Object relations theory and short-term dynamic psychotherapy

Clinical Psychology Review, Vol. 19, No. 6, pp. 669–685, 1999 Copyright © 1999 Elsevier Science Ltd Printed in the USA. All rights reserved 0272-7358/99/$–see front matter

PII S0272-7358(98)00080-4

OBJECT RELATIONS THEORY AND SHORT-TERM DYNAMIC PSYCHOTHERAPY: FINDINGS FROM THE QUALITY OF OBJECT RELATIONS SCALE William E. Piper University of British Columbia

Scott C. Duncan University of Alberta

ABSTRACT. This review focuses on the relevance of object relations theory to short-term dynamic psychotherapy (STDP). From diverse theoretical and research literatures, a small number of core theoretical concepts and assessment dimensions are identified. Specific assessment methods are also highlighted. Research evidence concerning a particular object relations concept (quality of object relations) and a corresponding interview scale (Quality of Object Relations Scale) that has emerged from a series of psychotherapy clinical trials is presented in support of the relevance of object relations theory to STDP. Clinical implications and future research directions are considered. © 1999 Elsevier Science Ltd

WIDESPREAD INTEREST IN short-term dynamic psychotherapy (STDP), as practiced in the individual situation, emerged in the 1980s. Part of its appeal has been practical in nature. STDP has the potential to be both effective and cost-efficient, which has enhanced its value in the current era of health-care reform. Its short-term format has also been an appealing practical feature for researchers. Another part of the STDP’s appeal has been conceptual in nature. It has allowed dynamically oriented clinicians to retain familiar concepts, such as unconscious processes, intrapsychic conflict, transference, interpretation, and insight, while making technical innovations. During the same period of time there has been emerging interest among clinicians and researchers in object relations theory. Quite naturally the question of its relevance to STDP has arisen. Correspondence should be addressed to William E. Piper, Department of Psychiatry, University of British Columbia, Vancouver, BC V6T 2A1, Canada.

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There are a number of ways in which object relations theory is relevant to STDP. Given the pressure of limited time, there is a need for the patient and therapist to quickly form a working relationship. A predisposition to form a relatively trusting giveand-take relationship with an authority figure is most helpful. As therapy progresses and the demands of STDP increase, the same can be said regarding the patient’s ability to tolerate the emotionally charged interpersonal situation. Thus, a more mature level of object relations is a favorable patient selection criterion for STDP. A patient’s level of object relations can also be viewed as an indicator of overall psychopathology, which has prognostic relevance for treatment in general. Quality of object relations theory additionally provides the therapist with a comprehensive means of understanding the patient. It considers affect regulation, self-esteem regulation, use of fantasy and defenses, as well as relationship patterns. It helps the therapist select a central focus, integrate here-and-now interaction, and choose appropriate interventions. Again, it is important that this occurs quickly in the short-term time frame of STDP. Despite the general relevance of object relations theory to STDP, the application of specific forms of the theory to the clinical situation has been challenging. Rather than representing a uniform theory, object relations theory encompasses a number of theoretical perspectives, each with its own set of assumptions and metapsychological concepts. Many are difficult to define and operationalize. Consequently, a diverse set of assessment approaches and methods have been generated to capture object relations phenomena. Deciding which are the most useful or productive for the clinician and researcher is not obvious from present knowledge. Research that has investigated the relevance of object relations theory to STDP is scarce, in particular research that is based on large samples. Despite the current state of affairs, some lines of research have produced promising findings. They lend a sense of excitement to the task of discovering knowledge about STDP from the perspective of object relations theory. The current review first considers a small number of core concepts that characterize object relations theory. Next, a range of assessment approaches for the various concepts are considered and specific methods are described. Then, a particular method that has been used in a series of clinical trials involving short-term dynamic psychotherapies is presented and the research evidence is examined. This line of research has generated findings that support the relevance of object relations theory to STDP. Finally, clinical implications are considered and suggestions for future research are offered.

OBJECT RELATIONS THEORY Object relations theory, within the broader context of psychoanalytic thought, has been a source of lively theoretical discourse and continues to inspire further interest. From Freud’s early, although imprecise, use of the concept, through the evolution of his and other’s views on the development and dynamics of the psyche, the object and object relations have been the subject of fruitful theoretical and clinical elaboration. General historical perspectives of the theories of object relations have been provided by Compton (1996), Kernberg (1976, 1985, 1996), and Greenberg and Mitchell (1983). In the present review, focus is limited to the distinctive conceptual features of the theories, highlighting their development and place in the overall field. Four core concepts are: (a) the object; (b) psychological structure; (c) the inner world; and (d) the dynamic processes of internalization and externalization, which are considered

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from a developmental perspective including their influence on day-to-day interpersonal relationships. From our perspective, these concepts represent the essence of object relations theories.

