Clinical Psychology Review, Vol. 19, No. 6, pp.

669–685, 1999
Copyright © 1999 Elsevier Science Ltd
Printed in the USA. All rights reserved
0272-7358/99/$–see front matter

PII S0272-7358(98)00080-4

OBJECT RELATIONS THEORY AND

SHORT-TERM DYNAMIC PSYCHOTHERAPY:
FINDINGS FROM THE QUALITY OF OBJECT
RELATIONS SCALE
William E. Piper
University of British Columbia

Scott C. Duncan
University of Alberta

ABSTRACT. This review focuses on the relevance of object relations theory to short-term dy-
namic psychotherapy (STDP). From diverse theoretical and research literatures, a small number
of core theoretical concepts and assessment dimensions are identified. Specific assessment methods
are also highlighted. Research evidence concerning a particular object relations concept (quality
of object relations) and a corresponding interview scale (Quality of Object Relations Scale) that
has emerged from a series of psychotherapy clinical trials is presented in support of the relevance of
object relations theory to STDP. Clinical implications and future research directions are consid-
ered. © 1999 Elsevier Science Ltd

WIDESPREAD INTEREST IN short-term dynamic psychotherapy (STDP), as prac-

ticed in the individual situation, emerged in the 1980s. Part of its appeal has been
practical in nature. STDP has the potential to be both effective and cost-efficient,
which has enhanced its value in the current era of health-care reform. Its short-term
format has also been an appealing practical feature for researchers. Another part of
the STDP’s appeal has been conceptual in nature. It has allowed dynamically oriented
clinicians to retain familiar concepts, such as unconscious processes, intrapsychic con-
flict, transference, interpretation, and insight, while making technical innovations.
During the same period of time there has been emerging interest among clinicians
and researchers in object relations theory. Quite naturally the question of its rele-
vance to STDP has arisen.

Correspondence should be addressed to William E. Piper, Department of Psychiatry, University

of British Columbia, Vancouver, BC V6T 2A1, Canada.

669
670 W. E. Piper and S. C. Duncan

There are a number of ways in which object relations theory is relevant to STDP.
Given the pressure of limited time, there is a need for the patient and therapist to
quickly form a working relationship. A predisposition to form a relatively trusting give-
and-take relationship with an authority figure is most helpful. As therapy progresses
and the demands of STDP increase, the same can be said regarding the patient’s abil-
ity to tolerate the emotionally charged interpersonal situation. Thus, a more mature
level of object relations is a favorable patient selection criterion for STDP. A patient’s
level of object relations can also be viewed as an indicator of overall psychopathology,
which has prognostic relevance for treatment in general. Quality of object relations
theory additionally provides the therapist with a comprehensive means of understand-
ing the patient. It considers affect regulation, self-esteem regulation, use of fantasy
and defenses, as well as relationship patterns. It helps the therapist select a central fo-
cus, integrate here-and-now interaction, and choose appropriate interventions. Again,
it is important that this occurs quickly in the short-term time frame of STDP.
Despite the general relevance of object relations theory to STDP, the application of
specific forms of the theory to the clinical situation has been challenging. Rather than
representing a uniform theory, object relations theory encompasses a number of the-
oretical perspectives, each with its own set of assumptions and metapsychological con-
cepts. Many are difficult to define and operationalize. Consequently, a diverse set of
assessment approaches and methods have been generated to capture object relations
phenomena. Deciding which are the most useful or productive for the clinician and
researcher is not obvious from present knowledge. Research that has investigated the
relevance of object relations theory to STDP is scarce, in particular research that is
based on large samples. Despite the current state of affairs, some lines of research
have produced promising findings. They lend a sense of excitement to the task of dis-
covering knowledge about STDP from the perspective of object relations theory.
The current review first considers a small number of core concepts that character-
ize object relations theory. Next, a range of assessment approaches for the various
concepts are considered and specific methods are described. Then, a particular
method that has been used in a series of clinical trials involving short-term dynamic
psychotherapies is presented and the research evidence is examined. This line of re-
search has generated findings that support the relevance of object relations theory to
STDP. Finally, clinical implications are considered and suggestions for future research
are offered.

OBJECT RELATIONS THEORY

Object relations theory, within the broader context of psychoanalytic thought, has
been a source of lively theoretical discourse and continues to inspire further interest.
From Freud’s early, although imprecise, use of the concept, through the evolution of
his and other’s views on the development and dynamics of the psyche, the object and
object relations have been the subject of fruitful theoretical and clinical elaboration.
General historical perspectives of the theories of object relations have been provided
by Compton (1996), Kernberg (1976, 1985, 1996), and Greenberg and Mitchell (1983).
In the present review, focus is limited to the distinctive conceptual features of the
theories, highlighting their development and place in the overall field. Four core
concepts are: (a) the object; (b) psychological structure; (c) the inner world; and (d)
the dynamic processes of internalization and externalization, which are considered
 Object Relations Theory 671

from a developmental perspective including their influence on day-to-day interper-

sonal relationships. From our perspective, these concepts represent the essence of ob-
ject relations theories.

THE OBJECT IN OBJECT RELATIONS

An object, psychologically distinct and standing in relation to a subject, is a primary
and axiomatic component of all object relations theories. Different functions, dynam-
ics, and roles are accorded the object, but all acknowledge its primacy. As with many
aspects of psychoanalytic theory, the notion of the object has evolved over the years.
Freud (1915/1957) defined the object by placing it in conjunction with the instinc-
tual drive, stating it is “the thing in regard to which or through which the drive is able
to achieve its aim” (p. 65). An object was considered not to have been originally con-
nected with the instinctual drive “but becomes attached to it only in consequence of
being peculiarly fitted to provide satisfaction” (p. 65). Freud also suggested that an ob-
ject is “the most variable thing about an instinct,” that it is “extraneous” and that “the
same object may serve for the satisfaction of several instincts simultaneously” (p. 65).
For Freud, the object was secondary to the instinctual drive. In fact, one’s connections
to the human environment were not regarded as inherent, but created out of patterns
of instinctual gratification by others.
Object relational theorists take a different stance regarding the object. Fairbairn
(1952) represents an object-based perspective that is antithetical to that of Freud. He
writes that “impulses cannot be considered apart from the endopsychic structures
which they energize and the object relationships they enable these structures to estab-
lish” (p. 85), and “‘instincts’ cannot profitably be considered as anything more than
forms of energy which constitute the dynamic of such endopsychic structures” (p. 85).
His point of view represents the other extreme of the theoretical pole in conceptualiz-
ing the importance and role of the object in the psyche.
By way of clarifying the ongoing theoretical utility of the object concept, Greenberg
and Mitchell (1983) make the following four points. The first is that the term object
can refer both to a real person in the external world and to the internally established
image of that person, thus accommodating inside and outside. The second point con-
cerns the variability of the object. It may be alive or dead, active or static, and benign
or malignant. Their third point refers to the phenomenological tangibility of the ob-
ject. The object is experienced as real. Their fourth point refers to the manipulability
and modifiability of the object, which occurs through certain operations (e.g., de-
struction and repair). These features provide object relations theories with flexibility
and allow their ease of application.
Moore and Fine (1990) suggest that the term object relations be reserved for the vicis-
situdes of intrapsychic object representations but that they must be inferred from the
basis of experience. Most of these ideas about the object can easily be related to expe-
rience. They facilitate our understanding of complex phenomena inherent in human
development and relationships.

