ORIGINAL ARTICLE
Therapeutic Interventions Related to Outcome in Psychodynamic
Psychotherapy for Anxiety Disorder Patients
Jenelle Slavin-Mulford, MA,* Mark Hilsenroth, PhD,† Joel Weinberger, PhD,† and Jerold Gold, PhD†
Abstract: This is the first study with acceptable inter-rater reliability to
examine specific therapeutic techniques related to change in anxiety disorder
patients during short-term psychodynamic psychotherapy. The study first
examined the effectiveness of short-term psychodynamic psychotherapy and
results showed significant and positive pre-/post-treatment changes on both
patient and independent clinical ratings for anxiety, global symptomatology,
relational, social, and occupational functioning. Likewise, the majority of
patients (76%) reported anxiety symptoms within a normal distribution at
termination. Importantly, psychodynamic interventions rated early in treat-
ment (third/fourth session) were positively related to changes in anxiety
symptoms. Further, results showed that several individual psychodynamic
techniques were meaningfully related to outcome including (1) focusing on
wishes, fantasies, dreams, and early memories; (2) linking current feelings or
perceptions to the past; (3) highlighting patients’ typical relational patterns;
and (4) helping patients to understand their experiences in new ways.
Clinical applications are discussed.
Key Words: Psychodynamic psychotherapy, anxiety, technique, STPP,
CPPS.
(J Nerv Ment Dis 2011;199: 214 –221)
A nxiety disorders are the most prevalent mental disorders in the
United States (Fonagy et al., 2005) and are associated with
severe impairments in functioning. As a result, they have significant
emotional and financial costs on personal and societal levels (Kes-
sler et al., 2001; Milrod et al., 2007; Siev and Chambless, 2007).
Psychodynamic therapy has a well-articulated model of psychother-
apeutic change for anxiety (ANX) and has been found to be both
effective and efficacious (e.g., Abbass et al., 2006; Crits-Christoph
et al., 1996; Ferrero et al., 2007; Milrod et al., 2001; Milrod et al.,
2007; Wiborg and Dahl, 1996). However, there is limited empirical
research on the specific treatment factors related to change in
psychodynamic therapy for ANX disorders.
One of the only studies to examine mechanisms of change
found that improvements in self-understanding of interpersonal
patterns predicted decreases in ANX in psychodynamic therapy, but
not in cognitive-behavioral (CB) therapy (Connolly Gibbons et al.,
2009). In discussing these findings, the authors conclude that addi-
tional research should examine the specific therapeutic interventions
that are related to change mechanisms. However, the only past study
to examine the relationship of therapeutic techniques to change in
ANX disorder patients receiving psychodynamic therapy had inad-
equate reliability (intraclass correlation coefficient 关ICC兴 ⬍0.40;
Klein et al., 2003). Thus, it cannot be interpreted meaningfully.
*Massachusetts General Hospital & Harvard Medical School, Boston, Massachu-
setts; and †Derner Institute of Advanced Psychological Studies, Adelphi
University, Garden City, New York.
Send reprint requests to: Jenelle Slavin-Mulford, MA, The Psychological Evalu-
ation and Research Laboratory (PEaRL), Massachusetts General Hospital &
Harvard Medical School, One Bowdoin Square, 7th Floor, Boston, MA
02114. E-mail: jenelle.slavin@gmail.com.
Copyright © 2011 by Lippincott Williams & Wilkins
ISSN: 0022-3018/11/19904-0214
DOI: 10.1097/NMD.0b013e3182125d60
214 | www.jonmd.com The Journal of Nervous and Mental Disease • Volume 199, Number 4, April 2011
This lack of empirical support for treatment interventions
related to change is not unique to psychodynamic therapy. In fact,
there have only been a few studies to examine the specific treatment
strategies for change in CB therapy for ANX and the results from
these studies are mixed and at times counter-intuitive (Borkovec and
Costello, 1993; Connolly Gibbons et al., 2009; Stangier et al., 2010).
For example, Borkovec and Costello (1993) found that the fre-
quency with which patients practiced relaxation and the level of
ANX they experienced during training negatively correlated with
improvement on some ANX scales. In line with these empirically
confusing findings, there has been disagreement surrounding the
explanations for how and why desensitization and exposure therapy
work (Tryon, 2005).
Thus, despite well-articulated models of psychotherapeutic
change for ANX, there are few empirical studies which demonstrate
that the proposed technique aspects of change account for the effects
of treatment (Connolly Gibbons et al., 2009). This is problematic
given that an understanding of specific therapeutic aspects of change
would provide opportunities for improving current treatments. The
aim of the current study is to begin filling in this gap.
Because change mechanisms are only important if the
changes are occurring as a result of treatment, this study starts by
examining treatment credibility, fidelity, satisfaction, and effective-
ness of short-term psychodynamic psychotherapy (STPP) for ANX.
In line with past research (Crits-Christoph et al., 1996; Milrod et al.,
2001), post-treatment changes from initial assessment across differ-
ent domains of functioning (i.e., ANX, global distress, interpersonal,
social, and occupational functioning) were expected to be moderate
(d ⬎ 0.5) to large (d ⬎ 0.8) in effect (Cohen, 1988). Next, the study
explores changes in ANX symptoms at the individual patient level.
It is the first psychodynamic study in this area to use the most
conservative clinical significance methodology in this process (Ja-
cobson and Truax, 1991; Jacobson et al., 1999). Finally, the rela-
tionship between therapist techniques and improvements in ANX is
examined to better understand the process of change in this psy-
chodynamic treatment. To rule out whether interventions from
alternate models of treatment can explain changes within the current
study, both psychodynamic and CB interventions are examined in
relation to improvement in ANX.