THE OBJECT IN OBJECT RELATIONS An object, psychologically distinct and standing in relation to a subject, is a primary and axiomatic component of all object relations theories. Different functions, dynamics, and roles are accorded the object, but all acknowledge its primacy. As with many aspects of psychoanalytic theory, the notion of the object has evolved over the years. Freud (1915/1957) defined the object by placing it in conjunction with the instinctual drive, stating it is “the thing in regard to which or through which the drive is able to achieve its aim” (p. 65). An object was considered not to have been originally connected with the instinctual drive “but becomes attached to it only in consequence of being peculiarly fitted to provide satisfaction” (p. 65). Freud also suggested that an object is “the most variable thing about an instinct,” that it is “extraneous” and that “the same object may serve for the satisfaction of several instincts simultaneously” (p. 65). For Freud, the object was secondary to the instinctual drive. In fact, one’s connections to the human environment were not regarded as inherent, but created out of patterns of instinctual gratification by others. Object relational theorists take a different stance regarding the object. Fairbairn (1952) represents an object-based perspective that is antithetical to that of Freud. He writes that “impulses cannot be considered apart from the endopsychic structures which they energize and the object relationships they enable these structures to establish” (p. 85), and “‘instincts’ cannot profitably be considered as anything more than forms of energy which constitute the dynamic of such endopsychic structures” (p. 85). His point of view represents the other extreme of the theoretical pole in conceptualizing the importance and role of the object in the psyche. By way of clarifying the ongoing theoretical utility of the object concept, Greenberg and Mitchell (1983) make the following four points. The first is that the term object can refer both to a real person in the external world and to the internally established image of that person, thus accommodating inside and outside. The second point concerns the variability of the object. It may be alive or dead, active or static, and benign or malignant. Their third point refers to the phenomenological tangibility of the object. The object is experienced as real. Their fourth point refers to the manipulability and modifiability of the object, which occurs through certain operations (e.g., destruction and repair). These features provide object relations theories with flexibility and allow their ease of application. Moore and Fine (1990) suggest that the term object relations be reserved for the vicissitudes of intrapsychic object representations but that they must be inferred from the basis of experience. Most of these ideas about the object can easily be related to experience. They facilitate our understanding of complex phenomena inherent in human development and relationships.

STRUCTURE AND RELATIONSHIPS Object relations theory suggests that it is the experience of relationships with external others that forms the structural constituents of the psyche. According to Rapaport

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and Gill (1959), the structures are “inferred from behavior,” have “a slow rate of change,” “are configurations within which, between which, and by means of which mental processes take place,” and “are hierarchically ordered” (pp. 802–804). Implied is the view that complex psychological processes create structures that have further effects on process. Blanck and Blanck (1986) suggest that “early structures consist of various internalizations, more primitive forms of defense, [and] early forms of connection with objects and object images” (p. 44). They consider these structures to “constitute the very warp and woof of the material...not only of the transferences [but of]...early forms of object relations” (p. 44). They also state that “self and object images are built out of myriad daily affective experiences that begin on day one or before” (p. 50) and that “structure builds by consolidation of single experiences into ‘islands’ and ‘continents’” (p. 51).

THE INNER WORLD Construing an inner world as a location for object relations creates the crucial distinction between inside and outside and delimits a boundary across which various exchanges are hypothesized to occur. This allows for descriptions of ways in which structuralization occurs as a result of vital interactions between outside relationships with real-world objects and their internal images and representations. Freud (1938/1957) suggests that a shift occurs developmentally wherein an individual’s objects, originally outside of him or her, come to be located in the internal world. His description of this process is that “a portion of the external world has, at least partially, been abandoned as an object and has instead, by identification, been taken into the ego and thus become an integral part of the internal world” (p. 205). Sandler and Rosenblatt (1962) consider the representational world to be made up of the multitude of “images and organizations of [the person’s] internal as well as external environment” (p. 132). It is in the representational world that the collection of stable object images corresponding to the outside world are kept. These authors differentiate between the image and representation of an object. An object image is one of many that make up an infant’s experience of another (the gratifying mother, the frustrating mother, and happy mother, etc.), and an object representation is formed gradually out of sequential accretions of these various images (the mother in her experiential entirety). Beres and Joseph (1970) contend that “mental representations form the unconscious basis of all conscious mental activities” (p. 4). Blanck and Blanck (1986) delineate numerous functions of object representations within the representational world. These include provision of a feeling of safety, establishment of internal regulatory functions, promotion of ego autonomy, character development, superego development, provision of an ego ideal, resolution of oedipal wishes, and progression to the latency period of development.

PROCESSES OF INTERNALIZATION AND EXTERNALIZATION The nature of the interaction between inside and outside is enhanced by explanations of the ways in which outer experience comes to be represented internally. Descriptions of the processes of internalization and externalization clarify the ways in which

