Psychotherapy Research 14(4) 401–414, 2004

doi:10.1093/ptr/kph034
© 2004 Society for Psychotherapy Research

THE ROLE OF INTERPERSONAL RELATIONSHIPS IN

THE PROCESS OF PSYCHOTHERAPY
Mary Beth Connolly Gibbons
University of Pennsylvania

Interpersonal patterns play an important role in the context of psycho-

therapy. The author reviews the research program that was established
to explore the role of interpersonal patterns in the psychotherapeutic pro-
cess. Five research areas related to interpersonal patterns are reviewed,
including (a) the patient’s perspective on exploring interpersonal
patterns, (b) the measurement of self-understanding of interpersonal
patterns, (c) transference of interpersonal patterns evident in psycho-
therapeutic narratives, (d) a molecular-level analysis of the use of inter-
personal interventions in various psychotherapy models, and (e) the
relation between use of transference interpretations and treatment
outcome.

From a public health standpoint, it is important to know which current treatments

work for which patients in order to implement treatment programs that have the
greatest impact on mental illness. Therefore, much psychotherapy intervention
research has focused on the effectiveness of specific psychotherapies in treating
psychiatric illnesses of the greatest public health concern. However, in order for
psychotherapy to have the greatest impact over time, it is important for us to under-
stand the processes of change that underlie therapeutic effectiveness. If we are to
develop new and better interventions, it is vital that we understand the factors that
produce treatment effects instead of focusing exclusively on the comparison of
present-day treatment models alone.
In my own research, I have been most intrigued with interpersonal relation-
ships as an important factor in the process of change of various treatment modalit-
ies. My earliest exposure to treatment mechanism research was within the dynamic
psychotherapy camp, namely exploring the process of change in supportive–
expressive (SE) dynamic psychotherapy (Luborsky, 1984). In this model, the
patient’s interpersonal relationships, both with important people in the patient’s life as
well as with the therapist, are viewed as central to the therapeutic approach. The
therapist helps the patient explore the maladaptive relationship patterns, formed
through earlier relationships, that impact the patient’s current interpersonal func-
tioning and result in symptomatology. The patient’s self-understanding of the

This project was supported in part by National Institute of Mental Health Grants MH063149, MH20369,
MH40472, MH40710, MH00756, MH39673, and MH45178.
Correspondence concerning this article should be addressed to Mary Beth Connolly Gibbons, Univer-
sity of Pennsylvania Medical Center, Center for Psychotherapy Research, Department of Psychiatry, 3535
Market Street, Room 649, Philadelphia, PA 19104–3309. E-mail: gibbonsm@mail.med.upenn.edu.

401
402 GIBBONS

impairing relationship conflicts, as expressed in important relationships, including

that with the therapist, is postulated to be the primary vehicle of symptom reduction.
Through better self-understanding, the patient can improve current interpersonal
functioning and decrease symptoms by learning to implement new more adaptive
behaviors toward others.
The role of interpersonal relationships is also an important factor in the process
of other treatment modalities. Interpersonal therapy (IPT; Klerman, Weissman,
Rounsaville, & Chevron, 1984) as well as cognitive models of psychotherapy (e.g.,
Safran & Segal, 1990) focus on interpersonal relationships in the process of psycho-
therapy (e.g., Safran & Segal, 1990). I have developed my research program to
explore the role of interpersonal relationships in the process and outcome of psycho-
therapy in the hopes that such a program will lead to the development of more
effective treatment interventions.
The role of interpersonal relationships in the course of psychotherapy is com-
plex, and many research questions need to be explored to understand this aspect
of treatment fully. Because interpersonal relationships are a key therapeutic focus
in theoretical models of dynamic and interpersonal psychotherapy, it is important
to understand the patient’s perspective on exploration of such relationship patterns
within the psychotherapeutic process. In particular, an important question is whether
patients’ reports of their self-understanding of impairing relationship patterns change
over the course of dynamic psychotherapy.
In dynamic psychotherapies, therapists are trained to use their experiences of
patients’ relationship conflicts as they are expressed in the therapeutic relationship
to understand the content of the patients’ relationship patterns and to help patients
explore these patterns. Thus, research needs to address the extent to which patients’
relationship patterns are actually expressed in the therapeutic relationship, parti-
cularly in time-limited therapeutic approaches. Further, it is important to have a
thorough understanding of how interpersonal relationships are explored in the ther-
apeutic interventions of treatment modalities as they are actually practiced (i.e., the
extent to which current relationships vs. past relationships are the focus of ther-
apeutic interventions, the proportion of therapeutic interventions that actually address
the transference in the therapeutic relationship). Finally, it is important to explore the
effectiveness of interventions based on such transference experiences. These are
the research questions I have addressed to date in developing a research program
exploring the role of interpersonal relationships in psychotherapy. I briefly review
the research literature as well as my research findings regarding each of these
research questions and then expand on my goals for future research directions.

