-responsiveness is operationalized empirically through the repeated application of the PQS to the sessions of a psychotherapy (Jones, 2000). The interaction structures are an essential part of the process and contribute to facilitating or impeding the therapeutic process (Ablon & Jones, 2005).

Through the application of Q type factor analysis procedures to the codifications of the therapeutic process undertaken using the PQS, various single and multiple case studies have identified interaction structures in long-term psychodynamic psychotherapies (Jones, Ghannam, Nigg, & Dyer, 1993; Jones & Price, 1998; Pole & Jones, 1998) and also in psychoanalysis (Ablon & Jones, 2005). Generally speaking, these revealed a limited number of factors (between 3 and 5), including both patterns which are unique to the specified dyad and patterns which are repeated in various cases (Goodman, Edwards, & Chung, 2014).

One search carried out by ourselves in the main psychotherapy databases (PsycINFO and PubMed) confirmed that, at the time of writing, there are no studies on interaction structures derived from PQS in brief psychotherapies. Specifically, we do not, therefore, know with certainty whether the above-mentioned patterns also occur in short-term psychotherapies. Hence, this exploratory study seeks to examine the presence of interaction structures in a short term psychotherapy. Specifically, its objective is to describe which interaction structures characterize the process, and to ascertain how these structures vary over the course of the treatment.

Method

This is a systematic single-case study (Edwards, 2007). The case is that of the psychotherapy of Maria (fictitious name), already analyzed with the aim of investigating the effects of the adherence to prototypes regarding the results of the psychotherapy (Serralta, Pole, Nunes, Eizirik, & Olsen, 2010). In the present reanalysis, the ideographic perspective of the interaction structures will be adopted.

Participants

The patient (Maria) is an adult woman, with higher education, who sought psychotherapeutic attendance due to complaints of anxiety and depression. The therapist is a psychotherapist with training in psychoanalytically oriented therapy and over seven years' clinical practice. The case is of a brief psychotherapy of 31 sessions attended in a private clinic. The treatment planning included the elaboration of past bereavements with the aim of helping Maria to face major heart surgery which was necessary, but which she had been refusing. The psychotherapy was successful. At the end of the treatment, Maria presented clinically significant and reliable change, according to Jacobson & Truax's Reliable Change Index (RCI; 1991), in social adjustment (Social Adjustment Scale, SAS; Weissman, Prusoff, Thompson, Harding, & Meyers, 1978), in the symptoms of depression (Beck Depression Inventory, BDI; Beck & Steer, 1993), somatization and anxiety, as well as in general psychological distress (Symptom Checklist 90 Revised, SCL-90-R; Derogatis & Savitz, 2000). The gains were maintained in the eight weeks of follow-up (Serralta et al., 2010).

Instruments

The Psychotherapy Process Q-Set - PQS (Jones, 2000) is an instrument of the Q-sort type. The Q method was invented in the 1930s by William Stephenson in order to study subjectivity in the perspective of the subject herself, this being adapted in the 1960s by Jack Block to be applied by external judges. A Q set is made up of a series of statements which describe a specified condition or situation, which must be ordered in terms of their greater or lesser relevance to the person who is being assessed. This ordering is ipsative, that is, each item is compared in relation to the others, and not in relation to any external criteria.

The PQS has 100 items which express the attitudes, behaviors or experience of the patient, the therapist, and the interaction between the two. It is a holistic measurement of the process, which has, as its unit of analysis, the therapeutic session recorded on audio and/or video. After examining the session, judges order the items on a nine point scale which varies from the extremely characteristic (category 9) to the extremely uncharacteristic. The number of items to be arranged in each pile is fixed, following the normal curve. There are two ways of carrying out this ordering: on a worktable, with the help of printed cards, or using an electronic database of the Excel type, developed specifically for this end. In any one of the situations, training is necessary to apply the instrument.

The original version of the PQS has good inter-rater reliability, construct validity and discriminant validity (Smith-Hansen et al., 2012). The factorial validity is irrelevant, as measurements of the Q sort suppose independence between the items. The Brazilian version of the PQS and of its manual were developed by Serralta, Nunes and Eizirik (2007). It is culturally equivalent to the original instrument, and presents good inter-rater reliability (Serralta et al., 2007), as well as being able to distinguish between treatments with different theoretical orientations (Serralta, 2014).