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inner and outer experiences become mutually influential on the development of the psyche. Phenomena such as transference and countertransference, as well as assessments of quality of object relations that focus on a person’s actual outside relationships, become understandable when these notions of inside and outside are considered. The processes whereby phenomenal experiences come to have a location within the subject are perhaps the most important and fundamental in object relations theory. In this sense an important link is established between inner and outer worlds. The integrity, quality, and nature of a person’s inner endowment is a function of and dependent on the nature of the complex interactions with real external objects, which occur throughout one’s development. Internalization, in fact, occurs via three mechanisms: incorporation, introjection, and identification, the last being the only observable “clinical manifestation” (Beres & Joseph, 1970, p. 5). These three mechanisms correspond to increasing levels of self and object differentiation. They range from a gross overinclusive process to a selective and precise one. Incorporation occurs during the early stages of development when there is confusion about what is self and what is other. The accompanying fantasies usually center around oral themes and imply destruction of the object. Later, incorporative processes give way to introjective ones, which are characterized by greater differentiation between self and object. Aspects of the object that are taken in are drawn into the growing realm of self-representations. Both self and object representations and the boundaries between them are strengthened. In the case of identification, aspects of the other are more selectively taken in. The aspects become integrated with parts of the self. They contribute directly to the establishment of a core sense of identity. The whole of the representational world and its contents comes into being via the repeated oscillations of internalized, externalized, and re-internalized experience. Conversely, daily relationships are colored to varying degrees by the quality of the inner world as internalizing and externalizing processes have their effect. Although the core concepts of object relations theory are relatively few in number, a large number of assessment methods have been developed to measure object relations phenomena. In part, this is due to the wide range of events that are encompassed within the internal and the external worlds of the person. It is also due to the attempt to elucidate ideas about psychopathology that correspond to the various levels of object relations. This has usually resulted in consideration of additional concepts. In the case of the internal world, this might involve how well differentiated mental representations are from each other and how well each integrates diverse qualities. In the case of the external world, this might involve how much the person relies on others for self-identity and how well the person tolerates both positive and negative qualities in other persons. Whether the focus has been on aspects of the internal or external worlds, levels of object relations have been construed as ranging from primitive to mature. The more primitive the structure of the internal world or the nature of external relationships, the more character pathology has been assumed.

OBJECT RELATIONS ASSESSMENT APPROACHES Assessment methods can be differentiated on several dimensions. These include the nature of the stimuli presented to the subject, the nature of the responses provided by the subject, and the degree of inference required to score and interpret the responses. Stim-

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uli range from those that are ambiguous to those that are objective. They include patterns, pictures, vignettes, and questions from interviews and questionnaires. Responses consist of perceptions, memories, dreams, drawings, autobiographical accounts, and narrative descriptions of people and relationships. The degree of inference that is required to score and interpret the responses ranges from minimal to considerable. As suggested above, methods also differ in their field of focus (i.e., the internal world or the external world). The former encompasses intrapsychic mental representations of the self, others, and their relationships, both realistic and fantasized. It is usually assumed to be inaccessible to consciousness. The latter encompasses the self, others, and their relationships as external figures and behaviors. They are accessible to direct observation. Despite the theoretical importance of understanding how one domain influences the other and their degree of interdependence, few researchers have attempted to measure both domains and their relationships. Typical of many areas of psychological research, individual research teams have tended to use specialized and limited methods over a series of studies. This makes it difficult to arrive at an integrative view of findings even within the same domain. Recently, however, several reviews have been published that attempt to organize the diverse set of methods and summarize findings associated with them (Fishler, Sperling, & Carr, 1990; Smith, 1993; Stricker & Healey, 1990). The current review of assessment approaches has benefited from them. Representative examples of some of the better known approaches will be cited. The previous reviews should be consulted for a more comprehensive and detailed survey of the various approaches and the findings associated with them. Assessment methods that have focused on the internal world have frequently involved projective stimuli such as Rorschach or TAT cards. Special scoring systems have been devised to rate the responses and make inferences about the structural and thematic characteristics of mental representations and their relationships. Two wellknown systems that have been applied to Rorschach responses are the Concept of the Object Scale (Blatt, Brenneis, Schimek, & Glick, 1976) and the Mutuality of Autonomy Scale (Urist, 1977). The Object Relations and Social Cognition Scale (Westen, Lohr, Silk, Gold, & Kerber, 1990) has been used with TAT cards. Other systems such as the Comprehensive Early Memories Scoring System (Last & Bruhn, 1983) and the Object Representation Scale for Dreams (Krohn & Mayman, 1974) have been used with early memories and dreams. The variables measured by the various projective methods are generally regarded as theoretically valid indicators of the internal world of mental representations. However, because of the level of inference required for their measurement, inability to demonstrate high reliability has at times been a problem. In part for this reason, more objective measures of internal object relations have been developed. An example is the Bell Object Relations Reality Testing Inventory (Bell, Billington, & Becker, 1986), a 90-item questionnaire. Assessment methods that have focused on the external world have involved observer ratings of actual interpersonal behavior and relationships, observer ratings of reports about previous interpersonal behavior and relationships, and self-ratings of previous or current interpersonal behavior and relationships. Although most of these methods have a theoretical basis that articulates internal concepts and processes, the ratings are primarily based on references to external behavior. Actual interpersonal behavior has come from special test situations, interviews, and therapy sessions. Examples of methods that have focused on actual samples of behavior include the Ainsworth Strange Situation Technique (Ainsworth, Blehar, Waters, & Wall, 1978) which is based

