An interview by Richard C. Simons with Lester Luborsky on the appearance of his new book with Paul Crits-Christoph, Jim Mintz and Arthur Auerbach: “Who Will Benefit from Psychotherapy—Measuring Therapeutic Outcomes”, Basic Books, 1988.
Dr. Simons: I first want to ask you what your goal was and the values to the field of your new book?
Dr. Luborsky: My aim was to try to fill a crucial need of our field. As Merton Gill observed long ago, our field has a plethora of theories, but very few of them have been affirmed or disconfirmed. The type of research in this book should move the field ahead because it accomplishes that purpose. It takes the most representative theories of the curative factors in psychoanalytic psychotherapy, translates them so that clinicians can judge them reliably, and then tests them in relation to the outcomes of the treatments. The wish to advance the field is what launched me in this direction.
Dr. S. What do you consider are the main findings reported in the book?
Dr. L. The main findings are based on the operational measures of the theory of psychoanalytic psychotherapy. The findings are about the reliability of our measures and their generally good capacity to predict the outcomes of the treatment: the therapeutic alliance (by the helping alliance measures); the transference pattern (by the Core Conflictual Relationship Theme or “CCRT” measure); the accuracy of interpretation (by the convergence of interpretation with the CCRT); the self-understanding (by convergence of the patient's understanding with the CCRT); and the changes in the transference pattern during the treatment (by measures of changes in CCRT)
Dr. S. It is a happy time for the field and for you to have your new book out. It must have taken a lot of time to get such a massive research done?
Dr. L. Yes, the research and the writing have taken about 20 years. This book was a hard one to do and it's a relief to have it done. I hope it will be a benefit for our field.
Dr. S. How and when did you get interested in the topic of research in the psychoanalytic process?
Dr. L. It has a long history. My research activity on this topic had started even before I went to the Menninger Foundation in 1947—while I was teaching at the University of Illinois from 1945-1947. In association with Raymond Cattell, I did a study of symptom contexts (stomach pains in an ulcer patient) during daily free association sessions. In 1949 I started psychoanalytic training at the Menninger Foundation. I remember my hopefulness that it would enable me to do more than achieve personal psychological benefit, but to add to psychoanalytic knowledge about the process of psychoanalysis. I tried over the next years but it was a fact that progress was very slow—in 1969 I wrote an article called “Research cannot yet influence clinical practice”. But more recently there has been a distinct turnaround in my judgment of the capacity of psychotherapy research to influence clinical practice—I wrote another paper in 1986, with an almost identical title except for the word “now” instead of “not”: “Research can now influence clinical practice”.
Dr. S. What is the style of the research in the new book?
Dr. L. Some of the style replicated or took off from the models in the Menninger Foundation Psychotherapy Research Project in which I participated for many years under the leadership of Robert Wallerstein and Otto Kernberg. First and foremost the style is “clinical quantitative”, that is, it starts with clinical theories and moves toward quantitative measurement. For each theory of change, an operational measure is constructed that captures an important aspect of the theory. For example, the theory holds that a good therapeutic alliance is a basic curative factor. We therefore made a measure that reliably guides clinical judges in scoring this aspect of psychotherapy sessions. In more recent years one part of our data has been recordings of psychoanalytic psychotherapy or psychoanalysis, not only the usual process notes. The set of data that is heavily represented in this book is based on the tape recordings of the sessions of 73 complete treatments by psychoanalytic psychotherapy in 1968 to 1973 as part of the Penn Psychotherapy Project. We have been studying these cases ever since. Every time we come up with an idea for a new operational measure of a likely curative factor we then can go back and try it on our main data set.
Dr. S. I understand you are planning more new books now. What are they?
Dr. L. My plans at this point have expanded. They are to complete a series of six basic books, all related to psychoanalytic psychotherapy and psychoanalysis. Book I (with Robert Holt)1 was “Personality patterns of psychiatrists”, which was about the selection for training of successful psychoanalytic psychotherapists. Book 22 was the 1984 manual for psychoanalytic psychotherapy. It grew out of my teaching of psychoanalytic psychotherapy in our Department of Psychiatry at the University of Pennsylvania, where I've been since 1959. In the course of the teaching and research I needed a manual. I started to develop one in 1975 and to use it generally in 1976. It was published in 1984 and served its purpose well. It not only helps with teaching but it also helps in research, so that the researcher can know the degree to which each sample of therapy fits the specifications of the manual. Book 33 is the just published book, “Who will benefit from psychotherapy?” As we've just discussed, it provides operational measures of psychoanalytic concepts of the curative factors. Book 44 is a just being completed guide book on the Core Conflictual Relationship Theme method. The “CCRT” is really quite close to a transference measure. The method serves as a tool for clinicians and researchers. I'll stop at this point rather than describe books five and six and maybe we'll talk again a year from now when the next book and interview are done.
Dr. S. Are you really going to stop there and leave me and us curious? But maybe that's a good point at which to end —with an anticipation of your future work.
Dr. L. Your curiosity overcomes my reticence—my inclination to not talk until the work is done. But why not? The fifth book may be called “Testing
Theories of Psychological Symptom Formation”. Competing theories of symptom formation need to be tested and my symptom context method is suited to that task. The book brings together studies that I and others have done since 1947. The evanescent symptom that I've worked with most is momentary forgetting during psychotherapy; one of the papers is called “What sets off momentary forgetting when one is about to say something”. The sixth book is on the relationship of mood and stress to immunoincompetence. There is evidence that depressed mood is associated with impairment on some measures of immune function. We have data on patients with major depression who are in psychoanalytic psychotherapy and on normal cyclothymic people who are not in treatment. With both groups we assess a broad range of immune functioning when the mood is depressed versus not depressed. But that book is three years away from seeing the light of day.
Dr. S. What is your secret of how you manage to get all these done?
Dr. L. It's simple—it involves how, when, where and with whom. In the last few years I've allowed myself more daytime time to write. The writing is mostly on the results of our research in the Penn Psychotherapy Research Center, managed together with a cracker jack co-director, Paul Crits-Christoph. But there has been some trade-off. As my earliest collaborator Raymond Cattell said, and he has been proven to be right, “the more you write the poorer you get.” It's still true but I'm hoping one day that will change. And there has been recurrent support. Beyond the Luborsky Biopsychosocial Foundation, there has been the very handy, timely, help from the Fund for Psychoanalytic Research of the American Psychoanalytic Association and the luckily-secured sustaining grants from the NIMH. As for the mechanics of the writing, I follow the advice of my friend Irving Janis to do the writing at home or in the library. And the writing starts with dictation followed by a rapid transcription turnaround. These are the basic secret components of the simple recipe.
Dr. S. On behalf of all of us in the Association, I want to thank you for your dedication over so many years to process and outcome research in psychoanalytic psychotherapy and psychoanalysis. We are deeply indebted to you, and we look forward with anticipation and pride to the publication of the last three books you have just described.