<p>The objective of this work was to investigate reflective-functioning (RF) as a measure of process in two independent studies that included three types of brief psychotherapy. RF is defined as the ability to recognize the existence and nature of mental processes taking place in the self and in others (e.g., intentions, beliefs, desires, and wishes). Theorists have suggested the ability for RF is crucial for predicting social causality and low RF has been found related to mental disorders. It has recently been suggested in the literature that improved ability for RF might be an important component of successful psychotherapy outcome, especially with respect to achieving structuralchange. RF was in this work investigated during the process through discourse analysis of the patients’ narratives of self-other interactions in the treatment sessions. The Psychotherapy Process Q-set (PQS) was implemented in order to isolate specific components of the process (process correlates) that identified high and low RF and to investigate the links between the process correlates and outcome. The first study investigated 29 cases of cognitive-behavioral therapy(CBT) and 35 cases of interpersonal psychotherapy (IPT) with an average treatment length of 16.2 sessions in a sample from the National Institute of Mental Health (NIMH) randomized clinical trial Treatment of Depression Collaborative Research Program (TDCRP). The sample in the first study consisted of 128 sessions in total, were one session from the early part (on average the 4th session) and one session in the later part of the treatment (on average the 12th session) were rated for RF. The second study investigated a sample of 30 cases of brief psychodynamic psychotherapy (BPDT) with an average treatment length of 15.8 sessions in a naturalistic designand obtained from the Mount Zion Psychotherapy Research Group. In total, the second study included 90 sessions of BPDT, and RF was assessed during the 1st, the 5th, and the 14th session of each treatment. The results from these two studies suggested that the patients’ ability for RF, as measured through the discourse from therapy sessions, is stable (in CBT and BPDT) or decreased(IPT) during the treatments. Furthermore, the process correlates defining high RF had a relation with good outcome, and process correlates defining low RF had a relation with poor outcome.The process correlates identified during the PQS-analysis suggested that both high and low RF was linked with personality characteristics in the patients. For example, high RF was linked to patients’ ability for introspection, expression of negative emotions, and commitment to treatment.Low RF was linked to patients’ expression of passivity, defensiveness, and suspiciousness. This work supported theorists’ suggestions that brief treatments are supportive in their nature and therefore do not promote structural changes (e.g., changes in RF). It is suggested that the abilityfor RF as assessed pre-treatment might be a useful predictor for success in brief psychotherapy and could therefore be used as a patient inclusion criteria for such treatments.</p>

The objective of this work was to investigate reflective-functioning (RF) as a measure of process in two independent studies that included three types of brief psychotherapy. RF is defined as the ability to recognize the existence and nature of mental processes taking place in the self and in others (e.g., intentions, beliefs, desires, and wishes). Theorists have suggested the ability for RF is crucial for predicting social causality and low RF has been found related to mental disorders. It has recently been suggested in the literature that improved ability for RF might be an important component of successful psychotherapy outcome, especially with respect to achieving structuralchange. RF was in this work investigated during the process through discourse analysis of the patients’ narratives of self-other interactions in the treatment sessions. The Psychotherapy Process Q-set (PQS) was implemented in order to isolate specific components of the process (process correlates) that identified high and low RF and to investigate the links between the process correlates and outcome. The first study investigated 29 cases of cognitive-behavioral therapy(CBT) and 35 cases of interpersonal psychotherapy (IPT) with an average treatment length of 16.2 sessions in a sample from the National Institute of Mental Health (NIMH) randomized clinical trial Treatment of Depression Collaborative Research Program (TDCRP). The sample in the first study consisted of 128 sessions in total, were one session from the early part (on average the 4th session) and one session in the later part of the treatment (on average the 12th session) were rated for RF. The second study investigated a sample of 30 cases of brief psychodynamic psychotherapy (BPDT) with an average treatment length of 15.8 sessions in a naturalistic designand obtained from the Mount Zion Psychotherapy Research Group. In total, the second study included 90 sessions of BPDT, and RF was assessed during the 1st, the 5th, and the 14th session of each treatment. The results from these two studies suggested that the patients’ ability for RF, as measured through the discourse from therapy sessions, is stable (in CBT and BPDT) or decreased(IPT) during the treatments. Furthermore, the process correlates defining high RF had a relation with good outcome, and process correlates defining low RF had a relation with poor outcome.The process correlates identified during the PQS-analysis suggested that both high and low RF was linked with personality characteristics in the patients. For example, high RF was linked to patients’ ability for introspection, expression of negative emotions, and commitment to treatment.Low RF was linked to patients’ expression of passivity, defensiveness, and suspiciousness. This work supported theorists’ suggestions that brief treatments are supportive in their nature and therefore do not promote structural changes (e.g., changes in RF). It is suggested that the abilityfor RF as assessed pre-treatment might be a useful predictor for success in brief psychotherapy and could therefore be used as a patient inclusion criteria for such treatments.