METHOD
Participants
Participants were drawn from patients who were consecu-
tively admitted for individual psychotherapy to the psychodynamic
psychotherapy treatment team (PPTT; Hilsenroth, 2007) at a com-
munity outpatient psychological clinic. Of the 100 patients who
began treatment in the larger study during this time period, 25 were
diagnosed with an ANX disorder, 4 withdrew from treatment, and
21 completed treatment (84%). Importantly, all patients were ac-
cepted into treatment regardless of disorder or comorbidity.
Of the 21 patients who completed treatment, 3 were males
and 18 were females. Of the total, 15 were single, 5 were married,
and 1 was divorced. The mean (M) age for the current sample was
27.67 years with a standard deviation (SD) of 10.05. The range of
The Journal of Nervous and Mental Disease • Volume 199, Number 4, April 2011
DSM-IV Axis I ANX spectrum disorders in the patient sample
included generalized ANX disorder (GAD; n ⫽ 12), posttraumatic
stress disorder (n ⫽ 4), ANX Not Otherwise Specified (NOS) (n ⫽
4), and panic disorder (n ⫽ 1). Fourteen of these individuals were
also diagnosed with a DSM-IV personality disorder and 4 others had
(subclinical) personality disorder features or traits. Six patients
entered treatment having used anxiolytic and/or antidepressant med-
ication continuously for at least 3 months prior to beginning psy-
chotherapy and then subsequently through their course of treatment.
Treatment
Treatment consisted of once or twice weekly sessions of
STPP. The decision about frequency of sessions was decided col-
laboratively between patient and therapist through a consideration of
the patient’s needs. Sessions were 50 to 60 minutes in length.
Treatment was organized, aided, and informed (but not prescribed)
by the technical guidelines delineated in 5 treatment manuals (Book,
1998; Luborsky, 1984; McCullough et al., 2003; Strupp and Binder,
1984; Wachtel, 1993). Additional technical material specific to the
STPP treatment of ANX (Crits-Christoph et al., 1995) was actively
integrated into the treatment of these patients. Key features of the
STPP model include (Blagys and Hilsenroth, 2000) (1) Focus on
affect and the expression of emotion; (2) The identification of
patterns in actions, thoughts, feelings, experiences, and relationships
with these patterns being explored/formulated using the core con-
flictual relationship theme (CCRT) format (Luborsky and Crits-
Christoph, 1997); (3) Emphasis on past experiences; (4) Focus on
interpersonal experiences; (5) Emphasis on the therapeutic relation-
ship/alliance; (6) Exploration of wishes, dreams, or fantasies; and
(7) Exploration of attempts to avoid topics or engage in activities
that may hinder the progress of therapy. In addition to these areas of
treatment focus, case presentations and symptoms are conceptual-
ized in the context of interpersonal/intrapsychic conflict (Luborsky
and Crits-Christoph, 1997). Finally, when a termination date is set,
this becomes a frequent area of intervention. Issues related to the
termination are also often linked to key interpersonal, affective, and
thought patterns prominent in that patient’s treatment.
Treatment was not of a fixed duration, but was determined by
the clinician’s judgment, patient’s decision, progress toward goals,
and life changes. Treatment goals were first explored during the
assessment period and a formal treatment plan was reviewed with
each patient in the third psychotherapy session. This treatment plan
was then subsequently reviewed in the 10th, 24th, 40th, 60th, and
80th session for changes, additions, or deletions. Reassessment of
patient functioning on a standard battery of outcome measures, as
well as process ratings, were completed by patients and therapists
immediately after selected sessions prior to these review points. At
the end of treatment, all patients completed an exit evaluation. Also,
all sessions in these treatments were videotaped, not just the coded
sessions of this study’s participants. Finally, all patients included in
the present analyses had attended a minimum of 9 sessions and had
completed, at least, a ninth session reassessment battery. The mean
number of sessions attended by these 21 patients was 29 (SD ⫽ 15)
and the median was 24. The maximum number of sessions attended
by a patient was 64.
Therapists
Fourteen advanced graduate students (6 men and 8 women),
enrolled in an American Psychological Association approved clini-
cal psychology PhD program, were trained in the use of STPP using
the texts described earlier. Of these therapists, 2 treated 3 study
patients, 3 treated 2 study patients, and 9 treated 1 study patient.
Each therapist received a minimum of 3.5 hours of supervision per
week (i.e., 1.5 hours individually, and 2 hours in a group treatment
team meeting) on the therapeutic model, conceptualization, process,
© 2011 Lippincott Williams & Wilkins
STPP and Anxiety
interpretation, and clinical interventions from a PhD-licensed psy-
chologist with extensive training in STPP. Individual and group
supervision focused heavily on the review of videotaped case
material and technical interventions (a more detailed description of
this training process is given in Hilsenroth et al., 2006).
Assessment
The assessment process was designed to assess ANX symp-
tomatology, global distress, interpersonal, social, and occupational
domains using a semi-structured clinical interview and standardized
measures. These various domains of functioning were assessed from
both clinician (i.e., therapist and external rater) and patient self-
report. Measures assessing symptomatic distress as well as interper-
sonal, social, and occupational functioning during pretreatment
evaluation and again at post-treatment (or when 90% of the treat-
ment was completed, Luborsky et al., 1983) were completed by both
patients and clinicians. A more thorough description of the assess-
ment procedures (semi-structured clinical interview and assessment
measures) and process used with this sample are provided in greater
detail elsewhere (Hilsenroth, 2007).