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on concepts from attachment theory, and the Structural Analysis of Social Behavior (SASB; McLemore & Benjamin, 1979). Methods that have utilized both actual behavior and reports about previous behavior are the Plan Diagnosis (Weiss, Sampson, & the Mount Zion Psychotherapy Research Group, 1986), Configurational Analysis (Horowitz, 1979, 1987), and the Cyclical Maladaptive Pattern (Strupp & Binder, 1984). Each of these methods includes a set of concepts that provide a unique patient formulation. Although a standard quantitative index based on predefined content is not generated, the formulation can be used to guide treatment plans and interventions. Other methods have relied entirely or primarily on reports about previous behavior and relationships. Similar to several of the above methods, the core conflictual relationship theme (Luborsky & Crits-Christoph, 1990) provides a unique patient formulation. It relies on spontaneous reports about previous interpersonal behavior and relationships, which are referred to as narratives. Other interview approaches are more structured. They include the Ego Function Assessment (Bellak, Hurvich, & Gediman, 1973), the Adult Attachment Interview (George, Kaplan, & Main, 1984), the Attachment Interview (Bartholomew & Horowitz, 1991), the Object Relations Inventory (Diamond, Kaslow, Coonerty, & Blatt, 1990), the Quality of Interpersonal Relationships Scale (Høglend, 1993a), and our own Quality of Object Relations Scale (Azim, Piper, Segal, Nixon, & Duncan, 1991). The last two measures differ from the others in providing a single dimension that indicates the overall quality of object relations. Smith (1993) suggested that the interview-based techniques have attempted to strike a balance between attending to patterns of behavior and making inferences about stable internal structure. Recently, several self-report scales that assess attachment patterns have emerged. They tend to focus on recent or current relationships. Examples, include the Adult Attachment Scale (AAS; Collins & Read, 1990), the Reciprocal Attachment Questionnaire (RAQ; West & Sheldon-Keller, 1994), and the Client Attachment to Therapist Scale (CATS; Mallinckrodt, Gantt, & Coble, 1995). They, too, are primarily based on references to external behavior. There are few studies that present evidence of significant relationships between object relations or attachment concepts and either the therapeutic alliance or outcome in STDP. Two studies using self-report scales of attachment patterns have reported significant associations with working alliance among clients receiving short-term counseling (Mallinckrodt, Coble, & Gantt, 1995; Satterfield & Lyddon, 1995). Two other studies have reported significant findings with inpatient populations. Ford, Fisher, and Larson (1997) found a direct relation between an interview measure of object relations and treatment outcome among patients with posttraumatic stress disorder. Similarly, Fonagy et al. (1996) reported preliminary findings of a direct relation between an interview measure of attachment patterns and treatment outcome among nonpsychotic patients with severe personality disorders. A study that did focus on STDP was that of Høglend (1993b). He reported finding a direct relation between an interview measure of object relations and treatment outcome among a mixed group of psychiatric outpatients. Perhaps the most substantial evidence for relationships between object relations and both the therapeutic alliance and outcome in STDP has emerged from a series of clinical trials from our research team that were conducted in Montreal and Edmonton. The findings involving STDP were further supported in clinical trials involving partial hospitalization programs. The measure of object relations that has been used by our research team is the Quality of Object Relations Scale.

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QUALITY OF OBJECT RELATIONS SCALE (QORS)

Scale Development The QORS originated in Montreal in the 1970s among a team of clinical researchers in the Individual and Group Psychotherapy Unit of the Allan Memorial Institute. Central members of the team included J. P. Bienvenu, F. L. de Carufel, E. G. Debbane, J. Garant, and W. E. Piper. The QORS was not derived from a particular object relations theory. Nevertheless, its conceptual basis included the core concepts (object, structure, inner world, internalization, externalization) that were described earlier. The first version of the scale was a product of practical necessity. One of the research team’s interests was investigating patient characteristics that were predictive of success in different forms of psychodynamic psychotherapy. Belief in the value of object relations theory in generating useful research measures led to the inclusion of three object relations variables among a larger set of 15 variables that therapists used to rate psychotherapy patients after conducting initial interviews. The three variables were based on subareas of criteria (object choice, type of relationship, sexual) from the Object Relations Scale of the Camarillo Dynamic Assessment Scales (May & Dixon, 1969). The Camarillo Object Relations Scale had been developed from the set of patient variables of The Menninger Foundation’s Psychotherapy Research Project (Robbins, Wallerstein, Sargent, & Luborsky, 1956). The original Menninger variable was called quality of interpersonal relationships. As the label suggests, the Menninger team, followed by the Camarillo and Montreal teams, was interested in rating the favorable and unfavorable aspects of interpersonal relationships in various spheres of the patient’s life from the perspective of the clinician. Because May and Dixon designed their scales for use in research with first admission schizophrenic patients, their criteria reflected relatively severe psychopathology. Our Montreal team revised many of the criteria in the upper range of the scales for the three variables to make them more appropriate for an outpatient psychotherapy population. Then, the variables were used to rate patients who were participating in a comparative outcome study for four forms of time-limited individual and group psychotherapy (Piper, Debbane, Bienvenu, & Garant, 1984). Although relatively simple in nature, the ratings of QOR were found to be directly and significantly related to desirable process and favorable outcome for both STDP and group psychotherapy (de Carufel & Piper, 1988; Piper, de Carufel, & Szkrumelak, 1985). Since its use in the Montreal, comparative outcome study, the QORS has progressed through several forms. In general, the criteria have become more explicit and detailed. Modifications of the scale typically occurred as part of preparation for its use in new psychotherapy clinical trials. For example, a modification was made prior to its use in a controlled clinical trial of STDP carried out in Edmonton (Piper, Azim, McCallum, & Joyce, 1990). In this 20-session treatment, the therapists were active, interpretive, and transference oriented. Modifications were also made prior to two Edmonton clinical trials on time-limited forms of day treatment (Piper, Rosie, Azim, & Joyce, 1993) and evening treatment (McCallum, Piper, & O’Kelly, 1997) partial hospitalization programs. These 4-month treatments were intensive, group oriented, and time limited. A further modification of the QORS was made prior to a recently completed clinical trial in Edmonton that compared interpretive and supportive forms of shortterm, time-limited individual therapy (Piper, Joyce, McCallum, & Azim, 1998). Over this series of studies, the criteria and their weights for each level of the QORS were adjusted to improve conceptual clarity and reliability of measurement. The adjustments