Procedure

Data collection. The 31 psychotherapy sessions were recorded on audio, transcribed in full, and codified using the PQS by pairs of independent judges. When the reliability between raters was not considered satisfactory (r ≤ .5), a third rater was added. The average scores of the two judges in agreement for each item of the PQS in the session formed the composite score which was used in the subsequent analyses. As already mentioned, various outcome measures were systematically applied during the course of the treatment. These instruments and procedures are not described here, as the present study does not describe the progress and the outcome of the treatment.

Data analysis. The first stage of the analysis involves the description of the process's general characteristics, obtained through the identification of the most and least characteristic items of the PQS in the treatment sessions. Based in this result, a narrative was made which characterizes the general process. In this, when the item's score is in the uncharacteristic or negatively salient end of the scale, the item's number is followed by the letter 'r', to indicate that the reverse of the item was used. The next step was to submit the assessments of the 100 items of the PQS in each one of the 31 treatment sessions to a Q type factor analysis of principal components, with varimax rotation in order to identify the sets of items which most explain the variance in the process of therapy, that is, the patient-therapist interaction structures.

The Q methodology was created for the systematic study of human subjectivity. Its characteristics can be better understood in comparison with the more known methods of data analysis, generically termed as the R method, in reference to the Pearson product-moment correlation coefficient. The R methods seek to establish relationships between variables in a sample of people. In the Q methodology, on the other hand, the sample constitutes not a population of people, but a population of points of view. As a result, differently from what occurs in the R methods, in the Q methodology, the researchers are interested in examining the relationships between a large set of data (variables which reflect distinct perceptions, opinions, experiences or processes) in a single subject or in a small number of subjects.

The Q set is the items which are ordered. The P set corresponds to the respondents who will undertake the ordering. The P set is always smaller than the Q set. Typically, the analysis and interpretation of data includes the calculation of the correlation matrix of all the orderings (Q-sorts) obtained. This represents the degree of agreement or disagreement between the respondents' points of view. The following step is generally the application of the procedure of factor analysis, in order to identify the natural groupings of orderings. In this way, people who share the same point of view are in the same factor (Van Exel & Graaf, 2005).

In using the PQS to examine the process of a single case of psychotherapy, we adopt the perspective of external raters (judges) in order to describe what occurs in each treatment session. In the examination of the therapeutic process, it is not the characteristics of different people which are being evaluated, but, rather, the multiple sessions of a single therapeutic process which is systematically examined with repeated applications of the same Q set of variables. Thus, in this case, for each session one obtains an ordering (calculated using the average individual orderings undertaken by two or more external judges). The set of sessions which makes up the process of the psychotherapy corresponds to the P set, that is, the sessions are the units of analysis. The correlation matrix identifies the processes which stand out positively or negatively in the sessions. The factor analysis serves to identify the natural groupings of variables of the patient and of the therapist, which make up the psychotherapy. These groupings or factors represent the interaction structures.

In the present study, the best solution found was that of five factors. The reliability of each factor (interaction structure) was ascertained using the Cronbach alpha coefficient. As some items of the PQS have a negative relationship with the factor, these items were inverted for calculating the means of the factors in each session. The variation of the factors over time was examined visually using a scatterplot. All the statistical procedures were undertaken using the SPSS software, version 21.0.

Ethical Considerations

The protocol of the case study of Maria's psychotherapy was approved in the Ethics Committee of the Universidade Federal do Rio Grande do Sul (CEP UFRGS, n. 03129). The reanalysis of this case was authorized by the Research Ethics Committee of the Universidade do Vale do Rio dos Sinos (CEP UNISINOS, n. 11/133). The psychotherapy sessions were recorded using audio, with the participants' authorization, obtained through the terms of free and informed consent.

Results

The general description of the therapeutic process of Maria's psychotherapy is based in the ten most and least characteristic items of the PQS in the set of the treatment sessions (N = 31). One must remember that the least characteristic items are equally relevant for the description of the process, as they represent what it is in this that is negatively salient. In addition to this, the meaning of the reverse item is not always the opposite of the original item, as it may have various meanings. For this reason, the items will be described in such a way as to respect their meaning in the context of the interaction in question.