DSM-IV Rating Scales
Axes I and II diagnoses were based on a semi-structured
clinical interview lasting approximately 1.5 to 2 hours in accordance
with the DSM-IV (American Psychiatric Association, 1994). This
diagnostic interview was conducted at the beginning of the psycho-
logical assessment process and focused on salient therapeutic topics
such as presenting complaints, psychiatric history, and medical
history as well as family, developmental, social, educational, and
vocational history. (A more detailed description of this psycholog-
ical assessment process is given in Hilsenroth et al., 2004). Further-
more, an exploration of historical and current relational episodes, a
mental status examination, and an assessment of all DSM-IV symp-
tom criteria for ANX, mood and other relevant disorders were
included in this interview.
The Spearman-Brown correction for a 1-way random effects
model ICC (ICC 关1, 2兴 Shrout and Fleiss, 1979) was calculated to
examine the reliability of DSM-IV Axes I and II diagnoses. Shrout
and Fleiss (1979) report the magnitude for interpreting ICC values
where “poor” ⫽ ⬍0.40, “fair” ⫽ 0.40 to 0.59, “good” ⫽ 0.60 to
0.74, and “excellent” ⫽ ⱖ0.74. The inter-rater reliability for the
classification of ANX disorders for this study was excellent (ICC 关1,
2兴⫽0.88). The inter-rater reliability for the classification of person-
ality pathology across 3 dimensions is as follows: (a) presence of a
personality disorder, (b) presence of subclinical traits/features, and
(c) absence of a personality disorder has also been previously
reported for this project to be in the excellent range (i.e., ICC ⬎0.74)
(Hilsenroth et al., 2007; Peters et al., 2006).
Each patient was also rated on the 3 Axis V global rating
scales: Global Assessment of Functioning scale (GAF; American
Psychiatric Association 关APA兴, 1994 关pp 32兴), Global Assessment
of Relational Functioning scale (GARF; APA, 1994 关pp 758兴), and
Social and Occupational Functioning Scale (SOFAS; APA, 1994 关pp
761兴). DSM-IV Axis V therapist ratings (i.e., on a scale of 0 –100)
were based on the level of functioning of patients at the time of
assessment prior to beginning treatment. At the different treatment
review points, therapists made routine ratings of these DSM-IV
rating scales (GAF, GARF, and SOFAS) based on the patients’ level
of functioning at that time. An independent rater scored all rating
scales (e.g., GAF, GARF, and SOFAS) for each participant after
viewing a videotape of the clinical interview/feedback sessions,
reassessment sessions, and those sessions or treatment review rep-
resentative of when 90% of the psychotherapy had been completed.
For all cases, scoring of the scales by the second rater was completed
without the knowledge of patient self-report data, and the assessing
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Slavin-Mulford et al. The Journal of Nervous and Mental Disease • Volume 199, Number 4, April 2011
clinician’s ratings for the GAF, GARF, and SOFAS. Spearman-
Brown correction for a 1-way random effects model ICC (ICC 关1,
2兴) was calculated for the study sample to examine the reliability of
the mean score for each DSM-IV Axis V scale. The GAF, GARF,
and SOFAS scales were all found to be in the “excellent” range
(Shrout and Fleiss, 1979, ICC ⬎0.74). Additional details regarding
the reliability data of these DSM-IV scales and aspects of related
research design procedures are given in Hilsenroth et al. (2000) and
Peters et al. (2006).
Brief Symptom Inventory
The Brief Symptom Inventory (BSI) is a 53-item self-report
inventory that assesses symptom distress in a number of different
domains/problem areas using a Likert scale of 0 (not at all) to 4
(extremely). The psychometric properties, reliability, and validity of
this measure, specific symptom subscale scores as well as a sum-
mary score, the Global Severity Index are provided in the manual
(Derogatis, 1994). Given the specific aims of this investigation, we
chose to use 3 subscales from this measure, the ANX, depression
(DEP), and interpersonal sensitivity (I-S) subscales. The mean ANX
for a normal population (n ⫽ 719 non-patients) was found to be 0.35
(SD ⫽ 0.45) and test-retest reliability over a 1-week period using an
outpatient sample was 0.79 (Derogatis, 1994). The mean DEP for a
normal population (n ⫽ 719 non-patients) was found to be 0.28
(SD ⫽ 0.46) and test-retest reliability over a 1-week period utilizing
an outpatient sample was 0.84 (Derogatis, 1994). The mean I-S for
a normal population (n ⫽ 719 non-patients) was found to be 0.32
(SD ⫽ 0.48) and test-retest reliability over a 1-week period utilizing
an outpatient sample was 0.49 (Derogatis, 1994).
Target Complaint
At the third session and again at the end of treatment, patients
were provided a questionnaire that asked them to rate on a scale of
1 (not at all) to 7 (very much), “To what extent have your original
complaints or symptoms improved?”
Social Adjustment Scale
The Social Adjustment Scale (SAS; Weissman and Bothwell,
1976) is a 42-item self-report measure that assesses social adjust-
ment in major areas of social/occupational functioning. This mea-
sure contains a summary score, the Global Adjustment Score
(SASG), which is considered an overall adjustment measure of
social/occupational functioning.
Treatment Fidelity
The Comparative Psychotherapy Process Scale (CPPS;
Hilsenroth et al., 2005) is a descriptive measure of psychotherapy
process designed to assess therapist activity and psychotherapy
techniques that are used and occur during the therapeutic hour.