What Is the Patient’s Perspective on Exploring Interpersonal

Relationships in Psychotherapy?

In 1977, Strupp and Hadley proposed their tripartite model of psychotherapy

outcome, which suggested that psychotherapy outcome should be assessed from
the perspective of not only the health care provider but also the patient and society.
The authors suggested that, from the patient’s perspective, well-being and happi-
ness were the most valued psychotherapy outcomes. Since the publication of the
Strupp and Hadley model, a number of studies have directly examined the patient’s
perspective on helpful aspects of psychotherapy. For example, Llewelyn (1988)
reported that, from the patient’s perspective, the psychotherapeutic events that
INTERPERSONAL RELATIONSHIPS IN PSYCHOTHERAPY 403

were most helpful included reassurance/relief events and solutions to problems. In

a review of the literature, Elliott and James (1989) reported that patients describe
two types of important therapeutic impacts during the course of psychotherapy,
including task- and problem-solving impacts and interpersonal–affective impacts.
The authors further reported that the most common treatment-related changes
described by patients included increased self-esteem, symptom relief, improved
interpersonal relationships, and greater mastery. Finally, Elliott et al. (1990) found
that patients reported three major domains of outcome: improvements in self, dealing
with others, and life situations.
We conducted a research project to build on this research literature examining
the important domains of psychotherapy outcome from the patient’s perspective
(Connolly & Strupp, 1996). We explored the patient’s retrospective view of psycho-
therapy outcome, which has the advantage of including patients’ views once they
have had the time and experience to reflect on the breadth of possible psychother-
apeutic benefits. Participants in the Vanderbilt II study of time-limited dynamic
psychotherapy (Henry, Butler, Strupp, & Schacht, 1993) were included in the current
investigation. Participants were heterogenous with regard to diagnosis. After the
completion of 16 sessions of outpatient time-limited dynamic psychotherapy, we
asked 67 patients to describe in writing, in an open-ended format, the most important
changes they experienced. We first converted each patient’s answer to a list of distinct
phrases. We assembled a list of 90 discrete changes across that sample of patients.
We were interested in empirically extracting broad categories of change that
best represented the changes described across the sample. We recruited 100 under-
graduate students to rate the semantic similarity for each possible pair of changes
within our list of 90 patient-reported changes. Similarity estimates were averaged
across judges to form a similarity matrix of the 90 therapeutic change items. The
similarity matrix was then submitted to a hierarchical cluster analysis. A four-cluster
solution was maintained based on the plot of the number of clusters versus the fusion
coefficients and a subjective examination of the conceptual clarity of the result.
The final clusters were named using a recaptured item technique (Meehl, Lykken,
Schofield, & Tellegen, 1971) in which a set of expert judges first provided labels for
each cluster, and a second set of judges were asked to match independently the
cluster items with the resulting cluster names.
The results indicated that, from the patient’s perspective, four domains of
psychotherapy outcome were most important: improved symptoms, improved self-
understanding of interpersonal patterns, improved self-confidence, and greater self-
definition. These results were consistent with earlier studies (Elliott & James, 1989),
indicating that, in addition to changes in symptoms and self-esteem, patients find
self-understanding of interpersonal patterns to be an important therapeutic outcome.

Can Self-Understanding of Interpersonal Patterns Be Measured,

and Can Changes in Self-Understanding Be Demonstrated
Across Dynamic Psychotherapy?

Given that self-understanding of interpersonal patterns is postulated in dynamic

and interpersonal models of psychotherapy to be a central ingredient to therapeutic
change (see Connolly, Crits-Christoph, Shelton, et al., 1999, for full review), and that
patients find changes in self-understanding of these interpersonal patterns to be an
important therapeutic outcome, it is important that a reliable and valid measure of
404 GIBBONS

this construct be developed to explore this important therapeutic process. Despite