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resulted in corresponding changes in the names for the five levels. Despite these changes, each form has retained the same general definition of quality of object relations and the same general distinctions among the five levels of the scale.

Scale Description QOR is defined as a person’s internal enduring tendency to establish certain types of relationships that range along an overall dimension from primitive to mature (Azim et al., 1991). QOR thus refers to a life-long pattern rather than one that characterizes only recent relationships. The five levels and anchor points of the overall dimension are presented in Table 1. Criteria are arranged within each of the five levels under the following four headings: behavioral manifestations, affect regulation, self-esteem regulation, and antecedent (etiological) factors. Behavioral manifestations consist of descriptions of an individual’s typical relationship patterns. Affect regulation is defined by the type of interpersonal relationships the subject unconsciously and consciously wishes for and engages in, both in fantasy and ultimately in action, to reduce anxiety, experience gratification, or both. Likewise, self-esteem regulation is considered as the wished-for, fantasized, and behaviorally expressed interpersonal relationships that enhance selfesteem or reduce mortification. Antecedents are those past events or relationships thought to be clinically or theoretically predisposing to a given level. More weight is given to behavioral manifestations because they are experience-near, observable, and usually manifested in the interviewer-interviewee interaction. Because of their relatively experience-distant nature and the greater need for inference in evaluating them,

TABLE 1. Quality of Object Relations Scale Level and Anchor Point Mature (9)

Triangular (7)

Controlling (5)

Searching (3)

Primitive (1)

Predominant Characteristics The person enjoys equitable relationships characterized by love, tenderness, and concern for objects of both sexes. There is a capacity to mourn and tolerate unobtainable relationships. The person is involved in real or fantasized triangular relationships. Competition for one object is inspired by victory over the other object. There is concern for the objects. The person engages in well-meaning attempts to control and possess objects. Relationships are characterized by ambivalence. Attempts to control the person are met with defiance or pseudocompliance. The person is driven to find substitutes for a longed-for lost object. Substitutes provide a short-lived sense of optimism and self-worth, which is followed by disillusionment and the re-experience of loss. The person reacts to perceived separation or loss of the object, or disapproval or rejection by the object, with intense anxiety and affect. There is inordinate dependence on the lost object, who provides a sense of identity for the person.

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affect regulation, self-esteem regulation, and antecedents, in that order, are given less weight. Prototypical patients for each level and scoring procedures are described in a manual that can be obtained from the authors (Piper, McCallum, & Joyce, 1993). QOR has usually been assessed during two 1-hour interviews that are conducted 1 week apart. The objective of the first interview, which is relatively unstructured, is to obtain a history of the patient’s important relationships in a spontaneously recounted manner. The objective of the second interview, which is more structured, is to differentiate and clarify the patient’s levels of object relations. After the second hour, the interviewer distributes 100 points among the five levels of the dimension. A simple arithmetic formula is used to weight the ratings for the five levels and generate an overall score that ranges from 1 to 9, the higher the score the higher the quality of object relations.

Psychometric Properties Considerable information concerning the rater reliability, concurrent validity, and predictive validity of the QORS has emerged from the four Edmonton clinical trials cited above. The sizes of the primary outcome samples from the trials were 105 for the controlled individual therapy study, 144 for the comparative individual therapy study, 120 for the day treatment study, and 142 for the evening treatment study, although subsamples were used for some hypothesis testing.

Rater Reliability In each clinical trial one or more independent raters provided overall scores for QOR using audiotapes of the original interview. Intraclass correlation coefficients were calculated. The respective coefficients were ICC(2, 1) 5 .50 for the controlled individual therapy study, ICC(2, 2) 5 .68 for the comparative individual therapy study, ICC(2, 1) 5 .62 for the day treatment study, and ICC(2, 1) 5 .72 for the evening treatment study. Thus, the QOR assessment method has evidenced moderate rater reliability.