Developed from an extensive empirical review of the compara-
tive psychotherapy process literature (Blagys and Hilsenroth,
2000; Blagys and Hilsenroth, 2002), the scale consists of 20
items to be rated on a 7-point Likert Scale ranging from 0 (“not
at all characteristic”), 2 (“somewhat characteristic”), 4 (“charac-
teristic”), through 6 (“extremely characteristic”). A more thor-
ough description of the development, procedures, reliability, and
validity of the CPPS is reported elsewhere (Hilsenroth et al.,
2005; Hilsenroth, 2007).
One unique feature of the items on the CPPS is that they were
derived from empirical studies comparing and contrasting psy-
chodynamic-interpersonal (PI) and CB-oriented approaches to treat-
ment. This measure consists of the following 2 subscales: a PI
subscale (PI; 10 items) and a CB subscale (CB; 10 items). The PI
subscale measures the 7 domains of therapist activity previously
described as key features of the STPP treatment model (Blagys and
Hilsenroth, 2000). The CB subscale consists of items that are
216 | www.jonmd.com
significantly more characteristic of CB-oriented therapy (Blagys and
Hilsenroth, 2002). Items include (1) Emphasis on cognitive or
logical/illogical thought patterns and belief systems; (2) Emphasis
on teaching skills to patients; (3) Assigning homework to patients;
(4) Providing information regarding treatment, disorder, or symp-
toms; (5) Direction of session activity; and (6) Emphasis on future
functioning.
Videotapes of an early treatment session (third/fourth) for
each patient were arranged in random order and entire sessions were
watched/rated by 2 judges independently. Immediately after viewing
a videotaped session, judges independently completed the CPPS.
Also, each subscale (PI and CB) was coded in random order.
Regular reliability meetings were held during the coding process to
prevent rater drift. (For a more detailed description of this rater
training process see Stein et al., 2010.) The reliability and clinical
validity of the CPPS have been well established, and we have
recently reported on the excellent inter-rater reliability and internal
consistency of the CPPS, as well as significant results on 6 separate
validity analyses conducted across several different contexts and
samples (Hilsenroth et al., 2005; Hilsenroth, 2007). The CPPS data
we use in the current study is derived from these recent reports,
follows procedures detailed there, and is rated by trained external
raters who have demonstrated the ability to rate these individual
techniques in the good (ICC, 0.60 – 0.74; Shrout and Fleiss, 1979) to
excellent range (ⱖ0.75; Shrout and Fleiss, 1979). In addition, all
Spearman-Brown corrected mean ICCs for the individual CPPS-PI
and CPPS-CB techniques were also in the excellent range (and
thus may be examined individually) as were the ICCs for the
CPPS-PI and CPPS-CB scale scores. Finally, with regard to the
specific subset of sessions used in the current study, the inter-
rater reliability, ICC, was in the excellent range (CPPS-PI ⫽ 0.86
and CPPS-CB ⫽ 0.78).
RESULTS
Treatment Credibility
After the socialization interview (Luborsky, 1984) and col-
laborative feedback session, but before treatment started, patients
answered 2 questions regarding their confidence in the treatment
they were to receive. They answered these questions a second time
at the end of the third session after reviewing the formal treatment
plan. These questions were “I feel that the things I do in therapy will
help me to accomplish the changes I want,” and “How confident do
you feel that through your own efforts and those of your therapist
you will gain relief from your problems?” Both were rated on a
7-point Likert scale ranging from 1 (never) to 7 (always). After the
assessment feedback session, prior to treatment, the mean (5.62) and
SD (1.4) were the same for both questions. When patients rated their
confidence in their treatment again at the end of the third session, the
mean scores for the first and second questions was 5.5 (SD ⫽ 1.4)
and 5.7 (SD ⫽ 1.2), respectively. These results indicate, with a score
of 5 being labeled as “often” and a score of 6 labeled as “very often,”
that patients were quite confident that this treatment would be
helpful.
Treatment Fidelity
Ratings of therapist activity were made on both the CPPS-PD
and CPPS-CB subscales for early session (third/fourth). The mean
CPPS-PD score for early session was 3.31 (SD ⫽ 0.55); the mean
CPPS-CB score for early session was 1.28 (SD ⫽ 0.64). This
difference in the 2 models of therapeutic focus/activity was signif-
icant (t ⫽ 10.06, p ⬍ 0.0001) and demonstrated a very large effect
(d ⫽ 3.49).
© 2011 Lippincott Williams & Wilkins
The Journal of Nervous and Mental Disease • Volume 199, Number 4, April 2011 STPP and Anxiety

TABLE 1. Comparison of Pre- to Post-Treatment Changes for Outcome Scales (N ⫽ 21)

Pretreatment Post-treatment Effect Sizea
Outcome Scale M SD M SD t p d g r
Anxiety Symptoms
BSI-ANXb 1.57 0.80 0.83 0.90 ⫺5.19 0.0001 0.89 0.85 0.40
Target complaintc 4.24 1.22 5.40 1.28 4.24 0.0002 0.95 0.91 0.42
Global Symptom Distress
GAFd 58.21 5.67 66.76 6.44 7.16 0.0001 1.44 1.38 0.58
GSIe 1.29 0.59 0.79 0.52 ⫺5.88 0.0001 0.92 0.88 0.41
DEPf 1.60 0.93 0.96 0.62 ⫺3.74 0.0006 0.83 0.79 0.38
Interpersonal Distress
GARFg 48.02 11.29 59.88 8.22 3.66 0.0008 1.23 1.18 0.52
I-Sh 1.34 0.80 1.11 0.63 ⫺1.79 0.04 0.33 0.31 0.16
Social/Occupational-Functioning
SOFASi 60.12 8.88 66.90 7.67 2.96 0.004 0.84 0.80 0.38
SASGj 2.18 0.39 1.96 0.46 ⫺1.84 0.04 0.53 0.51 0.25
a
Cohen d, utilizing pooled standard deviations from pre- and post-treatment (Cohen, 1977).
