Abstract
We used cluster analysis, a mixed dimensional-categorical design (Ward, 1963), to provide profiles of technique adherence and flexibility in psychodynamic therapy to examine the relationship between such profiles and outcome. A 4-cluster solution representing a 2 × 2 categorical model was predicted. Forty-six outpatients were consecutively enrolled in individual psychodynamic psychotherapy and received a DSM–IV Axis I diagnosis of a depressive spectrum disorder. Patients were assessed pre- and posttreatment through self-report of depressive symptoms. Treatment was videotaped, two early sessions were independently rated for use of PI (psychodynamic-interpersonal) and CB (cognitive–behavioral) techniques with excellent interrater reliability (ICC > .75). Mean technique ratings were calculated per case. A hierarchical cluster analysis was used and surprisingly produced a 3-cluster solution: (1) Adherent and Minimally Flexible, (2) Somewhat Adherent and Somewhat Flexible, and (3) Adherent and Somewhat Flexible. While all clusters demonstrated improvement in symptoms, it appears that psychodynamic therapists who incorporate CB techniques should be mindful of doing so at the expense of their primary modality. Minimally technique-flexible therapists seem to cluster as a group that is focused on adherence and not necessarily limited in overall technique use and engagement. However, adherent and somewhat flexible therapists appear to have significantly higher rates (85%) of clinically significant change compared to either less flexible or less adherent therapists (45% and 38%, respectively). Further research is needed to establish consistent clusters of adherence/flexibility and clarify how much of the relationship between adherence, flexibility, and outcome can be accounted for by other treatment factors, such as therapist engagement.