O objetivo principal da “investigação de processos” é compreender os mecanismos de ação das psicoterapias. Um dos instrumentos mais utilizados na atualidade para a avaliação do processo das psicoterapias é o Psychotherapy Process Q-Set (PQS). Esta tese teve como objetivo elaborar a versão em português do PQS e utilizá-la para avaliar a relação entre o processo e o resultado na Psicoterapia Psicodinâmica Breve (PPDB). Três artigos foram elaborados, sendo dois estudos empíricos e uma revisão da literatura. O primeiro artigo apresenta a elaboração da versão em português do PQS e sua metodologia inclui tradução, retrotradução, avaliação formal da equivalência semântica dos itens, e discussão dos resultados. Neste artigo o estudo de avaliação da fidedignidade interavaliadores do PQS é também apresentado. O segundo artigo é uma revisão crítica da literatura acerca da aplicabilidade do estudo de caso na pesquisa em psicoterapia. O terceiro artigo analisa o processo de mudança em um caso de PPDB. Os escores do PQS referentes ao processo real foram correlacionados com os protótipos do PQS para a psicoterapia psicodinâmica (PPD) e para a terapia cognitivo-comportamental (TCC), gerando escores de adesão. Testes t para amostras pareadas verificaram se o processo terapêutico aderiu mais ao modelo ideal PPD do que ao modelo alternativo, TCC. Análises de séries temporais bivariada (Gottman & Ringland, 1981) foram realizadas para avaliar as relações entre a adesão aos protótipos ideais da PPD e da TCC com o progresso terapêutico (reduções nos níveis estimados de sofrimento geral, ansiedade, depressão, somatização e ajustamento social). De modo geral, os resultados indicam que a versão em português do PQS é equivalente em termos semânticos à versão original e apresenta boa fidedignidade interavaliadores (coeficientes variaram entre 0,53 e 0,72 no estudo de fidedignidade relatado no artigo 1, e entre 0,52 e 0,85 no caso principal estudado no artigo 3). O PQS se mostrou capaz de fornecer dados relevantes à realização de um estudo abrangente do processo terapêutico de uma psicoterapia breve. Os achados do estudo de caso revelaram um quadro multifacetado e complexo e estão em consonância com outras pesquisas realizadas nesta linha de investigação que indicam que, na privacidade de seus consultórios, os psicoterapeutas efetivos muitas vezes se distanciam dos modelos ideais das psicoterapias que professam, adaptando suas técnicas às necessidades do contexto. A partir deste trabalho, os pesquisadores brasileiros agora dispõem de um instrumento capaz de fornecer descrições empírica e clinicamente válidas do processo terapêutico de diferentes psicoterapias, e de um modelo para investigar, de forma sistemática e seqüencial, a correspondência entre processos ideais e processos reais das psicoterapias e a sua influência sobre o progresso de tratamento. / The main goal of process studies is to understand how change occurs during treatment, identifying the mechanisms of therapeutic action. Nowadays, one of the most used instruments to assess psychotherapy process is the Psychotherapy Process Q-Set (PQS). This thesis aimed to develop the Portuguese version of PQS and to use it in examining the relationship between process and outcome in brief psychodynamic therapy (BPDT). Three articles were prepared, comprising two empirical studies and one literature review. The first article presents the development of the Portuguese version of PQS. Its methodology includes translation, back translation, semantic equivalence appreciation and discussion of results. In this paper, the study of inter-rater reliability of PQS is also presented. The second article reviews the literature about