b
Brief Symptom Inventory Anxiety subscale.
c
Patient reported estimate of improvement on original complaint or symptoms.
d
Global Assessment of Functioning scale.
e
Brief Symptom Inventory Global Severity Index.
f
Brief Symptom Inventory Depression subscale.
g
Global Assessment of Relational Functioning scale.
h
Brief Symptom Inventory Interpersonal Sensitivity subscale.
i
Social and Occupational Functioning Assessment scale.
j
Global Adjustment Score of the Social Adjustment scale.

Treatment Satisfaction
At the completion of treatment, each patient was asked to rate
their level of satisfaction with the psychotherapy on a ⫺4 to ⫹4
Likert scale for 3 questions. These questions were “How unhelpful
or helpful has therapy been for you?”; “Overall, how satisfied or
dissatisfied have you been with therapy?”; and “In general, how
productive do you feel the sessions have been with your therapist?”
The mean scores on these treatment satisfaction questions were very
positive (3.2, 3.3, and 3.3), with SDs of 1.1, 0.91, and 1.0, respec-
tively, indicating that most patients responded with one of the 2
highest possible ratings, either a 3 or 4.
Evaluation of Treatment Changes
Paired t tests (2-tailed, p ⬍ 0.05) were used to examine all
pre- and post-treatment changes (or at which approximately 90% of
the treatment was completed, Luborsky et al., 1983). The outcome
results are given in Table 1 for the 9 outcome scales organized in the
conceptual categories of ANX symptoms, global distress, interper-
sonal distress, and social/occupational-functioning. Results revealed
statistically significant change in all 4 of the conceptual outcome
categories. Treatment change in ANX symptoms, as assessed by
patient self-report, was shown to significantly decrease in this group
of treated patients (p ⬍ 0.0002), and these changes were considered
to be large in effect (d ⬎ 0.8). All 3 measures of global symptomatic
distress, GAF (therapist and external rater), Global Severity Index
(patient self-report), and DEP (patient self-reported DEP), were
shown to significantly decrease over the course of treatment as well
(p ⬍ 0.0006). These changes were also considered to be large in
effect (d ⬎ 0.8). Likewise measures of interpersonal distress, GARF
(therapist and external rater), and I-S (patient self-report), were
shown to significantly decrease over the course of treatment as well
(p ⬍ 0.05). These changes ranged from small (I-S d ⫽ 0.33) to large
effects (GARF d ⫽ 1.23). The two social/occupational functioning
scales, SASG (patient self-report) and SOFAS (therapist and exter-
nal rater), also showed significant changes (p ⬍ 0.05), and demon-
strated medium and large effects (d ⫽ 0.53 and 0.84, respectively).
Clinically Significant Change in Anxiety Symptoms
The Brief Symptom Inventory Anxiety Subscale (BSI-ANX)
was examined at the individual patient level for clinical significance.
Prior to the calculation of clinical significance information, to
address concerns of pretreatment score regression to the mean, each
of the pretest scores used in this stage of data analysis was adjusted
according to standard psychometric procedures (Speer, 1992). In
this formula, evaluation scores were “true score adjusted” to atten-
uate any regression effects. Reliable Change Index (RCI; Jacobson
and Truax, 1991) scores were then calculated for each variable
(using the adjusted pretest scores). An RCI score exceeding 1.96
suggests that the test score change was psychometrically reliable,
reflected real change, and was not the product of random error (p ⬍
0.05, 2-tail). Each post-treatment test score then was examined to
determine whether it fell below the cutoff score for a functional
distribution, within 2 SDs of the normative mean. Individuals who
met both of these criteria (i.e., reliable change and moved within 2
SD of the normative mean) were considered to have achieved
clinically significant change. RCIs were also examined to determine
whether any individuals reliably deteriorated over the course of
treatment.
All calculations of clinical significance for the BSI-ANX
subscale used the normative mean, SD, and test-retest reliability data
reported in the method. As presented in Table 2, over three-quarters
(76%) of patients who completed treatment had final BSI-ANX
scores in the normal, functional distribution. A third of patients
(33%) also made reliable and clinically significant change on ANX
symptoms. Moreover, none of the patients deteriorated during psy-
chotherapy on the BSI-ANX subscale. Finally, we examined the
distribution of our primary outcome variable BSI-ANX in relation to
Curran et al., (1996) criteria for normality (i.e., Skew ⬍ 2.0,

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TABLE 2. Clinically Significant Change in Anxiety TABLE 4. Individual Psychodynamic-Interpersonal

Symptoms Techniques Related to Change in Anxiety Symptoms
(N ⫽ 20)
Criterion BSI-ANX (N ⴝ 21)a
BSI-ANX-
RCI ⬎1.96b 7 (33%)
Early (Third/Fourth) Session PI BSI-ANX- Residual
Functional distributionc 16 (76%) Therapist Technique RCIa Gainb
Clinical significanced 7 (33%)
Encourages exploration of r ⫽ 0.28 r ⫽ ⫺0.31
Deterioratione 0 (0%) uncomfortable feelings
a
Anxiety subscale of the Brief Symptom Inventory. Links current feelings or perceptions r ⫽ 0.46** r ⫽ ⫺0.48**
b
Number of individuals who reliably improved after adjusting pretest scores for to past
regression to the mean.
c
Number of individuals who fell within 2 standard deviations of the general
Focuses on similarities among r ⫽ 0.35 r ⫽ ⫺0.36
population mean. relationships
d
Number of individuals who reliably improved and fell within 2 standard deviations Focuses on therapist/patient r ⫽ ⫺0.21 r ⫽ 0.22
of the general population mean. relationship
e
Number of individuals who reliably deteriorated during treatment.