STRUCTURE AND RELATIONSHIPS

Object relations theory suggests that it is the experience of relationships with external
others that forms the structural constituents of the psyche. According to Rapaport
672 W. E. Piper and S. C. Duncan

and Gill (1959), the structures are “inferred from behavior,” have “a slow rate of
change,” “are configurations within which, between which, and by means of which
mental processes take place,” and “are hierarchically ordered” (pp. 802–804). Implied
is the view that complex psychological processes create structures that have further ef-
fects on process.
Blanck and Blanck (1986) suggest that “early structures consist of various internal-
izations, more primitive forms of defense, [and] early forms of connection with ob-
jects and object images” (p. 44). They consider these structures to “constitute the very
warp and woof of the material...not only of the transferences [but of]...early forms of
object relations” (p. 44). They also state that “self and object images are built out of
myriad daily affective experiences that begin on day one or before” (p. 50) and that
“structure builds by consolidation of single experiences into ‘islands’ and ‘conti-
nents’” (p. 51).

THE INNER WORLD

Construing an inner world as a location for object relations creates the crucial distinc-
tion between inside and outside and delimits a boundary across which various ex-
changes are hypothesized to occur. This allows for descriptions of ways in which struc-
turalization occurs as a result of vital interactions between outside relationships with
real-world objects and their internal images and representations. Freud (1938/1957)
suggests that a shift occurs developmentally wherein an individual’s objects, originally
outside of him or her, come to be located in the internal world. His description of this
process is that “a portion of the external world has, at least partially, been abandoned
as an object and has instead, by identification, been taken into the ego and thus be-
come an integral part of the internal world” (p. 205). Sandler and Rosenblatt (1962)
consider the representational world to be made up of the multitude of “images and
organizations of [the person’s] internal as well as external environment” (p. 132). It is
in the representational world that the collection of stable object images correspond-
ing to the outside world are kept. These authors differentiate between the image and
representation of an object. An object image is one of many that make up an infant’s
experience of another (the gratifying mother, the frustrating mother, and happy
mother, etc.), and an object representation is formed gradually out of sequential ac-
cretions of these various images (the mother in her experiential entirety).
Beres and Joseph (1970) contend that “mental representations form the uncon-
scious basis of all conscious mental activities” (p. 4). Blanck and Blanck (1986) delin-
eate numerous functions of object representations within the representational world.
These include provision of a feeling of safety, establishment of internal regulatory
functions, promotion of ego autonomy, character development, superego develop-
ment, provision of an ego ideal, resolution of oedipal wishes, and progression to the
latency period of development.

PROCESSES OF INTERNALIZATION AND EXTERNALIZATION

The nature of the interaction between inside and outside is enhanced by explanations
of the ways in which outer experience comes to be represented internally. Descrip-
tions of the processes of internalization and externalization clarify the ways in which
 Object Relations Theory 673

inner and outer experiences become mutually influential on the development of the
psyche. Phenomena such as transference and countertransference, as well as assess-
ments of quality of object relations that focus on a person’s actual outside relation-
ships, become understandable when these notions of inside and outside are consid-
ered. The processes whereby phenomenal experiences come to have a location within
the subject are perhaps the most important and fundamental in object relations the-
ory. In this sense an important link is established between inner and outer worlds.
The integrity, quality, and nature of a person’s inner endowment is a function of and
dependent on the nature of the complex interactions with real external objects, which
occur throughout one’s development.
Internalization, in fact, occurs via three mechanisms: incorporation, introjection,
and identification, the last being the only observable “clinical manifestation” (Beres &
Joseph, 1970, p. 5). These three mechanisms correspond to increasing levels of self
and object differentiation. They range from a gross overinclusive process to a selective
and precise one.
Incorporation occurs during the early stages of development when there is confu-
sion about what is self and what is other. The accompanying fantasies usually center
around oral themes and imply destruction of the object. Later, incorporative pro-
cesses give way to introjective ones, which are characterized by greater differentiation
between self and object. Aspects of the object that are taken in are drawn into the
growing realm of self-representations. Both self and object representations and the
boundaries between them are strengthened. In the case of identification, aspects of
the other are more selectively taken in. The aspects become integrated with parts of
the self. They contribute directly to the establishment of a core sense of identity.
The whole of the representational world and its contents comes into being via the
repeated oscillations of internalized, externalized, and re-internalized experience.
Conversely, daily relationships are colored to varying degrees by the quality of the in-
ner world as internalizing and externalizing processes have their effect.
Although the core concepts of object relations theory are relatively few in number,
a large number of assessment methods have been developed to measure object rela-
tions phenomena. In part, this is due to the wide range of events that are encom-
passed within the internal and the external worlds of the person. It is also due to the
attempt to elucidate ideas about psychopathology that correspond to the various lev-
els of object relations. This has usually resulted in consideration of additional con-
cepts. In the case of the internal world, this might involve how well differentiated
mental representations are from each other and how well each integrates diverse qual-
ities. In the case of the external world, this might involve how much the person relies
on others for self-identity and how well the person tolerates both positive and negative
qualities in other persons. Whether the focus has been on aspects of the internal or
external worlds, levels of object relations have been construed as ranging from primi-
tive to mature. The more primitive the structure of the internal world or the nature of
external relationships, the more character pathology has been assumed.