the centrality of this construct to many therapeutic models of change, little research
effort has been made to develop a reliable and valid measure. Several early studies
implementing measures of self-understanding did not base their measures on ade-
quate definitions of the construct (Kelman & Parloff, 1957; Luborsky et al., 1980;
Mann & Mann, 1959; Sifneos, 1984; Smith, 1959; Tolor & Reznikoff, 1960). Other
investigations used single-item ratings or did not establish measure reliability
(Eskey, 1958; HØglend, Engelstad, Sorbye, & Heyerdahl, 1994; Husby et al., 1985;
Luborsky, 1962; Rosenbaum, Friedlander, & Kaplan, 1956). Finally, a few investi-
gations implemented measures with good content validity, but these measures were
extremely time consuming and costly because of their reliance on transcripts of
treatment sessions (Crits-Christoph & Luborsky, 1990; Dymond, 1948; Luborsky,
Crits-Christoph, Mintz, & Auerbach, 1988; Vargas, 1954).
We developed a measure of self-understanding of interpersonal patterns that
could be easily disseminated across large samples and performed a comprehensive
evaluation of the reliability and validity of the measure (Connolly, Crits-Christoph,
Shelton, et al., 1999). The Self-Understanding of Interpersonal Patterns (SUIP) scale
is a self-report inventory designed to assess the patient’s level of self-understanding
of maladaptive relationship patterns. Self-understanding is defined along a contin-
uum, ranging from mere recognition of an interpersonal pattern within a specific
interaction to recognition of the prevalence of the pattern across experiences to an
understanding of the history of the pattern. Interpersonal patterns are further
defined using the core conflictual relationship theme (Luborsky & Crits-Christoph,
1990), in which patterns consist of the interpersonal wishes or needs one experi-
ences, the individual’s perceived response of another person toward the individual,
and the response of the self toward the other person. Connolly, Crits-Christoph,
Shelton, et al. (1999) review and discuss the theory of self-understanding as
described in the theoretical and research literatures.
The SUIP consists of 19 items, each of which represents a maladaptive inter-
personal pattern that one might experience in relationships. These 19 patterns
were derived from research findings, theoretical descriptions of maladaptive inter-
personal patterns, and therapists’ formulations of important maladaptive patterns.
Patients first rate whether each pattern is a problem in their relationships in general.
They then rate, on a 4-point scale, the level of understanding they feel they have of
each pattern that they identify as problematic in their relationships. Two scores can
be derived: (a) A recognition score that represents the number of interpersonal
patterns recognized as problematic, and (b) the average level of self-understanding
the patient has across only those patterns that are uniquely problematic for that
patient.
Both the recognition score and the self-understanding score of the SUIP demon-
strated good internal consistency across the 19 items for multiple psychiatric samples
as well as a nonclinical sample. Across the samples evaluated, Cronbach’s alpha
coefficients ranged from .70 to .88 for the self-understanding score and from .70 to
.97 for the recognition score. The SUIP self-understanding score did not correlate
significantly with either level of symptoms or interpersonal distress, indicating that
it measures a distinct construct. The SUIP demonstrated convergent validity with
measures of personality, including the degree to which one is reflective and self-
improving, as measured by the Personality Research Form ( Jackson, 1989). Finally,
in a sample of patients with a diagnosis of generalized anxiety disorder, the SUIP
demonstrated significantly greater change in self-understanding among patients
INTERPERSONAL RELATIONSHIPS IN PSYCHOTHERAPY 405

who received dynamic psychotherapy compared with those who were treated
with medication despite comparable symptom change across treatment groups
(Connolly, Crits-Christoph, Shelton, et al., 1999).
These results suggested that the SUIP was an adequate first step in developing
a measure of self-understanding of interpersonal patterns. This investigation sug-
gested that self-understanding can be reliably measured and that change in self-
understanding can be demonstrated across the course of dynamic psychotherapy.
The SUIP is currently being revised to address some of the limitations found in the
original measure (Connolly, Crits-Christoph, Shelton, et al., 1999). The revised ver-
sion has been expanded to include the breadth of interpersonal patterns that
patients might experience. In addition, the self-understanding scale for each pattern
has been expanded to a 7-point scale that goes beyond understanding the historical
origins of one’s pattern to deeper levels of self-understanding. Finally, a rater ver-
sion of the measure has been developed and is currently being evaluated.

To What Extent Are Maladaptive Relationship Themes

Repetitive Across the Patient’s Relationship Experiences,
and Do Patients Express Similarities Between Their
Important Interpersonal Relationships and the
Relationship Experienced With the Therapist?

