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.
freud couch
Key Points
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 asdreams, conflicts, resistance, andtransference(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), anddefense 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 fromFreud(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 inpsychodynamic literature, core elements of interpretation can be found in other theoretical orientations, such as cognitive andschema 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.
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:
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.
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
Limitations
Implications
The results of this meta-analysis highlight the importance of interpretations inpsychotherapyand 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
Antichi, L., Giannini, M., & Loscalzo, Y. (2022). Interpretation in psychodynamic psychotherapy: A systematic review. Psychodynamic Practice, 28(3), 254–274.https://doi.org/10.1080/14753634.2022.2046140
Beck, A. T. (1976). Cognitive therapy and the emotional disorders. International Universities Press.
Bion, W. R. (1962). Learning from experience. Heinemann.
Bion, W. R. (1967). The Los Angeles seminars and supervision. Routledge.https://doi.org/10.4324/9780429485060
Bromberg, P. M. (2003). One need not be a house to be haunted: On enactment, dissociation, and the dread of “Not-Me”—A case study. Psychoanalytic Dialogues, 13(5), 689–709.https://doi.org/10.1080/10481881309348764
Colli, A., Gagliardini, G., & Gullo, S. (2022). Countertransference responses mediate the relationship between patients’ overall defense functioning and therapists’ interventions. Psychotherapy Research, 32(1), 32–45.https://doi.org/10.1080/10503307.2021.1884768
Crits-Christoph, P., & Gibbons, M. B. C. (2021). Psychotherapy process-outcome research: Advances in understanding causal connections. In M. Barkham, W. Lutz, & L. G. Castonguay (Eds.), Bergin and Garfield’s handbook of psychotherapy and behavior change (7th ed., pp. 263–296). Wiley.
Freud, S. (1895). Studien iiber Hysterie. Deuticke, Leipzig & Wien.
Freud, S. (1900). The interpretation of dreams. The standard edition of the complete psychological works of Sigmund Freud (Vol. IV–V). Hogarth Press.
Freud, S. (1911). The handling of dream-interpretation in psychoanalysis. The standard edition of the complete psychological works of Sigmund Freud (Vol. XII). Hogarth Press.
Freud, S. (1912). The dynamics of transference. The standard edition of the complete psychological works of Sigmund Freud (Vol. XII). Hogarth Press.
Freud, S. (1937). Constructions in analysis. The standard edition of the complete psychological works of Sigmund Freud (Vol. XXIII). Hogarth Press.
Gabbard, G. O. (2009). Techniques of psychodynamic psychotherapy. In G. O. Gabbard (Ed.), Textbook of psychotherapeutic treatments (pp. 43–67). American Psychiatric Publishing.
Gazzola, N., Iwakabe, S., & Stalikas, A. (2003). Counselor interpretations and the occurrence of in-session client change moments in non-dynamic psychotherapies. Counselling Psychology Quarterly, 16(2), 81–94. https://doi.org/10.1080/0951507031000136676
Høglend, P., & Gabbard, G. O. (2012). When is transference work useful in psychodynamic psychotherapy? A review of empirical research. In A. Levy, J. S. Ablon, & H. Kächele (Eds). Psychodynamic psychotherapy research: Evidence-based practice and practice-based evidence (pp. 449–467). Springer.
Klein, M. (1948). A contribution to the theory of anxiety and guilt. The International Journal of Psychoanalysis, 29(29), 114–123.
Kohut, H. (1984). How does analysis cure? University of Chicago Press.
Leahy, R. L. (2017). Cognitive therapy techniques: A practitioner’s guide. Guilford Press.
Mitchell, S. A. (2009). Relational concepts in psychoanalysis: An integration. Harvard University Press.
Mitchell, S. A., & Aron, L. E. (1999). Relational psychoanalysis: The emergence of a tradition. Analytic Press.
Ogden, T. H. (1994). The analytic third: Working with intersubjective clinical facts. International Journal of Psychoanalysis, 75, 3–20.
Olson, T. R., Perry, J. C., Janzen, J. I., Petraglia, J., & Presniak, M. D. (2011). Addressing and interpreting defense mechanisms in psychotherapy: General considerations. Psychiatry: Interpersonal & Biological Processes, 74(2), 142–165.https://doi.org/10.1521/psyc.2011.74.2.142
Oppenheimer, A. (2000). Heinz Kohut. Bookworm Publishers.
Petraglia, J., Bhatia, M., De Roten, Y., Despland, J. N., & Drapeau, M. (2015). An empirical investigation of defense interpretation depth, defensive functioning, and alliance strength in psychodynamic psychotherapy. American Journal of Psychotherapy, 69(1), 1–17.https://doi.org/10.1176/appi.psychotherapy.2015.69.1.1
Racker, H. (1968). Transference and countertransference. International Universities Press.
Summers, R. F., & Barber, J. P. (2010). Psychodynamic therapy: A guide to evidence-based practice. Guilford Press.
Wampold, B. E., Imel, Z. E, Bhati, K. S., & Johnson-Jennings, M. D. (2007). Insight as a common factor. In L. G. Castonguay & C. Hill (Eds.), Insight in psychotherapy (pp. 119–139). American Psychological Association.
Winnicott, D. W. (1962). The aims of psycho-analytical treatment. In D. W. Winnicott (Eds.), The maturational processes and the facilitating environment (pp. 166-170). Hogarth Press.
Winnicott, D. W. (1963). Communicating and not communicating leading to a study of certain opposites. In D. W. Winnicott (Ed.), The maturational processes and the facilitating environment (pp. 179-192) Hogarth Press.
Winnicott, D. W. (1968). Interpretation in psycho-analysis. In C. Winnicott, R. Shepherd, & M. Davis (Eds.), D. W. Winnicott: Psycho-analytic explorations (pp. 207–212). Harvard University Press.
Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy (p. 254). Guilford Press.
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
Keep Learning
Olivia Guy-Evans, MSc
BSc (Hons) Psychology, MSc Psychology of Education
Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.
Saul McLeod, PhD
BSc (Hons) Psychology, MRes, PhD, University of Manchester
Saul McLeod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.