OBJECT RELATIONS ASSESSMENT APPROACHES

Assessment methods can be differentiated on several dimensions. These include the
nature of the stimuli presented to the subject, the nature of the responses provided by the
subject, and the degree of inference required to score and interpret the responses. Stim-
674 W. E. Piper and S. C. Duncan

uli range from those that are ambiguous to those that are objective. They include pat-
terns, pictures, vignettes, and questions from interviews and questionnaires. Responses
consist of perceptions, memories, dreams, drawings, autobiographical accounts, and
narrative descriptions of people and relationships. The degree of inference that is re-
quired to score and interpret the responses ranges from minimal to considerable.
As suggested above, methods also differ in their field of focus (i.e., the internal
world or the external world). The former encompasses intrapsychic mental represen-
tations of the self, others, and their relationships, both realistic and fantasized. It is
usually assumed to be inaccessible to consciousness. The latter encompasses the self,
others, and their relationships as external figures and behaviors. They are accessible
to direct observation. Despite the theoretical importance of understanding how one
domain influences the other and their degree of interdependence, few researchers
have attempted to measure both domains and their relationships.
Typical of many areas of psychological research, individual research teams have
tended to use specialized and limited methods over a series of studies. This makes it
difficult to arrive at an integrative view of findings even within the same domain. Re-
cently, however, several reviews have been published that attempt to organize the di-
verse set of methods and summarize findings associated with them (Fishler, Sperling,
& Carr, 1990; Smith, 1993; Stricker & Healey, 1990). The current review of assessment
approaches has benefited from them. Representative examples of some of the better
known approaches will be cited. The previous reviews should be consulted for a more
comprehensive and detailed survey of the various approaches and the findings associ-
ated with them.
Assessment methods that have focused on the internal world have frequently in-
volved projective stimuli such as Rorschach or TAT cards. Special scoring systems have
been devised to rate the responses and make inferences about the structural and the-
matic characteristics of mental representations and their relationships. Two well-
known systems that have been applied to Rorschach responses are the Concept of the
Object Scale (Blatt, Brenneis, Schimek, & Glick, 1976) and the Mutuality of Auton-
omy Scale (Urist, 1977). The Object Relations and Social Cognition Scale (Westen,
Lohr, Silk, Gold, & Kerber, 1990) has been used with TAT cards. Other systems such
as the Comprehensive Early Memories Scoring System (Last & Bruhn, 1983) and the
Object Representation Scale for Dreams (Krohn & Mayman, 1974) have been used
with early memories and dreams. The variables measured by the various projective
methods are generally regarded as theoretically valid indicators of the internal world
of mental representations. However, because of the level of inference required for
their measurement, inability to demonstrate high reliability has at times been a prob-
lem. In part for this reason, more objective measures of internal object relations have
been developed. An example is the Bell Object Relations Reality Testing Inventory
(Bell, Billington, & Becker, 1986), a 90-item questionnaire.
Assessment methods that have focused on the external world have involved observer
ratings of actual interpersonal behavior and relationships, observer ratings of reports
about previous interpersonal behavior and relationships, and self-ratings of previous
or current interpersonal behavior and relationships. Although most of these methods
have a theoretical basis that articulates internal concepts and processes, the ratings
are primarily based on references to external behavior. Actual interpersonal behavior
has come from special test situations, interviews, and therapy sessions. Examples of
methods that have focused on actual samples of behavior include the Ainsworth
Strange Situation Technique (Ainsworth, Blehar, Waters, & Wall, 1978) which is based
 Object Relations Theory 675

on concepts from attachment theory, and the Structural Analysis of Social Behavior
(SASB; McLemore & Benjamin, 1979).
Methods that have utilized both actual behavior and reports about previous behav-
ior are the Plan Diagnosis (Weiss, Sampson, & the Mount Zion Psychotherapy Re-
search Group, 1986), Configurational Analysis (Horowitz, 1979, 1987), and the Cycli-
cal Maladaptive Pattern (Strupp & Binder, 1984). Each of these methods includes a set
of concepts that provide a unique patient formulation. Although a standard quantita-
tive index based on predefined content is not generated, the formulation can be used
to guide treatment plans and interventions.
Other methods have relied entirely or primarily on reports about previous behavior
and relationships. Similar to several of the above methods, the core conflictual rela-
tionship theme (Luborsky & Crits-Christoph, 1990) provides a unique patient formu-
lation. It relies on spontaneous reports about previous interpersonal behavior and re-
lationships, which are referred to as narratives. Other interview approaches are more
structured. They include the Ego Function Assessment (Bellak, Hurvich, & Gediman,
1973), the Adult Attachment Interview (George, Kaplan, & Main, 1984), the Attach-
ment Interview (Bartholomew & Horowitz, 1991), the Object Relations Inventory (Di-
amond, Kaslow, Coonerty, & Blatt, 1990), the Quality of Interpersonal Relationships
Scale (Høglend, 1993a), and our own Quality of Object Relations Scale (Azim, Piper,
Segal, Nixon, & Duncan, 1991). The last two measures differ from the others in pro-
viding a single dimension that indicates the overall quality of object relations. Smith
(1993) suggested that the interview-based techniques have attempted to strike a bal-
ance between attending to patterns of behavior and making inferences about stable
internal structure.
Recently, several self-report scales that assess attachment patterns have emerged.
They tend to focus on recent or current relationships. Examples, include the Adult At-
tachment Scale (AAS; Collins & Read, 1990), the Reciprocal Attachment Question-
naire (RAQ; West & Sheldon-Keller, 1994), and the Client Attachment to Therapist
Scale (CATS; Mallinckrodt, Gantt, & Coble, 1995). They, too, are primarily based on
references to external behavior.
There are few studies that present evidence of significant relationships between ob-
ject relations or attachment concepts and either the therapeutic alliance or outcome
in STDP. Two studies using self-report scales of attachment patterns have reported sig-
nificant associations with working alliance among clients receiving short-term counsel-
ing (Mallinckrodt, Coble, & Gantt, 1995; Satterfield & Lyddon, 1995). Two other stud-
ies have reported significant findings with inpatient populations. Ford, Fisher, and
Larson (1997) found a direct relation between an interview measure of object rela-
tions and treatment outcome among patients with posttraumatic stress disorder. Simi-
larly, Fonagy et al. (1996) reported preliminary findings of a direct relation between
an interview measure of attachment patterns and treatment outcome among nonpsy-
chotic patients with severe personality disorders. A study that did focus on STDP was
that of Høglend (1993b). He reported finding a direct relation between an interview
measure of object relations and treatment outcome among a mixed group of psychiat-
ric outpatients. Perhaps the most substantial evidence for relationships between ob-
ject relations and both the therapeutic alliance and outcome in STDP has emerged
from a series of clinical trials from our research team that were conducted in Mont-
real and Edmonton. The findings involving STDP were further supported in clinical
trials involving partial hospitalization programs. The measure of object relations that
has been used by our research team is the Quality of Object Relations Scale.
676 W. E. Piper and S. C. Duncan

QUALITY OF OBJECT RELATIONS SCALE (QORS)