Concurrent Validity Demographic and historic variables. In both the controlled and comparative individual therapy trials, no significant relationships were found between QOR and age, gender, marital status, educational status, or employment status. In the day treatment trial, high-QOR patients were more likely to have been married. In the evening treatment trial, QOR was directly related to educational status. In regard to previous psychiatric hospitalization, no significant relationship was found in the comparative individual therapy trial or the day treatment trial. In the evening treatment trial, QOR was significantly lower in patients with previous psychiatric hospitalization. Diagnostic variables. In the controlled individual therapy trial, no significant relationships were found between QOR and DSM-III Axis I diagnoses. In contrast, low-QOR patients were more likely to have an Axis II diagnosis, although the two variables were far from being synonymous. Of the low-QOR patients, 45% received a personality disorder diagnosis, compared with 17% of the high-QOR patients. In the comparative individual therapy trial, significant relationships were found for Axis II, but not Axis I di-

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agnoses. In the day treatment trial, there were no significant relationships between QOR and lifetime DSM-III Axis I disorders. However, two significant relationships were found for current Axis I disorders. Low-QOR patients were more likely to receive diagnoses of major depression and atypical bipolar disorder. There was no significant relationship between QOR and the presence of an Axis II diagnosis. In the evening treatment trial, no significant relationships were found between QOR and DSM-III Axis I diagnoses. There was just one significant relationship with an Axis II diagnosis. Patients with Schizoid Personality Disorder had lower QOR. Initial disturbance. In each of the four clinical trials, lower QOR scores were associated with greater disturbance on some of the initially assessed outcome variables. This was the case for 4 of 19 variables in the controlled individual therapy trial (partner dysfunction, sexual dysfunction, life satisfaction, and anxiety) and 4 of 13 variables in the comparative individual therapy trial (depression, general symptomatic distress, social functioning, and family functioning). In the day treatment trial, 3 of 17 variables demonstrated this pattern (social dysfunction, maladaptive defences, and number of friends). In the evening treatment trial, it was the case for 6 of 18 variables (family dysfunction, satisfaction with friends, interpersonal functioning on the Interpersonal Behavior Scale and the Inventory of Interpersonal Problems, target objective severity rated by an independent assessor, and global assessment of functioning). Although significant, the correlations with initial disturbance in the four clinical trials were not large. The personality variable psychological mindedness. In the controlled individual therapy trial, psychological mindedness was not assessed. In the other three trials, the relationship between QOR and psychological mindedness indicated nearly complete independence. In summary, the clinical trials indicated that QOR is largely independent of demographic, historic, and diagnostic variables, as well as the personality variable psychological mindedness. In contrast, some evidence for a direct relationship between QOR and initial disturbance has been found.

Predictive Validity In the controlled individual therapy trial (Piper, Azim, Joyce, McCallum, Nixon, & Segal, 1991), QOR was directly related to ratings of the therapeutic alliance provided by the patient, r(62) 5 .29, p , .05, and the therapist, r(62) 5 .28, p , .05. The large set of outcome variables was reduced to three conceptually meaningful factors by means of a principal components analysis (general symptomatology and dysfunction, individualized objectives of treatment, and social-sexual adjustment). QOR was directly related to favorable outcome for general symptomatology and dysfunction at posttherapy, r(60) 5 .25, p , .05, and individualized objectives at both posttherapy, r(62) 5 .35, p , .01, and 6-month follow-up, r(52) 5 .37, p , .01. Compared with a set of predictor variables representing recent interpersonal functioning, QOR emerged as the strongest predictor of alliance and outcome. In the comparative individual therapy trial, QOR was directly related to patient-rated therapeutic alliance during the first third of therapy, r(142) 5 .17, p , .05. QOR was also directly related to favorable outcome in interpretive therapy (multivariate set of 13 outcome variables) but virtually unrelated to outcome in supportive therapy.

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In the day treatment trial, QOR was directly related to remaining in the program, r(163) 5 .23, p , .01. It was also directly related to favorable outcome on two primary outcome factors, general symptomatology and target objectives at posttherapy, r(96) 5 .26, p , .01, and follow-up, r(48) 5 .31, p , .05; and social maladjustment and dissatisfaction at posttherapy, r(97) 5 .21, p , .05. QOR was not related to outcome in the evening treatment trial.