Generally speaking, the treatment sessions have a specific focus (PQS 23), the predominant themes being health (PQS 16) and the situations of the patient's current or recent life (PQS 69). The patient expressed herself clearly and in an organized way (PQS 54), was committed to the therapeutic work (PQS 73), collaborated with a therapist (PQS 87 r), and brought significant issues and material to the session (PQS 88). The patient did not present difficulties for initiating the sessions (PQS 25 r) and, in reality, tended to initiate the topics actively (PQS 15). She did not show resistance to examining thoughts, reactions and motivations related to her problems (PQS 58 r). Silences occurred frequently (PQS 12), possibly reflecting the patient's tendency for introspection and for the exploration of her internal world The therapist communicated clearly and coherently (PQS 46) and was easily understood by the patient (PQS 5 r). The therapist demonstrated sensitivity and tact in dealing with the patient (PQS 77 r) and seemed to be emotionally involved in the process (PQS 9 r), accepting the patient without being critical (PQS 18). The patient, in her turn, felt understood (PQS-14 r), confident and secure in the interaction (PQS 44 r), and tended to accept the therapist's comments and observations (PQS 5 r).

In this process, through the application of the Q type factor analysis of principal components, we found five factors (interaction structures) which, together, explained 46.31% of the variance. These are: 1 - Resistance, 2 - Alliance, 3 - Facing depression, 4 - Expectation of change, and 5 - Introspection and hearing.

The interaction structure Resistance (alpha of .86) explained 12.22% of the variance of the therapeutic process, and is made up of 15 items with factor loadings between -.757 and .652. The items which make up this interaction structure, and its respective factor loadings, are presented in Table 1. The mean score of this interaction structure was 4.67 (SD = 0.77), with scores varying between 3.53 (session 17) and 6.37 (session 24).

Table 1
Resistance Factor: Factor Loadings of the Items of the PQS Observed in the Exploratory Q Type Factor Analysis With Varimax Rotation

PQS Items	FL
PQS 68: Real vs. fantasized meanings of experiences are actively differentiated	-.757
PQS 40: T makes interpretations referring to actual people in the P's life	-.668
PQS 5: P has difficulty understanding the T's comment	.652
PQS 87: P é controlling	.645
PQS 82: P's behavior is reformulated by the T	-.635
PQS 29: P talks of wanting to be separate or distant from someone	.585
PQS 80: T presents a specific experience or event in a different perspective	-.542
PQS 69: P's current or recent life situation is emphasized in the session	.541
PQS 71: P s self-accusatory; expresses shame or guilt	.539
PQS 56: P discusses experiences as if distant from his or her feelings	.533
PQS 92: P's feelings or perceptions are linked to situations of the past	-.531
PQS 96: There is discussion of scheduling of hours, or fees	.529
PQS 34: P blames others, or external forces, for difficulties	.508
PQS 18: T conveys a sense of non-judgmental acceptance	.493
PQS 58: P resists in examining thoughts, reactions or motivations	.492

• ^Note:
  FL = factor loading, P = patient, T = therapist.

The interaction structure "Alliance" (alpha of .85) explained 11.78% of the variance of the therapeutic process, and is made up of 16 items with factor loadings between .790 and .843. The items which make up this interaction structure, and its respective factor loadings, are presented in Table 2. This interaction structure's mean score was 4.26 (SD = 1.07), with scores varying between 2.97 (session 6) and 6.56 (session 18).

Table 2
Alliance Factor: Factor Loadings of the Items of the PQS Observed in the Exploratory Q Type Factor Analysis With Varimax Rotation

PQS Items	FL
PQS 51: T condescends to or patronizes the patient	.843
PQS 93: T is neutral	-.790
PQS 24: T's own emotional conflicts intrude into the relationship	.763
PQS 28: T accurately perceives the therapeutic process	-.733
PQS 81: T emphasizes patient feelings	-.722
PQS 27: T gives explicit advice or guidance	.651
PQS 37: T behaves in a teacher-like (didactic) manner	.623
PQS 32: P achieves a new understanding or insight	-.613
PQS 6: T is sensitive to the patient's feelings; empathic	-.611
PQS 15: P does not initiate or elaborate topics	.600
PQS 49: P experiences ambivalent or conflicted feelings about T	.576
PQS 77: T is tactless	.559
PQS 17: T actively exerts control over the interaction	.521
PQS 42: P rejects T's comments and observations	.511
PQS 14: P does not feel understood by T	.507
PQS 66: T is directly reassuring	.507

The interaction structure Facing depression (alpha of .78) explained 9.19% of the variance of the therapeutic process, and is made up of 13 items with factor loadings between .674 and .726. The items which make up this interaction structure and its respective factor loadings are presented in Table 3. This interaction structure's mean score was 5.74 (SD = 0.74), with scores varying between 3.96 (session 28) and 6.96 (session 21).