the applicability of case studies in psychotherapy research. The third article analyzes the process of change of a brief psychotherapy single case. PQS ratings of the actual therapy process were correlated with PQS prototypes of ideal psychodynamic therapy (PDT) and ideal cognitive behavioral therapy (CBT) to derive adherence scores. Paired t tests examined whether the psychotherapy process adhered more closely to ideal PDT than ideal CBT. Bivarate times series analysis (Gottman & Ringland, 1981) were performed to verify relations between adherence to prototypes of ideal PDT and of ideal CBT and therapeutic progress (reductions in estimated levels of general distress, anxiety, somatization, depression and social adjustment). In general, results indicate that the Portuguese version of PQS is semantically equivalent to its original and has adequate inter-rater reliability (coefficients ranged between 0.53 and 0.72 in the study of reliability reported in article 1 and between 0.52 and 0.85 in the case study in the 3rd article). The PQS provided relevant data to perform a comprehensive study of a brief psychotherapy process. The case study findings revealed a multifaceted and complex picture, and are consistent with other studies of this line of research indicating that, in the privacy of their offices, effective psychotherapists, many times, stray away from the ideal model of psychotherapy they profess and adapt their techniques to context needs. From now on, Brazilian researchers have a research tool that provides clinical and empirically significant descriptions of different psychotherapies therapeutic processes. They also have now a model to investigate, in systematic and sequential manner, the correspondence between ideal and real processes, and the influence of the different elements of the process on therapeutic progress.

O objetivo principal da “investigação de processos” é compreender os mecanismos de ação das psicoterapias. Um dos instrumentos mais utilizados na atualidade para a avaliação do processo das psicoterapias é o Psychotherapy Process Q-Set (PQS). Esta tese teve como objetivo elaborar a versão em português do PQS e utilizá-la para avaliar a relação entre o processo e o resultado na Psicoterapia Psicodinâmica Breve (PPDB). Três artigos foram elaborados, sendo dois estudos empíricos e uma revisão da literatura. O primeiro artigo apresenta a elaboração da versão em português do PQS e sua metodologia inclui tradução, retrotradução, avaliação formal da equivalência semântica dos itens, e discussão dos resultados. Neste artigo o estudo de avaliação da fidedignidade interavaliadores do PQS é também apresentado. O segundo artigo é uma revisão crítica da literatura acerca da aplicabilidade do estudo de caso na pesquisa em psicoterapia. O terceiro artigo analisa o processo de mudança em um caso de PPDB. Os escores do PQS referentes ao processo real foram correlacionados com os protótipos do PQS para a psicoterapia psicodinâmica (PPD) e para a terapia cognitivo-comportamental (TCC), gerando escores de adesão. Testes t para amostras pareadas verificaram se o processo terapêutico aderiu mais ao modelo ideal PPD do que ao modelo alternativo, TCC. Análises de séries temporais bivariada (Gottman & Ringland, 1981) foram realizadas para avaliar as relações entre a adesão aos protótipos ideais da PPD e da TCC com o progresso terapêutico (reduções nos níveis estimados de sofrimento geral, ansiedade, depressão, somatização e ajustamento social). De modo geral, os resultados indicam que a versão em português do PQS é equivalente em termos semânticos à versão original e apresenta boa fidedignidade interavaliadores (coeficientes variaram entre 0,53 e 