Because maladaptive interpersonal patterns are the focus of dynamic

psychotherapies, therapists are trained in these models to formulate the relationship
theme for each patient by listening to the stories the patient tells about relationship
experiences as well as by paying attention to the relationship pattern that evolves
between the patient and the therapist in therapy. These models assume that
patients’ maladaptive relationship themes are pervasive across their relationship
experiences and that patients’ maladaptive relationship patterns will become
enacted within the therapeutic relationship, although very little research has speci-
fically examined transference, particularly within the short-term models of treatment.
Anderson et al. have used experiments to examine whether mental represent-
ations of significant others influence perceptions of a new person. These researchers
have found that representations about significant others can influence perceptions
of a new individual (Andersen & Cole, 1990; Andersen, Glassman, Chen, & Cole,
1995) as well as affective responses (Andersen & Baum, 1994).
Within the context of psychotherapy, Luborsky et al. (1985) explored the nar-
ratives that patients share during psychotherapy, defined as discrete stories told
about an interaction with another individual. They found that, across eight psycho-
therapy cases, patients demonstrated one core interpersonal theme in their psycho-
therapy narratives, and patients’ relationship themes with significant others were
similar to the relationship the patient experienced with the therapist. Crits-Christoph
and Luborsky (1990) found that a repetitive interpersonal theme was evident across
66.3% of the narratives that patients shared in psychotherapy. Further, Fried, Crits-
Christoph, and Luborsky (1992) found evidence for transference of maladaptive
relationship themes to the therapeutic relationship. The researchers compared each
patient’s core interpersonal theme with that patient’s own therapist narratives and
with the therapist narratives of other patients in the sample. They found that the
core themes for each patient were more similar to that patient’s therapist narratives
than the core themes of other patients in the sample.
406 GIBBONS

Crits-Christoph, Demorest, and Connolly (1990) developed the quantitative

analysis of interpersonal themes (QUAINT) method to explore further transference
of interpersonal patterns using a methodology in which the themes in patients’ nar-
ratives are rated in random order using a standard language in order to decrease
the possible bias in assessing pattern consistency. Previous investigations had used
methodologies in which raters used their own language to describe the interper-
sonal themes of patients. In the QUAINT method, the structural analysis of social
behavior (Benjamin, 1974) provides a standard set of possible interpersonal wishes
and responses defined across the domains of control and affiliation. Using the
QUAINT method, the investigators demonstrated that, across a single case, a patient
expressed multiple interpersonal themes with different people in his life. Further, the
theme evident in narratives about the therapist became more like the theme evident
with 3 women in the patient’s life later in treatment. Crits-Christoph, Demorest,
Muenz, and Baranackie (1994) used the QUAINT method to demonstrate that,
across a large sample, there was a small but statistically significant level of consis-
tency of interpersonal themes across patients’ psychotherapy narratives.
We built on this literature by using the QUAINT method, along with a cluster
analysis approach, to explore the similarity of interpersonal themes across psycho-
therapy narratives and the transference of interpersonal themes to the therapeutic
relationship (Connolly et al., 1996). In this investigation, we had independent judges
rate the presence of interpersonal themes in each psychotherapy narrative provided
by a sample of 35 patients treated with either cognitive therapy (CT) or SE psycho-
therapy for opiate addiction. The judges rated each narrative in random order,
unaware of which narrative belonged to which patient. Judges rated the degree to
which standard lists of wishes, responses of other, and responses of self were present
on a 4-point scale for each narrative, resulting in a 104-item interpersonal profile for
each psychotherapy narrative.
We selected a 38-item interpersonal profile to represent each psychotherapy
narrative, including only those wishes and responses that were reliably rated by the
judges. Most of the items that were not included as reliable simply did not occur
in this sample because the full list of 104 items includes all possible wishes and
responses across the affiliation and interdependence dimensions. We were first
interested in exploring whether the interpersonal themes were consistent across
narratives for each patient or whether patients had distinct interpersonal themes
with different people. We used a cluster analysis approach for each patient to
extract the unique pattern for each patient. For each patient in the sample, we inter-
correlated the 38-item interpersonal profiles for each narrative told and then cluster
analyzed the resulting correlation matrix. We selected the number of clusters for
each patient’s result by choosing the level of the hierarchical cluster structure in
which all narrative profiles within a cluster correlated at least .30.
The results revealed that patients had between 1 and 5 distinct clusters that rep-
resented separate interpersonal patterns (M = 2.4 clusters). For each patient, there
was a main cluster that contained the greatest number of interpersonal narratives
and thus represented the patient’s core pervasive maladaptive interpersonal theme.
However, all patients had additional clusters that represented themes they experi-
enced with just a few or only one other person in their life. This investigation also
demonstrated that 60% of patients had an interpersonal theme evident in one of
their narrative clusters that was significantly correlated with the theme evident in a
narrative in which the therapist was identified by judges as the main object of the
story. For 34% of patients, it was the interpersonal pattern evident in the main, most
INTERPERSONAL RELATIONSHIPS IN PSYCHOTHERAPY 407

