Association Between Interpretations and Psychotherapy Outcome

Interpretations are therapeutic techniques therapists use to raise patients’ awareness and understanding of recurrent maladaptive patterns. Interpretations label patients’ experiences in a new way and integrate various components of their experience, such as creating links between personal events and current functioning, past events and everyday experiences, or emotional and cognitive components, to uncover or reveal underlying conflicts.

Zilcha-Mano, S., Keefe, J. R., Fisher, H., Dolev-Amit, T., Veler-Poleg, N., & Barber, J. P. (2024). Is the use of interpretations associated with treatment outcome? A systematic review and meta-analytic answer. Clinical Psychology: Science and Practice, 31(1), 1–13. https://doi.org/10.1037/cps0000158

Key Points

• The meta-analysis of 16 studies (897 patients) found that higher scores on interpretation measures were significantly associated with more symptom improvement.
• Factors like the type of interpretation measure, assessor perspective, study quality, and number of sessions did not significantly affect the relationship between interpretations and treatment outcomes.
• Interpretation is a critical therapeutic technique that has received extensive theoretical and clinical attention, making this study universally relevant and important in the field of psychotherapy.

Rationale

Interpretation is a central technique in psychodynamic therapy, aiming to raise patients’ awareness and understanding of recurrent maladaptive patterns in their lives (Gabbard, 2009; Summers & Barber, 2010).

The literature suggests various ways of categorizing interpretations in psychotherapy. One approach is based on the content being interpreted, such as dreams, conflicts, resistance, and transference (Antichi et al., 2022). Another categorization considers the type of dynamic or conflict being interpreted, distinguishing between intrapersonal and interpersonal interpretations.

Intrapersonal interpretations relate to different parts of the patient’s personality, intrapsychic conflicts between parts of the ego (Racker, 1968) or between aspects of the self with conflicting needs (Bromberg, 2003), and defense mechanisms (Olson et al., 2011; Petraglia et al., 2015).

Interpersonal interpretations focus on the individual’s repetitive interpersonal patterns and can be further categorized as transference or nontransference interpretations (Høglend & Gabbard, 2012).

Interpretation has evolved significantly over the years, with notable contributions from Freud (1895, 1900, 1911, 1912, 1937), Klein (1948), Winnicott (1962, 1963, 1968), Bion (1962, 1967), and Kohut (1984; Oppenheimer, 2000).

The shift from one-person to two-person theoretical models has influenced the collaborative nature of interpretations, with relational psychoanalytic theoreticians conceptualizing therapy as an intersubjective meeting between the therapist and patient (Mitchell, 2009; Mitchell & Aron, 1999; Colli et al., 2022; Ogden, 1994).

Although originating in psychodynamic literature, core elements of interpretation can be found in other theoretical orientations, such as cognitive and schema therapies (Gazzola et al., 2003; Wampold et al., 2007; Beck, 1976; Leahy, 2017; Young et al., 2003).

Despite its theoretical importance, no meta-analysis has examined the effect of interpretations on psychotherapy outcomes (Zilcha-Mano et al., 2023). Previous reviews have suggested that greater use of psychodynamic techniques, including interpretations, is associated with better treatment outcomes (Crits-Christoph & Gibbons, 2021; Antichi et al., 2022).

However, these reviews were not systematic and did not quantify the size of the interpretation-outcome association or explore potential moderators of this relationship.

Therefore, the present study aimed to address these gaps by conducting a systematic review and meta-analysis of the association between interpretations and psychotherapy outcomes.

Method

The authors conducted a systematic review and meta-analysis adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

The study was preregistered in the international prospective register of systematic reviews (PROSPERO, registration number: CRD42021255798).

The authors searched for eligible studies in PubMed, PsycINFO, and MEDLINE databases from 1970 to May 2021, using the intersections of terms related to psychotherapy, interpretation, psychodynamic therapy, and therapists.

They also reviewed articles from previous literature reviews and contacted experts in the field for additional peer-reviewed studies.

Search strategy and terms

The authors searched PubMed, PsycINFO, and MEDLINE databases using the following terms: psychotherapy or therapy or treatment, interpretation or adherence or intervention or technique, psychodynamic or psychoanalytic or dynamic or supportive-expressive or insight-oriented, and psychotherapist or therapist.

Inclusion and exclusion criteria

Studies were included if they:

1. Referred to the therapy process variable as interpretations, psychodynamic adherence, or psychodynamic technique/intervention;
2. Provided data on outcome measures;
3. Involved individual psychotherapy;
4. Included at least five participants;
5. Reported data that allowed the extraction or estimation of the relation between interpretations and outcome;
6. Involved adult clients (age > 18 years);
7. Were written in English;
8. Were published in a peer-reviewed journal.

Statistical measures:

The authors used the R package robumeta to estimate the overall effect size and explore predictors of effect size using meta-regression. They used the I2 statistic to characterize the proportion of between-study heterogeneity in effect sizes.