Moderator Effects In addition to direct relationships between QOR and the therapeutic alliance, remaining, and treatment outcome in the various studies, QOR has emerged as an important moderator variable in the controlled individual therapy trial. Thus, relationships between other variables have differed depending on the level of QOR. For example, the relationship between the extent to which the therapist uses transference interpretations and the average level of the therapeutic alliance or treatment outcome have differed depending on the level of QOR (Piper, Azim, Joyce, & McCallum, 1991). Significant negative relationships with alliance and outcome were found for high-QOR patients. Similarly, the relationship between the extent to which the therapist provides “accurate” transference interpretations and the average level of the therapeutic alliance or treatment outcome have differed depending on the level of QOR (Piper, Joyce, McCallum, & Azim, 1993). Accurate is defined as correspondence between the content of the interpretation and the content of an initial patient formulation. For this variable, a significant positive relationship with treatment outcome was found for high-QOR patients, and significant negative relationships with the therapeutic alliance and with treatment outcome were found for low-QOR patients. These findings concerning both the extent of use and the accuracy of transference interpretations have received support in independent studies in Norway (Høglend, 1993a; Høglend & Piper, 1995). Further evidence of the importance of QOR as a moderator variable was found in two subsequent studies based on the patients treated in the controlled individual therapy trial. Both studies used hierarchical linear modeling (HLM) procedures. In the first, an increasing pattern of therapist-rated alliance over the course of therapy was directly related to favorable outcome in the case of low-QOR patients (Piper, Boroto, Joyce, McCallum, & Azim, 1995). In the second, the degree to which patients worked in response to transference interpretation was directly related to initial disturbance and inversely related to favorable treatment outcome in the case of high-QOR patients (Joyce & Piper, 1996). The consistent discovery of moderator effects suggests that the two samples (low-QOR, high-QOR) differ in important ways. The clinical relevance of these findings and the predictive validity findings for STDP will be considered next.

Relevance of QOR to STDP STDP usually refers to individual therapy with an interpretive emphasis. It has also been referred to as “exploratory,” “expressive,” or “insight oriented.” Interest in STDP heightened during the 1970s and 1980s in association with the publication of a number of persuasive books (Bellak & Small, 1978; Davanloo, 1978; Malan, 1976; Mann, 1973; Sifneos, 1972; Strupp & Binder, 1984). Most of the approaches emphasized therapist focus, therapist activity, and therapist interpretation, in particular the inter-

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pretation of transference. Because these technical emphases had previously been associated with supportive therapy (activity) or long-term interpretive therapy (interpretation), the approaches were regarded as controversial. However, many case reports and a small number of controlled outcome trials served to convince many clinicians of the potential effectiveness of STDP. As indicated previously, part of its appeal was conceptual; it allowed dynamically oriented therapists to retain familiar concepts while making technical innovations, and part was practical; it allowed therapists to cope with high demands for services in the face of limited staff resources. In the Edmonton controlled trial of STDP, the therapists were active, interpretive, and transference oriented. As part of the approach, the patient was expected to begin each session and share responsibility for what followed. There was ongoing pressure for the patient to talk. The therapist avoided attempts at direct gratification or praise. Instead, the therapist encouraged the patient to explore conflictual aspects of his/her experiences, which often included uncomfortable emotions. Interpretations, which involved sensitive and painful topics, were offered. Unpredictability of session content and process was part of the intended framework. Thus, the therapeutic situation was a challenging one that required adaptation on the part of the patient. The patient-therapist relationship was the medium of this adaptation. Within this challenging and somewhat unpredictable situation, one of the immediate tasks of the patient and therapist is to form a collaborative working relationship. One could assume that the patient’s life-long history and pattern of establishing meaningful give-and-take relationships was important. This was confirmed in the Edmonton trial by the direct relationships between QOR and both the therapeutic alliance and treatment outcome. The moderator effect findings from the Edmonton trial also highlighted the relevance of QOR.

Clinical Implications of QOR Findings Regarding STDP Given the small number of studies and the modest effect sizes associated with most of the findings, it is important to be cautious in drawing clinical implications. Nevertheless, if one regards the findings as tentative and in need of further confirmation, a number of potentially useful clinical implications can be formulated. Perhaps the simplest involves the direct relationships among QOR, alliance, and outcome. The findings suggest that QOR might serve as a useful selection criterion for STDP. The apparent relation between QOR and outcome stands in contrast to the frequently reported absence of a relation between DSM diagnostic disorders and the outcome of psychotherapy. In this context, the minimal relations between QOR and the diagnostic disorders in the clinical trials are not that surprising. The QOR scale is a dimensional one that spans a number of levels. Weights for levels are based on the presence of subdimensional features, not the presence of a number of necessary and sufficient symptoms or behaviors that define a discrete category. Patients may receive high weights for two or more distinctly different levels, which ultimately contribute to an overall score. Thus, the two approaches to conceptualizing patients are quite different and may be independent; patients with similar QOR scores may have different diagnoses, and patients with the same diagnosis may have different QOR scores. Although the chances of establishing a strong alliance and favorable outcome appear to be enhanced with high-QOR patients, it must be recognized that patients sometimes pleasantly surprise us. For that reason, clinicians may wish to take on a certain number of higher risk (low-QOR) patients as a means of providing them with an