RCI indicates Reliable Change Index. Encourages patient to experience r ⫽ 0.11 r ⫽ ⫺0.12
feelings
Addresses avoidance or shifts in r ⫽ ⫺0.10 r ⫽ 0.11
mood
TABLE 3. Treatment Techniques Related to Change in Suggests alternative ways to r ⫽ 0.45** r ⫽ ⫺0.46**
Anxiety Symptoms (N ⫽ 20) understand experiences not
previously recognized by patient
BSI-ANX-RCIa BSI-ANX-Residual Gainb
Identifies recurrent patterns in actions, r ⫽ 0.43* r ⫽ ⫺0.43*
CPPS-PIc r ⫽ 0.46** r ⫽ ⫺0.51** feelings, or experiences
CPPS-CBd r ⫽ 0.03 r ⫽ ⫺0.03 Allows patient to initiate discussion r ⫽ 0.14 r ⫽ ⫺0.15
Note: For BSI-ANX-Residual Gain correlations negative values indicate higher Focuses on wishes, fantasies, dreams, r ⫽ 0.53** r ⫽ ⫺0.54***
amounts of CPPS technique with lower scores (ie, more adaptive) on the BSI-ANX- early memories
Final (controlling for BSI-ANX-Evaluation scores). Also, only 20 patients were used in
the technique analyses because videotape was unavailable for 3rd/4th session for one of Note: For BSI-ANX-Residual Gain correlations negative values indicate higher
the patients. amounts of CPPS technique with lower scores (i.e., more adaptive) on the BSI-ANX-
a
Reliable Change in the Brief Symptom Inventory Anxiety subscale after adjusting Final (controlling for BSI-ANX-Evaluation scores).
a
pretest scores for regression to the mean and measurement error. Reliable Change in the Brief Symptom Inventory Anxiety subscale after adjusting
b
Residual Gain in the Brief Symptom Inventory Anxiety subscale after controlling pretest scores for regression to the mean and measurement error.
b
for initial pretreatment scores. Residual Gain in the Brief Symptom Inventory Anxiety subscale after controlling
c
Comparative Psychotherapy Process scale: Psychodynamic—Interpersonal Pro- for initial pretreatment scores.
cess subscale from a session early in treatment (third/fourth). *p ⫽ 0.06.
d
Comparative Psychotherapy Process scale: Cognitive-Behavioral Process subscale **p ⬍ 0.05.
from a session early in treatment (third/fourth). ***p ⫽ 0.01.
*p ⫽ 0.06.
**p ⬍ 0.05.
***p ⫽ 0.01. between a patient achieving reliable change (no ⫽ 0, yes ⫽ 1), with
amount of early session technique, were found to indicate a trend
toward significance for CPPS-PI (rpb ⫽ 0.42, p ⫽ 0.07) and
Kurtosis ⬍ 7.0), and found that our sample’s BSI-ANX-Evaluation, nonsignificant for CPPS-CB (rpb ⫽ 0.05, p ⫽ 0.82).
BSI-ANX-Final, BSI-ANX-Raw Change, and BSI-ANX-RCI scores To better understand the specific aspects of PI and CB
were all well within these limits (all variables Skew ⬍1.61, Kurtosis techniques that were most related to subsequent changes in ANX
⬍2.24). symptoms, we undertook post hoc, exploratory analyses to address
this issue. The results of these bivariate pairwise correlations re-
Treatment Process and Outcome Relationship vealed that 3 CPPS-PI items were significantly related to the crite-
The next analyses in this study examined the relationship rion variable BSI-ANX-RCI (Table 4). The first was “The therapist
between therapist activity and technique early in treatment with encourages discussion of patient’s wishes, fantasies, dreams, or
changes in post-treatment ANX symptomatology. Pretreatment early childhood memories (positive or negative)” (r ⫽ 0.53, p ⫽
scores of ANX symptoms were adjusted for regression to the mean 0.02). The second was “The therapist links the patient’s current
prior to these analyses as part of the previously described RCI feelings or perceptions to experiences of the past” (r ⫽ 0.46, p ⫽
methodology. The mean CPPS PI and CB subscale scores from a 0.04). The third was “The therapist suggests alternative ways to
session early in treatment (third/fourth session) was tabulated across understand experiences or events not previously recognized by the
all patient/therapist dyads. The amount of therapist technique early patient” (r ⫽ 0.45, p ⫽ 0.04). In addition, 2 items approached
in treatment was then examined in relation to that patient’s reliable significance. Specifically, “The therapist identifies recurrent patterns
degree of change in ANX symptomatology. in the patient’s actions, feelings, and experiences” (r ⫽ 0.43, p ⫽
As reported in Table 3, results demonstrated that higher levels 0.06) and “The therapist focuses attention on similarities among the
of PI techniques early in the treatment were significant and posi- patient’s relationships repeated over time, settings, or people” (r ⫽
tively related to the amount of reliable change in patient self- 0.35, p ⫽ 0.13) were positively correlated with improvement on the
reported changes in ANX symptoms (r ⫽ 0.46, p ⫽ 0.04). These criterion variable BSI-ANX-RCI. Consistent with our initial finding
findings also revealed that CB interventions early in this psychody- that there was not a significant correlation between the CB subscale
namic treatment were not significantly related to the amount of and subsequent change in ANX symptoms, the results of pairwise
reliable change in patient self-reported changes in ANX symptoms correlations revealed that none of the individual CPPS-CB items
(r ⫽ 0.03, p ⫽ 0.91). In addition, point biserial correlations (rpb) were significantly related to BSI-ANX-RCI (p ⬎ 0.05).