Scale Development
The QORS originated in Montreal in the 1970s among a team of clinical researchers
in the Individual and Group Psychotherapy Unit of the Allan Memorial Institute. Cen-
tral members of the team included J. P. Bienvenu, F. L. de Carufel, E. G. Debbane, J.
Garant, and W. E. Piper. The QORS was not derived from a particular object relations
theory. Nevertheless, its conceptual basis included the core concepts (object, struc-
ture, inner world, internalization, externalization) that were described earlier. The
first version of the scale was a product of practical necessity. One of the research
team’s interests was investigating patient characteristics that were predictive of success
in different forms of psychodynamic psychotherapy. Belief in the value of object rela-
tions theory in generating useful research measures led to the inclusion of three ob-
ject relations variables among a larger set of 15 variables that therapists used to rate
psychotherapy patients after conducting initial interviews.
The three variables were based on subareas of criteria (object choice, type of rela-
tionship, sexual) from the Object Relations Scale of the Camarillo Dynamic Assess-
ment Scales (May & Dixon, 1969). The Camarillo Object Relations Scale had been
developed from the set of patient variables of The Menninger Foundation’s Psycho-
therapy Research Project (Robbins, Wallerstein, Sargent, & Luborsky, 1956). The
original Menninger variable was called quality of interpersonal relationships. As the
label suggests, the Menninger team, followed by the Camarillo and Montreal teams,
was interested in rating the favorable and unfavorable aspects of interpersonal rela-
tionships in various spheres of the patient’s life from the perspective of the clinician.
Because May and Dixon designed their scales for use in research with first admission
schizophrenic patients, their criteria reflected relatively severe psychopathology. Our
Montreal team revised many of the criteria in the upper range of the scales for the
three variables to make them more appropriate for an outpatient psychotherapy pop-
ulation. Then, the variables were used to rate patients who were participating in a
comparative outcome study for four forms of time-limited individual and group psy-
chotherapy (Piper, Debbane, Bienvenu, & Garant, 1984). Although relatively simple
in nature, the ratings of QOR were found to be directly and significantly related to de-
sirable process and favorable outcome for both STDP and group psychotherapy (de
Carufel & Piper, 1988; Piper, de Carufel, & Szkrumelak, 1985).
Since its use in the Montreal, comparative outcome study, the QORS has pro-
gressed through several forms. In general, the criteria have become more explicit and
detailed. Modifications of the scale typically occurred as part of preparation for its use
in new psychotherapy clinical trials. For example, a modification was made prior to its
use in a controlled clinical trial of STDP carried out in Edmonton (Piper, Azim, Mc-
Callum, & Joyce, 1990). In this 20-session treatment, the therapists were active, inter-
pretive, and transference oriented. Modifications were also made prior to two Edmon-
ton clinical trials on time-limited forms of day treatment (Piper, Rosie, Azim, & Joyce,
1993) and evening treatment (McCallum, Piper, & O’Kelly, 1997) partial hospitaliza-
tion programs. These 4-month treatments were intensive, group oriented, and time
limited. A further modification of the QORS was made prior to a recently completed
clinical trial in Edmonton that compared interpretive and supportive forms of short-
term, time-limited individual therapy (Piper, Joyce, McCallum, & Azim, 1998). Over
this series of studies, the criteria and their weights for each level of the QORS were ad-
justed to improve conceptual clarity and reliability of measurement. The adjustments
 Object Relations Theory 677

resulted in corresponding changes in the names for the five levels. Despite these
changes, each form has retained the same general definition of quality of object rela-
tions and the same general distinctions among the five levels of the scale.

Scale Description
QOR is defined as a person’s internal enduring tendency to establish certain types of
relationships that range along an overall dimension from primitive to mature (Azim
et al., 1991). QOR thus refers to a life-long pattern rather than one that characterizes
only recent relationships. The five levels and anchor points of the overall dimension
are presented in Table 1.
Criteria are arranged within each of the five levels under the following four head-
ings: behavioral manifestations, affect regulation, self-esteem regulation, and anteced-
ent (etiological) factors. Behavioral manifestations consist of descriptions of an indi-
vidual’s typical relationship patterns. Affect regulation is defined by the type of
interpersonal relationships the subject unconsciously and consciously wishes for and
engages in, both in fantasy and ultimately in action, to reduce anxiety, experience
gratification, or both. Likewise, self-esteem regulation is considered as the wished-for,
fantasized, and behaviorally expressed interpersonal relationships that enhance self-
esteem or reduce mortification. Antecedents are those past events or relationships
thought to be clinically or theoretically predisposing to a given level. More weight is
given to behavioral manifestations because they are experience-near, observable, and
usually manifested in the interviewer-interviewee interaction. Because of their rela-
tively experience-distant nature and the greater need for inference in evaluating them,

TABLE 1. Quality of Object Relations Scale

Level and
Anchor Point Predominant Characteristics

Mature (9) The person enjoys equitable relationships characterized by love,

tenderness, and concern for objects of both sexes.
There is a capacity to mourn and tolerate
unobtainable relationships.
Triangular (7) The person is involved in real or fantasized triangular relationships.
Competition for one object is inspired by victory over the other object.
There is concern for the objects.
Controlling (5) The person engages in well-meaning attempts to control
and possess objects. Relationships are characterized by ambivalence.
Attempts to control the person are met with
defiance or pseudocompliance.
Searching (3) The person is driven to find substitutes for a longed-for lost object.
Substitutes provide a short-lived sense of optimism and self-worth,
which is followed by disillusionment and the
re-experience of loss.
Primitive (1) The person reacts to perceived separation or loss of the object, or
disapproval or rejection by the object, with intense anxiety and affect.
There is inordinate dependence on the lost object,
who provides a sense of identity for the person.
678 W. E. Piper and S. C. Duncan

affect regulation, self-esteem regulation, and antecedents, in that order, are given less
weight. Prototypical patients for each level and scoring procedures are described in a
manual that can be obtained from the authors (Piper, McCallum, & Joyce, 1993).
QOR has usually been assessed during two 1-hour interviews that are conducted 1
week apart. The objective of the first interview, which is relatively unstructured, is to
obtain a history of the patient’s important relationships in a spontaneously recounted
manner. The objective of the second interview, which is more structured, is to differ-
entiate and clarify the patient’s levels of object relations. After the second hour, the
interviewer distributes 100 points among the five levels of the dimension. A simple
arithmetic formula is used to weight the ratings for the five levels and generate an
overall score that ranges from 1 to 9, the higher the score the higher the quality of ob-
ject relations.