Table 3
Facing Depression Factor: Factor Loadings of the Items of the PQS Observed in the Exploratory Q Type Factor Analysis With Varimax Rotation

PQS Items	FL
PQS 16: There is discussion of physical symptoms, or health	.726
PQS 67: T draws P's attention to unconscious wishes, feelings, or ideas	-.674
PQS 36: T points out P's defenses	-.639
PQS 76: T suggests that P accept responsibility for his or her problems	-.625
PQS 89: T acts to strengthen the P's defenses	.624
PQS 83: P is demanding	.610
PQS 2: T draws attention to P's non-verbal behavior	.602
PQS 23: Dialogue has a specific focus	.592
PQS 94: P feels sad or depressed (vs. joyous or cheerful)	.582
PQS 62: T identifies a recurrent theme in the P's experience or conduct	-.576
PQS 54: P expresses himself or herself in a clear and organized fashion	.544
PQS 98: The therapy relationship is a focus of discussion	-.533
PQS 47: When the interaction with the P is difficult, the T accommodates	.507

The interaction structure Expectation of change (alpha of .64) explained 7.14% of the variance of the therapeutic process, and is made up of 6 items with factor loadings between .713 and .718. The items which make up this interaction structure and its respective factor loadings are presented in Table 4. This interaction structure's mean score was 4.66 (SD = 0.84), with scores varying between 3.17 (session 13) and 6.92 (session 3).

Table 4
Expectation of Change Factor: Factor Loadings of the Items of the PQS Observed in the Exploratory Q Type Factor Analysis With Varimax Rotation

PQS Items	FL
PQS 4: The P's treatment goals are discussed	.718
PQS 61: P feels shy and embarrassed (vs. unselfconscious and assured)	-.713
PQS 94: P feels sad or depressed (vs. joyous or cheerful)	-.679
PQS 26: P experiences discomforting or troublesome (painful) affect	-.676
PQS 55: P conveys positive expectations about therapy	.669
PQS 59: P feels inadequate and inferior (vs. effective and superior)	-.617

The interaction structure Introspection and hearing (alpha of .68) explained 5.99% of the variance of the therapeutic process, and is made up of 3 items with factor loadings between .547 and .507. The items which make up this interaction structure and its respective factor loadings are presented in Table 5. This interaction structure's mean score was 6.43 (SD = 0.81), with scores varying between 4.67 (session 15) and 7.83 (session 20).

Table 5
Introspection and Hearing Factor: Factor Loadings of the Items of the PQS Observed in the Exploratory Q Type Factor Analysis With Varimax Rotation

PQS Items	FL
PQS 97: P is introspective, readily explores inner thoughts and feelings	.547
PQS 50: T draws attention to feelings regarded by the P as unacceptable	.524
PQS 35: Self-image is a focus of discussion	.507

Discussion

This study is the first to investigate the presence of interaction structures detected empirically by the PQS in a brief psychotherapy. The results found demonstrate that in this therapeutic modality, the patient and therapist establish repetitive patterns of interaction and relationship, as in the example of what happens in long-term psychotherapies (Jones et al., 1993; Jones & Price, 1998; Pole & Jones, 1998) and in psychoanalysis (Ablon & Jones, 2005). Hence, independently of the frequency or duration of the psychotherapy, the set of the studies undertaken in this line of investigation shows that each therapeutic pair interacts repeatedly in different ways over the course of a single treatment. This conception of the therapeutic process presupposes that patient and therapist influence each other mutually, which is in accordance with the intersubjective orientation dominant in the most up-to-date schools and psychoanalytic currents (Bohleber, 2013). Technique and relationship are only artificially disassociated. In this regard, we agree with the premise of McAleavey and Castonguay (2015), that the specific and common factors most probably function in a symbiotic (or even parasitical) way. Our hypothesis is that these two modes of therapeutic action are interdependent and, therefore, are unlikely to produce change in isolation.