pervasive cluster that correlated with the therapist pattern. This investigation suggested
that there is consistency of interpersonal themes across patients’ psychotherapeutic
narratives. However, patients have multiple interpersonal themes with different
people in their lives. Although there appears to be one predominant theme for
each patient, patients also have secondary or idiosyncratic interpersonal patterns
with specific other people in their lives. Further, this investigation indicates that
transference of interpersonal themes to the therapeutic relationship is evident in the
majority of patients’ interpersonal narratives. However, not all patients expressed
similarity between the interpersonal patterns experienced outside of therapy and
those experienced with the therapist in these short-term treatments. This finding is
consistent with some short-term dynamic approaches, such as SE, that sparingly sup-
port the use of transference interpretations regarding the therapeutic relationship.
We replicated these findings across a sample of 18 patients treated with SE
psychotherapy for major depressive disorder (MDD; Connolly, Crits-Christoph,
Barber, & Luborsky, 2000). We used a similar methodology, with the exception that
narratives about significant people in the patient’s life were drawn from a pretreat-
ment interview that asked the patient to provide 10 stories of interactions they had
with other people, whereas the narratives about the therapist were drawn from the
psychotherapy sessions. The results were remarkably similar in this sample. Each
patient had between one and three clusters of similar narratives in terms of interper-
sonal patterns. There was a main cluster evident for each patient representing the
main, most pervasive interpersonal pattern for that patient. In this sample, 44% of
patients had an interpersonal theme that correlated significantly with the theme
evident in the therapist narratives. This transference was evident for the main theme
for 33% of patients. For one sample patient, the main theme evident across 10 psycho-
therapy narratives was best represented by a wish for the other to be nurturing and
protecting, the perceived response of other as ignoring and neglecting, and the
response of self to feel annoyed and irritated. The full interpersonal profile for
the main cluster was correlated with the theme evident in the therapist narrative
(r = .69, p = .01). Together, these studies demonstrate that patients have multiple
interpersonal themes in their relationships, although there is consistency of inter-
personal patterns across at least some relationships in their lives. Further, in short-term
treatments, some patients experience a theme with the therapist that is consistent with
their other relationships.

To What Extent Do Therapist Interventions Actually Address

Important Aspects of Interpersonal Relationships?

In exploring the effects of specific therapeutic approaches, it is valuable to have a

detailed understanding of the interventions actually implemented in the treatment
in practice. Although many studies of psychotherapy are based on manual-guided
treatment protocols, few studies actually describe the specific interventions evident
in either manual-based or non-manual-based psychotherapies. Such “molecular”-
level analyses of treatment sessions are necessary to understand what therapists
actually say in their sessions. This knowledge can inform the development of treat-
ment manuals and the training of therapists as well as provide clues regarding the
types of interventions that are most effective.
Most molecular-level studies of psychotherapy have examined the frequency
of different therapist response modes. Hill, Thames, and Rardin (1979) found
408 GIBBONS

theoretically consistent differences in response mode usage across three sessions

conducted by expert therapists with the same patient. Stiles, Shapiro, and Firth-
Cozens (1988), using a molecular-level assessment of therapist response modes,
reported that interpersonal–psychodynamic therapists used more interpretations
and reflections than therapists with a cognitive–behavioral orientation. Finally,
Piper, Debbane, de Carufel, and Bienvenu (1987) evaluated therapist response
modes across short-term dynamic psychotherapy. The results indicated that ther-
apists used, on average, 10 interpretations per session.
We conducted a molecular-level descriptive analysis of SE psychotherapy for
depression to characterize specifically what trained expert therapists do in this
treatment modality (Connolly, Crits-Christoph, Shappell, Barber, & Luborsky, 1998).
We evaluated three early treatment transcripts for each of 33 patients treated with
16 sessions of SE psychotherapy for major depression. Three independent trained
judges coded each therapist response mode using our own system in the context of
the therapy transcript. The descriptive analyses revealed that SE therapists were
very active, averaging 125 therapist statements per session. On average, five ther-
apist statements per session were coded by independent judges as interpretations,
meaning that the statements addressed aspects of the patient’s interpersonal
conflicts.
We further found that the majority of interventions focused on relationships
with patients’ parents, significant others, and the self, whereas very few statements
explicitly focused on the relationship with the therapist. In addition, less than 5% of
interpretations implemented by these SE therapists focused on the patient’s early
childhood experiences. This descriptive analysis revealed that SE psychotherapy is
an extremely active, present-focused treatment, which includes exploration of the
childhood past and the relationship with the therapist sparingly.
We replicated this molecular-level assessment of therapist response modes on
the interpersonal and CT sessions implemented in the Treatment of Depression
Collaborative Research Program (Elkin et al., 1989). We evaluated four early-session
transcripts and four late-session transcripts of 72 patients who participated in either
IPT or CT (Connolly Gibbons et al., 2002). We transcribed a total of 260 CT sessions
and 288 IPT sessions. Three independent judges trained in our classification system
coded 135,552 therapist statements, defined as unique speaking turns, for response
mode category, time frame, and person. This coding was undertaken as an interim
step in a large study in which specific therapist interventions were extracted so that
an assessment of the relation of specific therapeutic techniques to outcome could
be assessed. This interim data set of response mode coding provided a unique
opportunity to evaluate the response modes used in these two manual-guided treat-
ments. Seven advanced graduate students were trained in this classification system.
Judges participated in monthly recalibration sessions to maximize reliability and
prevent rater drift. We found good interjudge agreement on selecting the response
mode category that best fit each therapist speaking turn (κ = .72); intraclass correla-
tions for the classification of response mode categories ranged from .71 to .95.
Therapists in both treatments were quite active; Cognitive therapists used an
average of 263 therapist statements per session and interpersonal therapists used 233.
Four percent of therapist statements in the cognitive sessions and 6% of interpersonal
therapist statements were coded as learning statements, which included statements
designed to help patients learn about aspects of their interpersonal relationships.
Cognitive therapists used an average of 10 learning statements per session com-
pared with interpersonal therapists’ average of 11. Most therapist statements in both
INTERPERSONAL RELATIONSHIPS IN PSYCHOTHERAPY 409