Psychometric Properties
Considerable information concerning the rater reliability, concurrent validity, and
predictive validity of the QORS has emerged from the four Edmonton clinical trials
cited above. The sizes of the primary outcome samples from the trials were 105 for the
controlled individual therapy study, 144 for the comparative individual therapy study,
120 for the day treatment study, and 142 for the evening treatment study, although
subsamples were used for some hypothesis testing.

Rater Reliability
In each clinical trial one or more independent raters provided overall scores for QOR
using audiotapes of the original interview. Intraclass correlation coefficients were cal-
culated. The respective coefficients were ICC(2, 1) 5 .50 for the controlled individual
therapy study, ICC(2, 2) 5 .68 for the comparative individual therapy study, ICC(2, 1) 5
.62 for the day treatment study, and ICC(2, 1) 5 .72 for the evening treatment study.
Thus, the QOR assessment method has evidenced moderate rater reliability.

Concurrent Validity
Demographic and historic variables. In both the controlled and comparative individual
therapy trials, no significant relationships were found between QOR and age, gender,
marital status, educational status, or employment status. In the day treatment trial,
high-QOR patients were more likely to have been married. In the evening treatment
trial, QOR was directly related to educational status.
In regard to previous psychiatric hospitalization, no significant relationship was
found in the comparative individual therapy trial or the day treatment trial. In the
evening treatment trial, QOR was significantly lower in patients with previous psychi-
atric hospitalization.

Diagnostic variables. In the controlled individual therapy trial, no significant relation-

ships were found between QOR and DSM-III Axis I diagnoses. In contrast, low-QOR
patients were more likely to have an Axis II diagnosis, although the two variables were
far from being synonymous. Of the low-QOR patients, 45% received a personality dis-
order diagnosis, compared with 17% of the high-QOR patients. In the comparative in-
dividual therapy trial, significant relationships were found for Axis II, but not Axis I di-
 Object Relations Theory 679

agnoses. In the day treatment trial, there were no significant relationships between
QOR and lifetime DSM-III Axis I disorders. However, two significant relationships
were found for current Axis I disorders. Low-QOR patients were more likely to receive
diagnoses of major depression and atypical bipolar disorder. There was no significant
relationship between QOR and the presence of an Axis II diagnosis. In the evening
treatment trial, no significant relationships were found between QOR and DSM-III
Axis I diagnoses. There was just one significant relationship with an Axis II diagnosis.
Patients with Schizoid Personality Disorder had lower QOR.

Initial disturbance. In each of the four clinical trials, lower QOR scores were associated
with greater disturbance on some of the initially assessed outcome variables. This was
the case for 4 of 19 variables in the controlled individual therapy trial (partner dys-
function, sexual dysfunction, life satisfaction, and anxiety) and 4 of 13 variables in the
comparative individual therapy trial (depression, general symptomatic distress, social
functioning, and family functioning). In the day treatment trial, 3 of 17 variables dem-
onstrated this pattern (social dysfunction, maladaptive defences, and number of
friends). In the evening treatment trial, it was the case for 6 of 18 variables (family dys-
function, satisfaction with friends, interpersonal functioning on the Interpersonal Be-
havior Scale and the Inventory of Interpersonal Problems, target objective severity
rated by an independent assessor, and global assessment of functioning). Although
significant, the correlations with initial disturbance in the four clinical trials were not
large.

The personality variable psychological mindedness. In the controlled individual therapy

trial, psychological mindedness was not assessed. In the other three trials, the relation-
ship between QOR and psychological mindedness indicated nearly complete inde-
pendence.
In summary, the clinical trials indicated that QOR is largely independent of demo-
graphic, historic, and diagnostic variables, as well as the personality variable psycho-
logical mindedness. In contrast, some evidence for a direct relationship between QOR
and initial disturbance has been found.

Predictive Validity
In the controlled individual therapy trial (Piper, Azim, Joyce, McCallum, Nixon, & Se-
gal, 1991), QOR was directly related to ratings of the therapeutic alliance provided by
the patient, r(62) 5 .29, p , .05, and the therapist, r(62) 5 .28, p , .05. The large set
of outcome variables was reduced to three conceptually meaningful factors by means
of a principal components analysis (general symptomatology and dysfunction, individ-
ualized objectives of treatment, and social-sexual adjustment). QOR was directly re-
lated to favorable outcome for general symptomatology and dysfunction at postther-
apy, r(60) 5 .25, p , .05, and individualized objectives at both posttherapy, r(62) 5
.35, p , .01, and 6-month follow-up, r(52) 5 .37, p , .01. Compared with a set of pre-
dictor variables representing recent interpersonal functioning, QOR emerged as the
strongest predictor of alliance and outcome. In the comparative individual therapy
trial, QOR was directly related to patient-rated therapeutic alliance during the first
third of therapy, r(142) 5 .17, p , .05. QOR was also directly related to favorable out-
come in interpretive therapy (multivariate set of 13 outcome variables) but virtually
unrelated to outcome in supportive therapy.
680 W. E. Piper and S. C. Duncan

In the day treatment trial, QOR was directly related to remaining in the program,
r(163) 5 .23, p , .01. It was also directly related to favorable outcome on two primary
outcome factors, general symptomatology and target objectives at posttherapy, r(96) 5
.26, p , .01, and follow-up, r(48) 5 .31, p , .05; and social maladjustment and dissat-
isfaction at posttherapy, r(97) 5 .21, p , .05. QOR was not related to outcome in the
evening treatment trial.

Moderator Effects
In addition to direct relationships between QOR and the therapeutic alliance, re-
maining, and treatment outcome in the various studies, QOR has emerged as an im-
portant moderator variable in the controlled individual therapy trial. Thus, relation-
ships between other variables have differed depending on the level of QOR. For
example, the relationship between the extent to which the therapist uses transference
interpretations and the average level of the therapeutic alliance or treatment out-
come have differed depending on the level of QOR (Piper, Azim, Joyce, & McCallum,
1991). Significant negative relationships with alliance and outcome were found for
high-QOR patients. Similarly, the relationship between the extent to which the thera-
pist provides “accurate” transference interpretations and the average level of the ther-
apeutic alliance or treatment outcome have differed depending on the level of QOR
(Piper, Joyce, McCallum, & Azim, 1993). Accurate is defined as correspondence be-
tween the content of the interpretation and the content of an initial patient formula-
tion. For this variable, a significant positive relationship with treatment outcome was
found for high-QOR patients, and significant negative relationships with the thera-
peutic alliance and with treatment outcome were found for low-QOR patients. These
findings concerning both the extent of use and the accuracy of transference interpre-
tations have received support in independent studies in Norway (Høglend, 1993a;
Høglend & Piper, 1995).
Further evidence of the importance of QOR as a moderator variable was found in
two subsequent studies based on the patients treated in the controlled individual ther-
apy trial. Both studies used hierarchical linear modeling (HLM) procedures. In the
first, an increasing pattern of therapist-rated alliance over the course of therapy was
directly related to favorable outcome in the case of low-QOR patients (Piper, Boroto,
Joyce, McCallum, & Azim, 1995). In the second, the degree to which patients worked
in response to transference interpretation was directly related to initial disturbance
and inversely related to favorable treatment outcome in the case of high-QOR pa-
tients (Joyce & Piper, 1996). The consistent discovery of moderator effects suggests
that the two samples (low-QOR, high-QOR) differ in important ways. The clinical rel-
evance of these findings and the predictive validity findings for STDP will be consid-
ered next.