0,72 no estudo de fidedignidade relatado no artigo 1, e entre 0,52 e 0,85 no caso principal estudado no artigo 3). O PQS se mostrou capaz de fornecer dados relevantes à realização de um estudo abrangente do processo terapêutico de uma psicoterapia breve. Os achados do estudo de caso revelaram um quadro multifacetado e complexo e estão em consonância com outras pesquisas realizadas nesta linha de investigação que indicam que, na privacidade de seus consultórios, os psicoterapeutas efetivos muitas vezes se distanciam dos modelos ideais das psicoterapias que professam, adaptando suas técnicas às necessidades do contexto. A partir deste trabalho, os pesquisadores brasileiros agora dispõem de um instrumento capaz de fornecer descrições empírica e clinicamente válidas do processo terapêutico de diferentes psicoterapias, e de um modelo para investigar, de forma sistemática e seqüencial, a correspondência entre processos ideais e processos reais das psicoterapias e a sua influência sobre o progresso de tratamento. / The main goal of process studies is to understand how change occurs during treatment, identifying the mechanisms of therapeutic action. Nowadays, one of the most used instruments to assess psychotherapy process is the Psychotherapy Process Q-Set (PQS). This thesis aimed to develop the Portuguese version of PQS and to use it in examining the relationship between process and outcome in brief psychodynamic therapy (BPDT). Three articles were prepared, comprising two empirical studies and one literature review. The first article presents the development of the Portuguese version of PQS. Its methodology includes translation, back translation, semantic equivalence appreciation and discussion of results. In this paper, the study of inter-rater reliability of PQS is also presented. The second article reviews the literature about the applicability of case studies in psychotherapy research. The third article analyzes the process of change of a brief psychotherapy single case. PQS ratings of the actual therapy process were correlated with PQS prototypes of ideal psychodynamic therapy (PDT) and ideal cognitive behavioral therapy (CBT) to derive adherence scores. Paired t tests examined whether the psychotherapy process adhered more closely to ideal PDT than ideal CBT. Bivarate times series analysis (Gottman & Ringland, 1981) were performed to verify relations between adherence to prototypes of ideal PDT and of ideal CBT and therapeutic progress (reductions in estimated levels of general distress, anxiety, somatization, depression and social adjustment). In general, results indicate that the Portuguese version of PQS is semantically equivalent to its original and has adequate inter-rater reliability (coefficients ranged between 0.53 and 0.72 in the study of reliability reported in article 1 and between 0.52 and 0.85 in the case study in the 3rd article). The PQS provided relevant data to perform a comprehensive study of a brief psychotherapy process. The case study findings revealed a multifaceted and complex picture, and are consistent with other studies of this line of research indicating that, in the privacy of their offices, effective psychotherapists, many times, stray away from the ideal model of psychotherapy they profess and adapt their techniques to context needs. From now on, Brazilian researchers have a research tool that provides clinical and empirically significant descriptions of different psychotherapies therapeutic processes. They also have now a model to investigate, in systematic and sequential manner, the correspondence between ideal and real processes, and the influence of the different elements of the process on therapeutic progress.