treatment modalities focused on the current time frame, including 42% of cognitive
therapist statements and 30% of interpersonal therapist statements. Both treatments
included infrequent exploration of the childhood past time frame, representing less
than 1% of cognitive session statements and only 1.5% of interpersonal sessions.
Both treatments also included infrequent references to the here-and-now interaction
between the patient and therapist. The in-session time frame was coded for 7% of
cognitive session learning statements and 4% of interpersonal session learning state-
ments, whereas 5% of both cognitive and interpersonal learning statements included
the therapist as a focus of the statement. Similar to the results of the descriptive
analysis of SE psychotherapy reviewed previously (Connolly, Crits-Christoph, et al.,
1998), this study found that both IPT and CT are extremely active, present-focused
treatments, which, in rare instances, include exploration of the childhood past and the
relationship with the therapist. An analysis of variance (ANOVA) also highlighted
some treatment differences. The percentage of variance explained by differences
between treatments was significant and in the moderate to large effect size range for
frequencies of questions, restatements, and informational statements. There was also
a significant, if small, effect for the frequency of learning statements linking the current
conflict to the past; IPT therapists used significantly more of these responses.
A further analysis of this data set (Connolly Gibbons, Crits-Christoph, Levinson, &
Barber, 2003) revealed that therapists, although trained to adherence in manualized
techniques, implemented interventions that responded to the specific needs of
patients. This study includes a complete ANOVA in response mode usage that can be
accounted for by difference in patients, therapists, sessions, treatments, and phase of
therapy. This study provided evidence that therapists actually had considerable
flexibility in implementing a standardized psychotherapy. For example, therapists
used significantly more clarifications and questions with patients rated higher on pre-
treatment depression.
Across this set of studies, molecular-level assessments of psychotherapy
revealed that interpersonal content is an important therapeutic focus of SE dynamic
psychotherapy, IPT, and CT. Each of these treatment modalities focus on helping
patients learn about their interpersonal worlds by exploring their thoughts, feelings,
and behaviors within interpersonal relationships. Although there are important dif-
ferences between these treatment modalities, they are similar in their present-day
focus on conflicts within the context of interpersonal relationships.

What Is the Relationship Between Therapist

Interventions That Address the Patient’s Relationship
Conflicts With the Therapist and the Outcome of Treatment?

Because transference interpretations regarding the relationship between the patient

and therapist are considered a powerful and central intervention in dynamically
oriented psychotherapies, it is important to evaluate their effectiveness within psycho-
therapy. Does exploration of the relationship between the patient and therapist
lead to symptom reduction? As a replication and extension of two studies found in
the empirical literature (Piper, Azim, Joyce, & McCallum, 1991; Høglend, 1993), we
explored the relationship between the frequency of transference interpretations and
treatment outcome as a function of the patient’s level of quality of interpersonal
functioning. Connolly, Crits-Christoph, Shapell, et al. (1999) provide a full review of
the literature on the relation of transference interpretations and treatment outcome.
410 GIBBONS