Relevance of QOR to STDP

STDP usually refers to individual therapy with an interpretive emphasis. It has also
been referred to as “exploratory,” “expressive,” or “insight oriented.” Interest in STDP
heightened during the 1970s and 1980s in association with the publication of a num-
ber of persuasive books (Bellak & Small, 1978; Davanloo, 1978; Malan, 1976; Mann,
1973; Sifneos, 1972; Strupp & Binder, 1984). Most of the approaches emphasized
therapist focus, therapist activity, and therapist interpretation, in particular the inter-
 Object Relations Theory 681

pretation of transference. Because these technical emphases had previously been asso-
ciated with supportive therapy (activity) or long-term interpretive therapy (interpreta-
tion), the approaches were regarded as controversial. However, many case reports
and a small number of controlled outcome trials served to convince many clinicians of
the potential effectiveness of STDP. As indicated previously, part of its appeal was con-
ceptual; it allowed dynamically oriented therapists to retain familiar concepts while
making technical innovations, and part was practical; it allowed therapists to cope
with high demands for services in the face of limited staff resources.
In the Edmonton controlled trial of STDP, the therapists were active, interpretive,
and transference oriented. As part of the approach, the patient was expected to begin
each session and share responsibility for what followed. There was ongoing pressure
for the patient to talk. The therapist avoided attempts at direct gratification or praise.
Instead, the therapist encouraged the patient to explore conflictual aspects of his/her
experiences, which often included uncomfortable emotions. Interpretations, which
involved sensitive and painful topics, were offered. Unpredictability of session content
and process was part of the intended framework. Thus, the therapeutic situation was a
challenging one that required adaptation on the part of the patient. The patient-ther-
apist relationship was the medium of this adaptation.
Within this challenging and somewhat unpredictable situation, one of the immedi-
ate tasks of the patient and therapist is to form a collaborative working relationship.
One could assume that the patient’s life-long history and pattern of establishing
meaningful give-and-take relationships was important. This was confirmed in the Ed-
monton trial by the direct relationships between QOR and both the therapeutic alli-
ance and treatment outcome. The moderator effect findings from the Edmonton trial
also highlighted the relevance of QOR.

Clinical Implications of QOR Findings Regarding STDP

Given the small number of studies and the modest effect sizes associated with most of
the findings, it is important to be cautious in drawing clinical implications. Neverthe-
less, if one regards the findings as tentative and in need of further confirmation, a
number of potentially useful clinical implications can be formulated. Perhaps the sim-
plest involves the direct relationships among QOR, alliance, and outcome. The find-
ings suggest that QOR might serve as a useful selection criterion for STDP. The appar-
ent relation between QOR and outcome stands in contrast to the frequently reported
absence of a relation between DSM diagnostic disorders and the outcome of psycho-
therapy. In this context, the minimal relations between QOR and the diagnostic disor-
ders in the clinical trials are not that surprising. The QOR scale is a dimensional one
that spans a number of levels. Weights for levels are based on the presence of subdi-
mensional features, not the presence of a number of necessary and sufficient symp-
toms or behaviors that define a discrete category. Patients may receive high weights
for two or more distinctly different levels, which ultimately contribute to an overall
score. Thus, the two approaches to conceptualizing patients are quite different and
may be independent; patients with similar QOR scores may have different diagnoses,
and patients with the same diagnosis may have different QOR scores.
Although the chances of establishing a strong alliance and favorable outcome ap-
pear to be enhanced with high-QOR patients, it must be recognized that patients
sometimes pleasantly surprise us. For that reason, clinicians may wish to take on a cer-
tain number of higher risk (low-QOR) patients as a means of providing them with an
682 W. E. Piper and S. C. Duncan

opportunity to benefit. Some undoubtably will. Thus, high QOR might be regarded as
a favorable but not essential selection criterion.
The clinical implications regarding the use of transference interpretations and the
therapeutic alliance are more complex because correlational findings regarding si-
multaneous events do not indicate causal direction. For example, therapists may be
more inclined to use more transference interpretations with high-QOR patients when
faced with a weak alliance because they believe they will be tolerated and used. Or,
high-QOR patients may be more sensitive to high concentrations of transference in-
terpretations, that is, more prone to regard it as negative criticism, which results in a
weak alliance. In conjunction with the outcome results, the findings suggest that ther-
apists should avoid becoming entrenched in a negative cycle that is characterized by a
high concentration of transference interpretations and a weak alliance. If one also
considers the findings concerning accuracy of transference interpretations and out-
come, there is the suggestion that therapists should consider providing few (low con-
centration) but accurate interpretations to high-QOR patients. The HLM findings
concerning work and outcome for high-QOR patients are consistent with these find-
ings in suggesting that too much of a good thing (work) may actually be detrimental,
at least in the short run (i.e., immediately following treatment). In the cases of trans-
ference interpretation and work, moderation seems to be indicated.
A similar consideration may apply regarding the use of accurate transference inter-
pretations with low-QOR patients. These patients have a history of relatively nongrati-
fying relationships. They may be more in need of forming a gratifying relationship
with the therapist than exploring their pattern of nongratifying relationships in ther-
apy. Emphasizing similarities between past abusive relationships and the current
transferential one may result in the patient feeling criticized, rejected, or abandoned.
Consequently, the alliance may be weakened. Alternatively, a weak alliance may elicit
high accuracy of transference interpretation by the therapist in an effort to encourage
work. In either case, the therapist should avoid getting caught up in a negative cycle
that is characterized by high accuracy of transference interpretations and a weak alli-
ance. Again, moderation seems to be indicated.
The HLM finding regarding an increase in the strength of the alliance and favor-
able outcome suggests that strengthening the alliance during the course of therapy
may be particularly important for low-QOR patients. Improvement or deterioration of
the relationship over the sessions of therapy may be viewed as evidence of the success
or failure of therapy itself. The finding argues against attempting to establish a very
strong, perhaps overly intense, working relationship initially. Given their history of
unsatisfactory relationships, such patients may be intimidated and react adversely. In-
stead, a moderately strong initial alliance followed by gradual strengthening would
seem to enhance the possibilities of therapeutic success. This finding, as well as those
involving concentration and accuracy of transference interpretation, suggest the im-
portance of carefully assessing the patient’s life-long pattern of relationships and plan-
ning treatment accordingly. It is clear that the patient’s QOR has implications for
therapist technique as well as patient selection.