The global description of Maria's treatment, undertaken through the PQS, shows high levels of collaboration between a patient who was inclined to explore her internal world and an empathetic therapist. In this process, five interaction structures were found, which represent the distinct means of patient-therapist interaction which characterized the psychotherapy. The structure Resistance covers not only the patient's attitudes which are opposed to the process of change, but also the patient's mental states, the attitudes of her therapist, and specific characteristics of the therapeutic dialog. The patient's negative feelings predominate in this, in particular the self-accusations (shame and guilt). Such manifestations are accompanied by the therapist's attitudes of non-critical acceptance and formulation of more general interpretations.

One can note, however, that, taking into account the Q scale of 9 points, the resistance was present, predominantly in a slightly negative way, in the process (M = 4.67; SD = 0.77), indicating the presence of a collaborative work directed towards the examination of the patient's internal world. Small amounts of resistance, accepted and understood by the therapist, were present in various sessions of Maria's treatment and may indicate the therapeutic work underway, as helping the patient overcome inevitable resistance is essential work of the psychodynamic therapist. Resistance entails varying levels of ambivalence on the part of the patient in relation to change, which are, to a large extent, determined by the quality of the therapeutic relationship. The results of studies suggest that more empathetic and supportive therapists help their patients to reduce the levels of resistance (Ribeiro et al., 2014). This seems to have occurred in Maria's treatment.

The second structure, Alliance, seems to be compatible with the notion of ruptures and repairs in the therapeutic alliance. Ruptures in the therapeutic alliance are episodes of tension or breaks in the collaborative work being undertaken by the patient-therapist pair. Repairs in the ruptures in the alliance are associated with positive results in psychotherapy (Safran, Muran, & Eubanks-Carter, 2011). Considering the outcome of the case studied, in conjunction with the elements which are more characteristic of the global process, and with the visual inspection of this structure's variation in the process, what is ascertained is the existence, in a general way, of a collaborative work supported by a solid therapeutic alliance, although, on average, the alliance was slightly negative (M = 4.26; SD = 1.07). It is not the presence of ruptures that is associated with negative outcomes in psychotherapy, but rather the non-resolution of these. In the case of Maria, it is only in a few sessions that the conflict in the dyad is slightly characteristic (as in session 18, which presented the highest score in this interaction structure). In the majority of sessions, what was observed was this structure's negatively salient presence, which indicates a positive interaction marked by empathy, sensitivity and neutrality on the part of the therapist, accompanied by the feeling on the part of the patient that she was being heard and understood, as her feelings were explored, favoring new insights.

As is known, brief psychotherapies are generally focal. Among their central characteristics, emphasis is placed on the work geared towards the expression of emotions, the exploration of the defenses to avoid thoughts and feelings, the identification of repetitive patterns of functioning and the relationship between the present and past (Abbass et al., 2014). The third interaction structure found, Facing depression, was positively present in a large majority of the sessions at a slight or moderate level and depicts the central theme related to the patient's issue (health problems) and the efforts made by the therapist in adjusting to her depressive functioning, pointing out aspects of the nonverbal behavior and promoting or reinforcing more adaptive defenses, instead of interpreting unconscious defenses and desires. It is possible that the choice of this strategy may have occurred in order not to further disturb the patient, as the predefined limitation of the therapy time, and the patient's need to have the operation, are elements of the context which seems to contra-indicate, in this case, a deeper analysis of the unconscious determinants of her psychopathology. In this regard, when Maria showed herself to be more depressed, the therapist tended to adopt a more supportive stance. This stance is consistent with the recommendation that, when the patient's health capacities are more compromised, the psychotherapist must prioritize strategies which promote the strengthening of the alliance and the resources of the ego (Barber, Muran, McCarthy, & Keefe, 2013).

The fourth structure found, Expectation of change, was, in general, slightly low (M = 4.66; SD = 0.84). The visual inspection revealed that this interaction structure had its highest scores in the initial sessions of the psychotherapy. In this interaction structure, the patient's positive feelings, and her optimism in relation to the therapy's progress, are evident. Both - patient and therapist - work focused on the objectives established for the treatment. The expectation of change, and the optimism in relation to the therapeutic results, are generic factors which are indicative of therapeutic success (Krause et al., 2006), in particular when present in the initial phase of treatment. In this context, expectation of change and therapeutic alliance are practically indistinguishable, principally when one considers the affective-relational component of the alliance (Hersoug, Høglend, Gabbard, & Lorentzen, 2013).