O objetivo principal da “investigação de processos” é compreender os mecanismos de ação das psicoterapias. Um dos instrumentos mais utilizados na atualidade para a avaliação do processo das psicoterapias é o Psychotherapy Process Q-Set (PQS). Esta tese teve como objetivo elaborar a versão em português do PQS e utilizá-la para avaliar a relação entre o processo e o resultado na Psicoterapia Psicodinâmica Breve (PPDB). Três artigos foram elaborados, sendo dois estudos empíricos e uma revisão da literatura. O primeiro artigo apresenta a elaboração da versão em português do PQS e sua metodologia inclui tradução, retrotradução, avaliação formal da equivalência semântica dos itens, e discussão dos resultados. Neste artigo o estudo de avaliação da fidedignidade interavaliadores do PQS é também apresentado. O segundo artigo é uma revisão crítica da literatura acerca da aplicabilidade do estudo de caso na pesquisa em psicoterapia. O terceiro artigo analisa o processo de mudança em um caso de PPDB. Os escores do PQS referentes ao processo real foram correlacionados com os protótipos do PQS para a psicoterapia psicodinâmica (PPD) e para a terapia cognitivo-comportamental (TCC), gerando escores de adesão. Testes t para amostras pareadas verificaram se o processo terapêutico aderiu mais ao modelo ideal PPD do que ao modelo alternativo, TCC. Análises de séries temporais bivariada (Gottman & Ringland, 1981) foram realizadas para avaliar as relações entre a adesão aos protótipos ideais da PPD e da TCC com o progresso terapêutico (reduções nos níveis estimados de sofrimento geral, ansiedade, depressão, somatização e ajustamento social). De modo geral, os resultados indicam que a versão em português do PQS é equivalente em termos semânticos à versão original e apresenta boa fidedignidade interavaliadores (coeficientes variaram entre 0,53 e 0,72 no estudo de fidedignidade relatado no artigo 1, e entre 0,52 e 0,85 no caso principal estudado no artigo 3). O PQS se mostrou capaz de fornecer dados relevantes à realização de um estudo abrangente do processo terapêutico de uma psicoterapia breve. Os achados do estudo de caso revelaram um quadro multifacetado e complexo e estão em consonância com outras pesquisas realizadas nesta linha de investigação que indicam que, na privacidade de seus consultórios, os psicoterapeutas efetivos muitas vezes se distanciam dos modelos ideais das psicoterapias que professam, adaptando suas técnicas às necessidades do contexto. A partir deste trabalho, os pesquisadores brasileiros agora dispõem de um instrumento capaz de fornecer descrições empírica e clinicamente válidas do processo terapêutico de diferentes psicoterapias, e de um modelo para investigar, de forma sistemática e seqüencial, a correspondência entre processos ideais e processos reais das psicoterapias e a sua influência sobre o progresso de tratamento. / The main goal of process studies is to understand how change occurs during treatment, identifying the mechanisms of therapeutic action. Nowadays, one of the most used instruments to assess psychotherapy process is the Psychotherapy Process Q-Set (PQS). This thesis aimed to develop the Portuguese version of PQS and to use it in examining the relationship between process and outcome in brief psychodynamic therapy (BPDT). Three articles were prepared, comprising two empirical studies and one literature review. The first article presents the development of the Portuguese version of PQS. Its methodology includes translation, back translation, semantic equivalence appreciation and discussion of results. In this paper, the study of inter-rater reliability of PQS is also presented. The second article reviews the literature about the applicability of case studies in psychotherapy research. The third article analyzes the process of change of a brief psychotherapy single case. PQS ratings of the actual therapy process were correlated with PQS prototypes of ideal psychodynamic therapy (PDT) and ideal cognitive behavioral therapy (CBT) to derive adherence scores. Paired t tests examined whether the psychotherapy process adhered more closely to ideal PDT than ideal CBT. Bivarate times series analysis (Gottman & Ringland, 1981) were performed to verify relations between adherence to prototypes of ideal PDT and of ideal CBT and therapeutic progress (reductions in estimated levels of general distress, anxiety, somatization, depression and social adjustment). In general, results indicate that the Portuguese version of PQS is semantically equivalent to its original and has adequate inter-rater reliability (coefficients ranged between 0.53 and 0.72 in the study of reliability reported in article 1 and between 0.52 and 0.85 in the case study in the 3rd article). The PQS provided relevant data to perform a comprehensive study of a brief psychotherapy process. The case study findings revealed a multifaceted and complex picture, and are consistent with other studies of this line of research indicating that, in the privacy of their offices, effective psychotherapists, many times, stray away from the ideal model of psychotherapy they profess and adapt their techniques to context needs. From now on, Brazilian researchers have a research tool that provides clinical and empirically significant descriptions of different psychotherapies therapeutic processes. They also have now a model to investigate, in systematic and sequential manner, the correspondence between ideal and real processes, and the influence of the different elements of the process on therapeutic progress.