FUTURE RESEARCH
Recommendations for future research involving object relations theory and STDP are
rather straightforward. In regard to the QOR concept, although several of the main
 Object Relations Theory 683

findings from the Edmonton clinical trials have received independent confirmation
in studies conducted in Oslo, additional attempts at cross-validation and investigation
of new hypotheses remain worthwhile objectives. Inclusion of QOR measures in both
randomized clinical trials and naturalistic predictor studies provide such opportuni-
ties. For example, we have included the measure in a new clinical trial of time-limited
group therapies for patients experiencing pathological bereavement. Although signif-
icant relationships between QOR and outcome have been found, the limited amount
of variance accounted for suggests that additional variables are influential and should
be investigated as part of multivariate models. Other patient characteristics, therapist
characteristics, and technical variables are promising variables to investigate.
Despite the existence of a variety of object relations concepts and assessment tech-
niques, little is known about the relationship among them in the context of STDP. For
example, it is possible that QOR is related to certain core conceptual relationship
themes or to the content of other patient formulation systems. In addition, informa-
tion about the relationships among the various patient formulation systems is scarce.
Even more scarce is information about the relationships between object relations con-
cepts that focus on the internal world and those that focus on the external world. This
is surprising given the fact that most theories include processes that involve their in-
terdependence (e.g., internalization, externalization). Overall, it is fair to conclude
that relatively little work has been conducted that investigates the relevance of object
relations theory to STDP. The initial lines of research are promising and opportuni-
ties for useful research contributions are plentiful.

REFERENCES

Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of
the strange situation. Hillsdale, NJ: Erlbaum.
Azim, H. F. A., Piper, W. E., Segal, P. M., Nixon, G. W. H., & Duncan, S. (1991). The quality of object rela-
tions scale. Bulletin of the Menninger Clinic, 55, 323–343.
Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults: A test of a four-category
model. Journal of Personality and Social Psychology, 61, 226–244.
Bell, M., Billington, R., & Becker, B. (1986). A scale for the assessment of object relations: Reliability, valid-
ity, and factorial invariance. Journal of Clinical Psychology, 42, 733–741.
Bellak, L., Hurvich, M., & Gediman, H. K. (Eds.). (1973). Ego functions in schizophrenics, neurotics, and nor-
mals. New York: Wiley.
Bellak, L., & Small, L. (1978). Emergency psychotherapy. (2nd ed.). New York: Grune & Stratton.
Beres, D., & Joseph, E. (1970). The concept of mental representation in psychoanalysis. International Journal
of Psychoanalysis, 51(1), 1–9.
Blanck, R., & Blanck, G. (1986). Beyond ego psychology: Developmental and object relations theory. New York:
Columbia University Press.
Blatt, S. J., Brenneis, C. B., Schimek, J. G., & Glick, M. (1976). Normal development and psychopathologi-
cal impairment of the concept of the object on the Rorschach. Journal of Abnormal Psychology, 85, 364–373.
Collins, N. L., & Read, S. J. (1990). Adult attachment, working models, and relationship quality in dating
couples. Journal of Personality and Social Psychology, 58, 644–663.
Compton, A. (1996). Objects and object relationships. In B. Moore & B. Fine (Eds.), Psycho-analysis: The
major concepts (pp. 433–449). London: Yale University Press.
Davanloo, H. (Ed.). (1978). Basic principles and techniques in short-term dynamic psychotherapy. New York: Spec-
trum.
de Carufel, F. L., & Piper, W. E. (1988). Group psychotherapy or individual psychotherapy: Patient charac-
teristics as predictive factors. International Journal of Group Psychotherapy, 38, 169–188.
Diamond, D., Kaslow, N., Coonerty, S., & Blatt, S. J. (1990). Changes in separation-individuation and inter-
subjectivity in long-term treatment. Psychoanalytic Psychology, 7, 363–397.
684 W. E. Piper and S. C. Duncan