For the sample of 33 patients treated with SE psychotherapy for MDD, we eval-
uated the relationship of transference interpretations to symptom course across treat-
ment. The coding of therapist response modes was used to define the frequency of
transference interpretations. Specifically, statements coded as interpretations by our
judges that also included the therapist as an object of the statement were defined as
transference interpretations. Pretreatment quality of interpersonal functioning was
based on a global rating from the Health Sickness Rating Scale.
On the basis of the results of a hierarchical multiple regression analysis, we
found that pretreatment quality of interpersonal functioning significantly moderated
the relation between use of transference interpretations and treatment outcome
(Connolly, Crits-Christoph, Shapell, et al., 1999). We conducted a median split of
patients on the quality of interpersonal relationships variable and found that high
levels of transference interpretations were associated with poor outcome in patients
who demonstrated poor interpersonal functioning before treatment. The median split
was conducted for descriptive purposes. Because of the reduction in power, the
associations between level of transference interpretation and outcome did not reach
statistical significance within the subgroups. However, the association for the patients
with poor interpersonal functioning before treatment ranged from .31 to .40 across
the symptom measures, indicating that the association within this subgroup may
have been driving the interaction effect.

Summary and Conclusions

This program of research has been designed to inform the role of interpersonal
relationships in the process of psychotherapy. I consider these studies to be the
beginning of a program of research that I will use to develop more effective inter-
vention packages. These studies together suggest a number of important findings
regarding the role of interpersonal relationships in the process of psychotherapy.
First, it appears that self-understanding of interpersonal patterns is an important
treatment outcome from the patient’s perspective. Further, self-understanding of
interpersonal patterns can be reliably measured, and this measure can be used to
demonstrate treatment specific changes across dynamic psychotherapy.
Because self-understanding is central to theories of psychotherapy and patients
find this to be an important psychotherapeutic outcome, it is important to demonstrate
that therapists actually have adequate material in the psychotherapeutic session to
formulate the patient’s interpersonal patterns accurately. The results of my research
program to date suggest that patients do tell narratives in their psychotherapy sessions
that demonstrate consistency of interpersonal themes. Patients tend to have one pre-
dominant interpersonal pattern that is consistent across the majority of the stories that
they tell in psychotherapy. However, patients also relay stories to the therapist of inter-
personal episodes that have themes that are idiosyncratic to a specific relationship.
These findings, based on only a small number of studies, suggest that therapists can be
most effective in helping patients explore their interpersonal worlds if they look for
common patterns across relations but avoid trying to fit all therapy narratives for a
given patient into a single dynamic formulation. Rather, patients may have multiple
interpersonal patterns that are problematic in their worlds. Although future research is
needed, these studies suggest that the therapist’s job is to formulate these multiple
interpersonal patterns for each patient from the narratives shared in psychotherapy
and to work with the patient to decide which patterns warrant further exploration.
INTERPERSONAL RELATIONSHIPS IN PSYCHOTHERAPY 411

Furthermore, these studies suggest that, for some patients, therapists can use
their own experience of the therapeutic relationship to inform their understanding
of patients’ maladaptive relationship pattern. However, therapists using short-term
treatments should be aware that not all patients develop transference across the
short-term treatments or at least not all patients articulate elements of the transfer-
ence theme in their therapeutic dialogue. Further, the pattern that is transferred to the
therapeutic relationship may not be the one that is most pervasive across patients’
other relationships. Finally, it appears that exploring relationship patterns through
the exploration of the therapeutic relationship can be a helpful technique for some
patients. Those with a history of positive relationships outside of therapy may be able
to make use of such interventions to learn about their problems, whereas those
with poor interpersonal functioning before treatment may not be able to work suc-
cessfully within the therapeutic relationship, at least within a short-term treatment.

Future Research Directions

I plan to continue a program of research exploring the role of interpersonal

relationships in the therapeutic process. As described earlier, I am already developing
a revised self-report measure of self-understanding as well as an observer-rated
measure because I believe adequate measurement of self-understanding of inter-
personal patterns is central to exploring the pathways to change in psychotherapy.
I am interested in how and when self-understanding changes across various psycho-
therapeutic approaches and whether such changes predict symptom course.
I am further interested in exploring the role of transference of interpersonal
patterns across patients’ relationships, specifically within the therapeutic relation-
ship. Understanding more about how transference emerges in short-term treatments
can be helpful to therapists who use the therapeutic relationship to inform them of
the patient’s interpersonal formulation. Further, it will be helpful to understand more
about how the therapeutic relationship can be used to help patients of different
functional levels learn about their interpersonal problems.
Finally, I am interested in exploring the effectiveness of interpersonal psycho-
therapies in community settings. Is exploration of self-understanding of inter-
personal patterns important to consumers in community mental health centers, and
is exploration of interpersonal patterns useful in achieving symptom relief in these
populations? In conclusion, interpersonal patterns are an important element of the
therapeutic process. Exploration of the role of interpersonal patterns may be useful
in further understanding psychotherapeutic processes and in developing more effec-
tive treatment approaches for patients seeking psychotherapy for mental health
problems.