The last interaction structure found was Introspection and Hearing. Of the interaction structures which characterize Maria's therapeutic process, this was the one which was the most positively salient and constant (M = 6.43; SD = 0.81). In this mode of interaction, the therapeutic work seems to be taking place in a fluid way: the patient explores her internal world, the therapist helps the patient to become aware of avoided feelings, and the dialog concentrates on the patient's view of herself. The exploration, through introspection, of unconscious aspects or aspects which are unknown by the self itself, is the basis of the work of the patient in psychoanalytic therapy, being the examination of the attempt, on the part of the patients, to avoid disturbing thoughts and feelings - which is one of the specific factors of the psychodynamic technique (Shedler, 2010). We understand that this interaction structure represents the psychodynamic factor of the therapeutic process in question. It is possible that its striking presence in Maria's treatment may be an explanatory factor for the significant changes that the patient presented at the end of her treatment and during the follow-up undertaken.

It is emphasized, however, that the psychodynamic factor cannot be considered independently of the other factors of the process. Combinations of significant interventions and support interventions, which are characteristic of the brief psychodynamic psychotherapies (Town, McCullough, & Hardy, 2012; Yoshida, 2012), were found in Maria's case. Although the identification of the mechanisms of therapeutic action still represents a challenge for researchers, there is evidence that psychotherapists' flexibility to provide interventions which are adjusted to their patients is beneficial for the results of the psychodynamic psychotherapies (Owen & Hilsenroth, 2014). This seems to have occurred in this case.

Through the analysis of the case of Maria, this study presented and illustrated the concept of interaction structure and its operationalization, through the application of Q type factor analysis to the evaluations of the therapeutic process obtained with the PQS. Generally speaking, the study showed that it is possible to identify patient-therapist interaction structures in brief psychotherapies, using empirical procedures previously consolidated in the study of the process of long-term psychotherapies. The structures found reflect the different modalities of patient-therapist relationship which are expressed over the course of the treatment. The analysis of the variation of these structures in Maria's treatment indicates that the modes of interaction are not linear and can be positively or negatively salient in different sessions (such as "resistance", for example), or predominate at some stage of the treatment (such as "expectation of change", for example).

In this successful process of brief psychodynamic psychotherapy, the more accentuated and constant presence of Introspection and Hearing suggests that this mode of interaction was the driving force for the therapeutic action. However: without the analysis of the contribution of the different interaction structures found to treatment progress and results - by using time series analysis, for example - it cannot be asserted whether and how this or other structures have contributed to the outcome of the psychotherapy.

As this is a case of a brief psychotherapy, Maria's case has a small number of sessions. Although the Q method ensures the normality of the data due to the ipsative scale used, the results of the statistical analyses must be interpreted with some caution, bearing in mind the low number of observations made. Nevertheless, all the sessions were examined, rather than a sample of them. The interaction structures revealed in the study showed clinical validity (they are easily interpretable in the context of the case examined) and are consistent with the global description of the process obtained using the PQS. The replication of the study and other psychotherapies could help to better understand its unique processes, as well as the processes which are common to various cases.

We believe that this study, when examined together with those already undertaken with long-term psychotherapies, shows that therapist and patient influence each other mutually and develop modes of interaction which are repeated over the course of the treatment. As a consequence, we consider that studying an isolated aspect of the process (for example, a specific intervention such as interpretation) in relation to another (for example, the patient's emotional states) can lead to the false premise of a direct influence of one element of the dyad on the other. On the other hand, examining the nature of the dyad's interaction, one breaks with the patient and therapist dichotomy and extends the ability to understand what takes place in the privacy of the therapeutic encounter. In this way, it is possible to distinguish the "live" process, this shared field or space which is created and re-created by both, patient and therapist, in relationship to each other.

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• National Council for Scientific and Technological Development (CNPq; Grant # 401268/2011-0) and Foundation for Research Support of the State of Rio Grande do Sul (FAPERGS; Grant # 12/1551-6).

Publication Dates

• Publication in this collection
  May-Aug 2016

History

• Received
  24 Mar 2015
• Reviewed
  01 Aug 2015
• Accepted
  27 Aug 2015