218 | www.jonmd.com © 2011 Lippincott Williams & Wilkins

The Journal of Nervous and Mental Disease • Volume 199, Number 4, April 2011
In addition to evaluating specific therapeutic techniques in
relation to BSI-ANX-RCI, we also conducted further post hoc,
exploratory analyses using residual gain scores (adjusting post-test
scores in relation to initial levels of pretest scores) for the primary
outcome variable BSI-ANX (partial correlations of the CPPS vari-
ables with BSI-ANX-Final scores, controlling for BSI-ANX-Eval-
uation scores). These values are presented in the second column in
Tables 3 and 4. It is important to note that negative values for these
correlations are expected with regard to relationship between CPPS
and BSI-ANX scores as this indicates higher amounts of technique
with lower scores (i.e., more adaptive) on the BSI-ANX-Final
(controlling for BSI-ANX-Evaluation scores). As one can observe,
both sets of these conservative analyses (each controlling for differ-
ent potential sources of error) produced virtually identical results.
Moreover, despite the power limitations regarding levels of statis-
tical significance of our sample size, the magnitude of effects are
especially encouraging. Specifically, according to Cohen’s (1988)
criteria (r ⬎ 0.3 ⫽ medium; r ⬎ 0.5 ⫽ large), the majority of
findings are considered moderate to large effects, and if Hemphill’s
(2003) criteria is used (r ⬎ 0.3 ⫽ large) the majority of effects
would be considered large. This provides further confidence in the
robust nature of these findings.
DISCUSSION
This is one of the first studies to examine treatment fidelity,
credibility, and satisfaction within a naturalistic/effectiveness model
of STPP for ANX disorder patients, and all were found to be high.
Significant adaptive changes were also found in the 4 domains of
ANX symptoms, global symptom distress, interpersonal distress, as
well as social and occupational functioning. Importantly, the major-
ity of these changes were large (d ⬎ 0.80) and consistent with past
research (e.g., Crits-Christoph et al., 1996; Milrod et al., 2001).
Moreover, at termination most patients (76%) reported that their
ANX symptoms were within 2 SDs of the normative mean. This is
similar to or even more encouraging than past psychodynamic (e.g.,
Ferrero et al., 2007; Crits-Christoph et al., 2005; Durham et al.,
1999) and CB therapy (Barlow et al., 1992; Borkovec and Costello,
1993; Brokovec et al., 2002) studies on ANX disorder patients. In
addition, it is important to note that these changes occurred in a
sample where the majority of patients also exhibited Axis II comor-
bidity, a fact that would have led to their exclusion from many prior
studies on the treatment of ANX disorder patients. However, similar
to past CB therapy research on ANX disorders less than half of the
patients in this study (33%) made clinically significant change.
Stewart and Chambless (2009) identified 15 benchmark CB therapy
studies on ANX disorders, 6 of which used Jacobson and Truax full
criteria to examine the percentage of patients who made clinically
significant change (Clark et al., 2006; Kenardy et al., 2003; McLean
et al., 2001; Stangier et al., 2003; Van Oppen et al., 1995; Whittal et
al., 2005). Across all of the cognitive and behavioral conditions in
these studies, an average of 49% of patients who completed treat-
ment made clinically significant change. When intent to treat anal-
yses were used, this average dropped to 41.83%.
In understanding these findings, it is important to recognize
that clinically significant change is the most stringent definition of
improvement. Thus, the fact that 33% of patients made clinically
significant change does not mean that the other 67% of patients
remained unimproved. In fact, the average RCI value for ANX
symptoms among the patients who did not make reliable change, but
who were in the functional distribution at the end of treatment, was
1.22. According to Wise (2004), an RCI of 1.28 can be understood
as “remitted” and an RCI of 0.84 can be understood as “improved.”
This suggests that considerable improvement/remittance was at-
tained with regards to ANX symptoms among the patients in our
© 2011 Lippincott Williams & Wilkins
STPP and Anxiety
study who were in the functional distribution, but who did not meet
the full criteria for clinically significant change.
Importantly, this is the first study, with acceptable inter-rater
reliability, to find a direct link between psychodynamic interventions
and subsequent changes in ANX symptoms. Further, results showed
that several individual PI techniques were meaningfully related to
outcome. These included (1) focusing on wishes, fantasies, dreams,
and early memories; (2) linking current feelings or perceptions to the
past; (3) highlighting patients’ typical patterns; and (4) helping
patients to understand their experiences in new ways. This compi-
lation of techniques fits well with psychodynamic theories for ANX
as well as the empirically supported treatments derived from them
(Crits-Christoph et al., 1996; Milord et al., 2001). Specifically, it is
supportive of the Panic-Focused Psychodynamic Psychotherapy
(PFPP) which emphasizes exploring panic patients’ unconscious
wishes and fantasies, connecting current stressors for panic with
frightening experiences in childhood, and helping patients identify
how thematic patterns in their feelings, behaviors, and relationships
relate to panic (Milrod et al., 1997). The current findings are also
highly consistent with Supportive Expressive therapy (SE) for GAD
which focuses on the CCRT (Luborsky, 1984). The parallels be-
tween the CCRT and the integration of techniques related to ANX
reduction in the current study are striking as the CCRT focuses on
helping patients to gain insight into their wishes and relational
patterns. Furthermore, our finding that there is a positive correlation
between techniques designed to increase understanding in relational
patterns and subsequent improvement in ANX symptoms is also
consistent with prior research. Specifically, past research has dem-
onstrated that improvements in self-understanding of interpersonal
patterns predicted decreases in ANX during psychodynamic therapy
(Connolly Gibbons et al., 2009).