Publication bias was examined using Egger’s regression test, Henmi and Copas’s method, and Rosenberg’s variant of the fail-safe N.

Results

The meta-analysis included 16 studies comprising 897 patients.

• Higher scores on interpretation measures were significantly associated with more symptom improvement (r = -0.23, 95% CI: [-0.36, -0.11], p = .002), with a medium degree of between-study heterogeneity (I2 = 58.3%).
• The association remained consistent across types of interpretation measures, assessor perspectives, study quality, and number of sessions.
• Sensitivity analyses demonstrated the robustness of the results, and there was no indication of publication bias.

Interpretations

The meta-analysis included various measures for assessing interpretations, with most studies (87.5%) assessing the frequency and intensity of interpretations used in a session.

Other studies assessed the competence (6.3%) or accuracy and quality (6.3%) of the interpretations. The perspective of the assessor also varied, with 68.8% focusing on the perspective of an external observer, 18.8% on the therapists’ perspective, and 12.5% on the patients’ perspective.

Treatment Outcome

Measuring treatment outcome, 31.3% of the studies used the severity of depression as the outcome, 31.25% used general symptom severity, and 31.3% used general life satisfaction, level of functioning, or problem improvement as the outcome.

Additional treatment outcomes included panic disorder severity, borderline disorder severity, and anxiety symptom severity, with a single article examining each of these outcomes.

The perspective of the outcome assessor varied, with 62.5% focusing on the patients’ perspective, 18.75% on the external diagnostician’s perspective, and the remaining studies using a combination of perspectives.

Moderators

The authors examined several potential study-level moderators of the relationship between interpretations and outcomes that could explain heterogeneity between studies.

However, none of the moderators significantly affected the interpretation-outcome association. The total rated quality score, adherence to temporal precedence, study year, randomized controlled trial design, primary treatment of major depressive disorder, and number of sessions did not predictably relate to effect sizes.

Adherence scores did not significantly differ from competence scores in predicting outcomes. The use of observer report or therapist report measures of interpretation did not affect effect sizes.

The use of specific measures, such as the Multitheoretical List of Therapeutic Interventions (MULTI) or the Core Conflictual Relationship Theme (CCRT), did not result in different effect estimates.

There were insufficient studies to meta-analytically examine the role of different focus of interpretation, potential moderators, or mediators of the interpretation-outcome relationship.

Insight

The key finding of this meta-analysis is that the use of interpretations in psychotherapy is associated with better treatment outcomes.

This association is low-to-moderate in size and comparable to other key mechanisms in treatment, such as the therapeutic alliance (Eubanks et al., 2018).

The consistency of the association across various moderators suggests that interpretations may be a robust predictor of treatment outcomes.

However, the moderate heterogeneity in the interpretation-outcome correlation between studies indicates that some individuals in certain situations may benefit more from interpretations than others.

Future research should explore patient and therapist characteristics, timing within treatment, and the quality and nature of interpretations as potential moderators of the interpretation-outcome relationship.

Strengths

• The study had several methodological strengths, including adherence to PRISMA guidelines, preregistration of the meta-analysis, a comprehensive search strategy,
• The use of robust statistical methods to account for between-study heterogeneity and publication bias.
• The inclusion of studies with diverse patient populations, therapist characteristics, and study designs also contributes to the generalizability of the findings.

Limitations

• The main limitations of the study include the relatively small sample size (16 studies, 897 patients) and the moderate heterogeneity in the interpretation-outcome correlation between studies.
• The diversity in measures used to evaluate interpretations, patient and therapist populations, and study designs, while contributing to generalizability, may have also contributed to heterogeneity and limited the specificity of the findings.
• Additionally, the correlational nature of the included studies precludes inferring causality between interpretations and treatment outcomes.

Implications

The results of this meta-analysis highlight the importance of interpretations in psychotherapy and their potential to contribute to positive treatment outcomes.

The findings support the theoretical and clinical emphasis on interpretations in psychodynamic therapy and suggest that interpretations may be a valuable technique across various therapeutic approaches.

However, the moderate heterogeneity in the interpretation-outcome correlation underscores the need for further research to identify the specific conditions, patient and therapist characteristics, and types of interpretations that may optimize treatment outcomes.

Clinicians should consider the potential benefits of interpretations in their practice while remaining attentive to individual patient needs and responses.

References

Primary reference

Zilcha-Mano, S., Keefe, J. R., Fisher, H., Dolev-Amit, T., Veler-Poleg, N., & Barber, J. P. (2024). Is the use of interpretations associated with treatment outcome? A systematic review and meta-analytic answer. Clinical Psychology: Science and Practice, 31(1), 1–13. https://doi.org/10.1037/cps0000158

Other references

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Zilcha-Mano, S., Keefe, J. R., Fisher, H., Dolev-Amit, T., Veler-Poleg, N., & Barber, J. P. (2023). Is the use of interpretations associated with treatment outcome? A systematic review and meta-analytic answer. Clinical Psychology: Science and Practice. Advance online publication. https://doi.org/10.1037/cps0000158

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