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Zusammenfassung
Interpersonale Beziehungsmuster spielen eine wichtige Rolle im Kontext von Psychotherapie. Die
Autorin gibt einen Überblick über das Forschungsprogramm, das initiiert wurde, um die Rolle der
interpersonalen Beziehungsmuster im Psychotherapieprozess zu erkunden. Fünf Forschungsgebiete,
verbunden mit interpersonalen Beziehungsmustern werden zusammengefasst: a) die Perspektive des
Patienten bei der Erkundung interpersonaler Beziehungsmuster, b) die Messung des Selbstverständnisses
von interpersonalen Beziehungsmustern, c) Übertragungsreaktionen in interpersonalen Beziehungsmustern,
die in psychotherapeutischen Narrativen sichtbar werden, d) eine Analyse interpersonaler Beziehungsmuster
in verschiedenen Auffassungen von Psychotherapie auf einem molekularen Niveau und, e) die Beziehung
zwischen Übertragungsdeutungen und dem Behandlungsergebnis.

Résumé
Les patterns interpersonnels jouent un rôle important dans le contexte de la psychothérapie. L’auteur
résume le programme de recherche établi pour explorer le rôle des patterns interpersonnels dans le
processus psychothérapeutique. Cinq domaines de recherche liés aux patterns interpersonnels sont
résumés, à savoir: (a) la perspective du patient au sujet de l’exploration de patterns interpersonnels, (b)
la mesure de l’auto-compréhension de patterns interpersonnels, (c) l’évidence d’un transfert de patterns
interpersonnels dans des narrations psychothérapeutiques, (d) une analyse au niveau moléculaire de
l’emploi d’interventions interpersonnelles dans des modèles psychothérapeutiques variés, (e) la relation
entre l’emploi d’interprétations de transfert et le résultat d’un traitement.
414 GIBBONS

Resumen
Los patrones de relación interpersonal juegan un rol importante en el contexto de la psicoterapia. La
autora pasa revista al programa de investigación que se adoptó para explorar el rol de los patrones
interpersonales en el proceso psicoterapéutico. Se revistaron cinco áreas de investigación relacionadas
con los patrones interpersonales, las que incluyen (a) la perspectiva del paciente respecto de la
exploración de patrones interpersonales, (b) la medición de la autocomprensión de los patrones
interpersonales, c) transferencia de patrones interpersonales evidentes en narrativas psicoterapéuticas,
(d) análisis de nivel molecular del uso de intervenciones interpersonales en varios modelos de
psicoterapia, y (e) relación entre el uso de interpretaciones transferenciales y el resultado del
tratamiento.

Resumo
Os padrões interpessoais têm um papel importante no contexto da psicoterapia. A autora revê um
programa de investigação que foi estabelecido para explorar o papel dos padrões interpessoais no
processo psicoterapêutico. São revistas cinco áreas de investigação relacionadas com padrões
interpessoais, incluindo (a) a perspectiva do paciente em explorar padrões interpessoais, (b) a avaliação
da auto-compreensão de padrões interpessoais, (c) a transferência de padrões interpessoais evidentes
nas narrativas psicoterapeuticas, (d) a análise ao nível molecular do uso de intervenções interpessoais
em vários modelos de psicoterapia, e (e) a relação entre o uso de interpretações da transferência e o
resultado do tratamento.

Sommario
I pattern interpersonali rivestono un ruolo molto importante in psicoterapia. L’autore compie una
revisione del programma di ricerca che è stato creato per esplorare il ruolo dei patterns interpersonali
durante il processo terapeutico. Vengono qui presi in esame cinque aree di ricerca relativamente ai
pattern interpersonali ed in particolare: a) la prospettiva del paziente nell’esplorazione dei pattern, b) la
misurazione della comprensione da parte dei pazienti dei propri pattern, c) I pattern interpersonali nel
transfert evidenti dalle narrative di sedute di psicoterapia, d) un’analisi molecolare circa l’uso di
interventi interpersonali in terapie di differente orientamento, e) la relazione tra interpretazioni di
transfert e outcome.

Received September 9, 2003

Revision received May 14, 2004
Accepted May 25, 2004