Fairbairn, W. R. D. (1952). An object-relations theory of the personality. London: Tavistock. (Original work pub-
lished in 1944)
Fishler, P. H., Sperling, M. B., & Carr, A. C. (1990). Assessment of adult relatedness: A review of empirical
findings from object relations and attachment theories. Journal of Personality Assessment, 55, 499–520.
Fonagy, P., Leigh, T., Steele, M., Steele, H., Kennedy, R., Matton, G., Target, M., & Gerber, A. (1996). The
relation of attachment status, psychiatric classification, and response to psychotherapy. Journal of Consult-
ing and Clinical Psychology, 64, 22–31.
Ford, J. L., Fisher, P., & Larson, L. (1997). Object relations as a predictor of treatment outcome with
chronic posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 65, 547–559.
Freud, S. (1957). An outline of psychoanalysis. In J. Strachey (Ed.), The standard edition of the complete psycholog-
ical works of Sigmund Freud (Vol. 23, pp. 144–207). London: Hogarth Press. (Original work published 1938)
Freud, S. (1957). Instincts and their vicissitudes. In J. Strachey (Ed.), The standard edition of the complete psycholog-
ical works of Sigmund Freud (Vol. 14, pp. 109–140). London: Hogarth Press. (Original work published 1915)
George, C., Kaplan, N., & Main, M. (1984). Adult Attachment Interview. Unpublished manuscript.
Greenberg, J. R., & Mitchell, S. A. (1983). Object relations in psychoanalytic theory. Cambridge, MA: Harvard
University Press.
Høglend, P. (1993a). Transference interpretations and long-term change after dynamic psychotherapy of
brief to moderate length. American Journal of Psychotherapy, 47, 494–507.
Høglend, P. (1993b). Suitability for brief dynamic psychotherapy: Psychodynamic variables as predictors of
outcome. Acta Psychiatrica Scandinavica, 88, 104–110.
Høglend, P., & Piper, W. E. (1995). Focal adherence in brief dynamic psychotherapy: A comparison of find-
ings from two independent studies. Psychotherapy, 32, 618–628.
Horowitz, M. J.(1979). States of mind: Analysis of change in psychotherapy. New York: Plenum.
Horowitz, M. J. (1987). States of mind: Analysis of change in psychotherapy (2nd ed.). New York: Plenum.
Joyce, A. S., & Piper, W. E. (1996). Interpretive work in short-term individual psychotherapy: An analysis
using hierarchical linear modeling. Journal of Consulting and Clinical Psychology, 64, 505–512.
Kernberg, O. (1976). Object relations theory and clinical psychoanalysis. New York: Aronson.
Kernberg, O. (1985). Internal world external reality. Northvale, NJ: Aronson.
Kernberg, O. (1996). Psychoanalytic object relations theory. In B. Moore & B. Fine (Eds.), Psycho-analysis:
The major concepts (pp. 450–462). London: Yale University Press.
Krohn, A., & Mayman, M. (1974). Object representation in dreams and projective tests. Bulletin of the Men-
ninger Clinic, 43, 515–524.
Last, J. M., & Bruhn, A. R. (1983). The psychodiagnostic value of children’s earliest memories. Journal of Per-
sonality Assessment, 47, 597–603.
Luborsky, L., & Crits-Christoph, P. (1990). Understanding transference: The Core Conflictual Relationship Theme
method. New York: Basic Books.
Malan, D. H. (1976). The frontier of brief psychotherapy. New York: Plenum.
Mallinckrodt, B., Coble, H. M., & Gantt, D. L. (1995). Working alliance, attachment memories, and social
competencies of women in brief therapy. Journal of Counseling Psychology, 42, 79–84.
Mallinckrodt, B., Gantt, D. L., & Coble, H. M. (1995). Client patterns in the psychotherapy relationship:
Development of the Client Attachment to Therapist Scale. Journal of Counseling Psychology, 42, 307–317.
Mann, J. (1973). Time-limited psychotherapy. Cambridge, MA: Harvard University Press.
May, P. R. A., & Dixon, W. J. (1969). The Camarillo dynamic assessment scale I: Measurement of psychody-
namic factors. Bulletin of the Menninger Clinic, 33, 1–35.
McCallum, M., Piper, W. E., & O’Kelly, J. G. (1997). Predicting patient benefit from a group oriented,
evening treatment program. International Journal of Group Psychotherapy, 47, 291–314.
McLemore, C., & Benjamin, L. S. (1979). Whatever happened to interpersonal diagnosis: A psychological
alternative to DSM-III. American Psychologist, 34, 17–34.
Moore, B., & Fine, B. (1990). Psychoanalytic terms and concepts. London: Yale University Press.
Piper, W. E., Azim, H. F. A., Joyce, A. S., & McCallum, M. (1991). Transference interpretations, therapeutic
alliance and outcome in short-term individual psychotherapy. Archives of General Psychiatry, 48, 946–953.
Piper, W. E., Azim, H. F. A., Joyce, A. S., McCallum, M., Nixon, G. W. H., & Segal, P. S. (1991). Quality of
object relations vs. interpersonal functioning as predictors of therapeutic alliance and psychotherapy
outcome. Journal of Nervous and Mental Disease, 179, 432–438.
Piper, W. E., Azim, H. F. A., McCallum, M., & Joyce, A. S. (1990). Patient suitability and outcome in short-
term individual psychotherapy. Journal of Consulting and Clinical Psychology, 58, 475–481.
Piper, W. E., Boroto, D. R., Joyce, A. S., McCallum, M., & Azim, H. F. A. (1995). Pattern of alliance and out-
come in short-term individual psychotherapy. Psychotherapy, 32, 639–647.
 Object Relations Theory 685

Piper, W. E., Debbane, E. G., Bienvenu, J. P., & Garant, J. (1984). A comparative study of four forms of psy-
chotherapy. Journal of Consulting and Clinical Psychology, 52, 268–279.
Piper, W. E., de Carufel, F. L., & Szkrumelak, N. (1985). Patient predictor of process and outcome in short-
term individual psychotherapy. Journal of Nervous and Mental Disease, 173, 726–733.
Piper, W. E., Joyce, A. S., McCallum, M., & Azim, H. F. A. (1993). Concentration and correspondence of
transference interpretations in short-term psychotherapy. Journal of Consulting and Clinical Psychology, 61,
586–595.
Piper, W. E., Joyce, A. S., McCallum, M., & Azim, H. F. A. (1998). Interpretive and supportive forms of psy-
chotherapy and patient personality variables. Journal of Consulting and Clinical Psychology, 66, 558–567.
Piper, W. E., McCallum, M., & Joyce, A. S. (1993). Manual for assessment of quality of object relations. Unpub-
lished manuscript.
Piper, W. E., Rosie, J. S., Azim, H. F. A., & Joyce, A. S. (1993). A randomized trial of psychiatric day treat-
ment. Hospital and Community Psychiatry, 44, 757–763.
Rapaport, D., & Gill, M. (1959). The points of view and assumptions of metapsychology. The International
Journal of Psychoanalysis, 40, 153–162.
Robbins, L. L., Wallerstein, R. S., Sargent, H. D., & Luborsky, L. (1956). The psychotherapy research project
of The Menninger Foundation: Orientation, rationale, design, concepts, sample use of method. Bulletin
of the Menninger Clinic, 20, 221–278.
Sandler, J., & Rosenblatt, B. (1962). The concept of the representational world. Psychoanalytic Study of the
Child, 17, 285–296.
Satterfield, W. A., & Lyddon, W. J. (1995). Client attachment and perception of the working alliance with
counselor trainees. Journal of Counseling Psychology, 42, 187–189.
Sifneos, P. E. (1972). Short-term psychotherapy and emotional crisis. Cambridge, MA: Harvard University Press.
Smith, T. E. (1993). Measurement of object relations: A review. Journal of Psychotherapy Practice and Research,
2, 19–37.
Stricker, G., & Healey, B. J. (1990). Projective assessment of object relations: A review of the empirical liter-
ature. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 2, 219–230.
Strupp, H., & Binder, J. (1984). Psychotherapy in a new key: A guide to time-limited dynamic psychotherapy. New
York: Basic Books.
Urist, J. (1977). The Rorschach test and the assessment of object relations. Journal of Personality Assessment,
41, 3–9.
Weiss, J., Sampson, H., & the Mount Zion Psychotherapy Research Group. (1986). The psychoanalytic process:
Theory, clinical observations, and empirical research. New York: Guilford.
West, M. L., & Sheldon-Keller, A. E. (1994). Patterns of relating: An adult attachment perspective. New York: Guil-
ford.
Westen, D., Lohr, N., Silk, K. R., Gold, L., & Kerber, K. (1990). Object relations and social cognition in bor-
derlines, major depressives, and normals: A TAT analysis. Psychological Assessment: A Journal of Consulting
and Clinical Psychology, 2, 355–364.