However, it is not being suggested that this set of techniques
used in isolation would constitute a treatment, per se, for ANX
disorder patients. To do so would be a very concrete interpretation
of the data presented here and clinically unsophisticated. What these
data do suggest is that within a psychodynamic model of treatment,
delivered in an optimally responsive manner and where patient
alliance was found to be high (Hilsenroth et al., 2004, 2007), using
these 4 specific interventions at moderate levels (i.e., CPPS mean
scores 3– 4) was related to greater degrees of ANX reduction during
the course of therapy. Thus, the current findings provide support for
accentuating these therapeutic techniques within a comprehensive
approach that is consistent with psychodynamic theory, research,
and practice.
It is also very important to understand the nonsignificant
relationship between CB interventions and change in ANX symp-
toms within the context of this specific study. These findings
indicate that within a study of STPP for outpatient ANX, the very
limited amount of CB interventions used within this larger psy-
chodynamic treatment did not contribute to outcome. This finding
should not be generalized beyond this limited context as several
studies have shown that CB interventions are successful in treating
anxiety (e.g., Stewart and Chambless, 2009). However, this result
does help to clarify that CB interventions were not driving the
change process in this study. As such, our findings imply that there
may be “many paths to the mountain top” and support the rationale
for noninferiority trials using STPP in the treatment of ANX disor-
der patients.
Despite being one of the first studies to examine the change
process in psychodynamic psychotherapy for ANX, there are a few
limitations that should be addressed. First, the study has a small
sample size. However, although more than 21 participants would
clearly have been ideal, it is important to recognize that our sample
size is similar to the average sample size per treatment group in past
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Slavin-Mulford et al. The Journal of Nervous and Mental Disease • Volume 199, Number 4, April 2011
psychodynamic (e.g., Wiborg and Dahl, 1996; Milrod et al., 2001)
and CB therapy (Norton and Price, 2007) studies for ANX. A second
potential objection is that the patient population is an outpatient
sample and thus only has a mild to moderate level of distress in
impairment and functioning. However, it should be noted that our
sample’s pretreatment PAI ANX mean T score of 71 is in the 98th
percentile (Morey, 1991) and our sample’s pretreatment BSI ANX
mean T score of 68 is in the 96th percentile (Derogatis, 1994).
Regarding other issues related to generalizability and external validity,
some might object to our inclusion of the 6 patients who entered
treatment using anxiolytic and/or antidepressant medication in the
analyses. These patients were included because this medication regimen
had been stabilized upon entry to treatment (at least 3 months use) and
remained so throughout the course of treatment (i.e., consistent at each
assessment point), yet these patients still desired additional treatment
beyond medication to address their personal goals.
Other objections to our study might be that there is no control
group and the results are correlational. As such, we cannot conclu-
sively rule out the potential impact of common factors unrelated to
our specific treatment. However, this does not detract from the direct
technique-outcome relationships that were found to be significant.
Also, some may argue that early positive change from baseline to
session 3 or 4 may make it easier to conduct psychodynamic work
and in turn produce spurious correlations between the process
measures and outcome measured from pre to post treatment. Al-
though this is possible, research has demonstrated that process
variables measured very early in supportive-expressive dynamic
psychotherapy, consistent with our approach to treatment and mea-
surement points, significantly predicted change in psychopathology
even when prior change in functioning was partialed out (Barber, et
al., 2000). This prior research, that early process-outcome findings
are not due to significant changes in prior pathology, is further
supported in our data. Specifically, pretreatment global functioning,
GAF (M ⫽ 58.2, SD ⫽ 5.7), was found to be significantly related (r
⫽0.89, p ⬍ 0.0001) to early session functioning, GAF (M ⫽ 59, SD
⫽ 5.2; rated third/fourth session concurrent with CPPS ratings),
demonstrating nonsignificant changes (t ⫽ 1.3, p ⫽ 0.20) and a quite
minimal effect (Hedges g ⫽ 0.14). Thus, although it cannot be
entirely ruled out, it seems unlikely that changes from baseline to
session 3 or 4 are driving the relationship found between our early
process and outcome results.
These limitations notwithstanding, this treatment study is one
of the first to examine specific therapeutic interventions related to
change in the psychodynamic treatment of ANX disorder patients.
Moreover, although our study does not have a control group, our
finding that certain interventions are positively related to a reduction
in ANX symptoms suggests that there are specific techniques in
psychodynamic therapy important to that change process. This is
important as it not only supports the use of psychodynamic
therapy in the treatment of ANX disorders, but it also provides
some suggestions to clinicians about the specific types of tech-
niques they may want to consider accentuating in their work with
this population.
ACKNOWLEDGMENTS
We thank Dr. Andrew Gerber for his comments on an earlier
version of this manuscript.
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