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opportunity to benefit. Some undoubtably will. Thus, high QOR might be regarded as a favorable but not essential selection criterion. The clinical implications regarding the use of transference interpretations and the therapeutic alliance are more complex because correlational findings regarding simultaneous events do not indicate causal direction. For example, therapists may be more inclined to use more transference interpretations with high-QOR patients when faced with a weak alliance because they believe they will be tolerated and used. Or, high-QOR patients may be more sensitive to high concentrations of transference interpretations, that is, more prone to regard it as negative criticism, which results in a weak alliance. In conjunction with the outcome results, the findings suggest that therapists should avoid becoming entrenched in a negative cycle that is characterized by a high concentration of transference interpretations and a weak alliance. If one also considers the findings concerning accuracy of transference interpretations and outcome, there is the suggestion that therapists should consider providing few (low concentration) but accurate interpretations to high-QOR patients. The HLM findings concerning work and outcome for high-QOR patients are consistent with these findings in suggesting that too much of a good thing (work) may actually be detrimental, at least in the short run (i.e., immediately following treatment). In the cases of transference interpretation and work, moderation seems to be indicated. A similar consideration may apply regarding the use of accurate transference interpretations with low-QOR patients. These patients have a history of relatively nongratifying relationships. They may be more in need of forming a gratifying relationship with the therapist than exploring their pattern of nongratifying relationships in therapy. Emphasizing similarities between past abusive relationships and the current transferential one may result in the patient feeling criticized, rejected, or abandoned. Consequently, the alliance may be weakened. Alternatively, a weak alliance may elicit high accuracy of transference interpretation by the therapist in an effort to encourage work. In either case, the therapist should avoid getting caught up in a negative cycle that is characterized by high accuracy of transference interpretations and a weak alliance. Again, moderation seems to be indicated. The HLM finding regarding an increase in the strength of the alliance and favorable outcome suggests that strengthening the alliance during the course of therapy may be particularly important for low-QOR patients. Improvement or deterioration of the relationship over the sessions of therapy may be viewed as evidence of the success or failure of therapy itself. The finding argues against attempting to establish a very strong, perhaps overly intense, working relationship initially. Given their history of unsatisfactory relationships, such patients may be intimidated and react adversely. Instead, a moderately strong initial alliance followed by gradual strengthening would seem to enhance the possibilities of therapeutic success. This finding, as well as those involving concentration and accuracy of transference interpretation, suggest the importance of carefully assessing the patient’s life-long pattern of relationships and planning treatment accordingly. It is clear that the patient’s QOR has implications for therapist technique as well as patient selection.

FUTURE RESEARCH Recommendations for future research involving object relations theory and STDP are rather straightforward. In regard to the QOR concept, although several of the main

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findings from the Edmonton clinical trials have received independent confirmation in studies conducted in Oslo, additional attempts at cross-validation and investigation of new hypotheses remain worthwhile objectives. Inclusion of QOR measures in both randomized clinical trials and naturalistic predictor studies provide such opportunities. For example, we have included the measure in a new clinical trial of time-limited group therapies for patients experiencing pathological bereavement. Although significant relationships between QOR and outcome have been found, the limited amount of variance accounted for suggests that additional variables are influential and should be investigated as part of multivariate models. Other patient characteristics, therapist characteristics, and technical variables are promising variables to investigate. Despite the existence of a variety of object relations concepts and assessment techniques, little is known about the relationship among them in the context of STDP. For example, it is possible that QOR is related to certain core conceptual relationship themes or to the content of other patient formulation systems. In addition, information about the relationships among the various patient formulation systems is scarce. Even more scarce is information about the relationships between object relations concepts that focus on the internal world and those that focus on the external world. This is surprising given the fact that most theories include processes that involve their interdependence (e.g., internalization, externalization). Overall, it is fair to conclude that relatively little work has been conducted that investigates the relevance of object relations theory to STDP. The initial lines of research are promising and opportunities for useful research contributions are plentiful.

REFERENCES Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Hillsdale, NJ: Erlbaum. Azim, H. F. A., Piper, W. E., Segal, P. M., Nixon, G. W. H., & Duncan, S. (1991). The quality of object relations scale. Bulletin of the Menninger Clinic, 55, 323–343. Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults: A test of a four-category model. Journal of Personality and Social Psychology, 61, 226–244. Bell, M., Billington, R., & Becker, B. (1986). A scale for the assessment of object relations: Reliability, validity, and factorial invariance. Journal of Clinical Psychology, 42, 733–741. Bellak, L., Hurvich, M., & Gediman, H. K. (Eds.). (1973). Ego functions in schizophrenics, neurotics, and normals. New York: Wiley. Bellak, L., & Small, L. (1978). Emergency psychotherapy. (2nd ed.). New York: Grune & Stratton. Beres, D., & Joseph, E. (1970). The concept of mental representation in psychoanalysis. International Journal of Psychoanalysis, 51(1), 1–9. Blanck, R., & Blanck, G. (1986). Beyond ego psychology: Developmental and object relations theory. New York: Columbia University Press. Blatt, S. J., Brenneis, C. B., Schimek, J. G., & Glick, M. (1976). Normal development and psychopathological impairment of the concept of the object on the Rorschach. Journal of Abnormal Psychology, 85, 364–373. Collins, N. L., & Read, S. J. (1990). Adult attachment, working models, and relationship quality in dating couples. Journal of Personality and Social Psychology, 58, 644–663. Compton, A. (1996). Objects and object relationships. In B. Moore & B. Fine (Eds.), Psycho-analysis: The major concepts (pp. 433–449). London: Yale University Press. Davanloo, H. (Ed.). (1978). Basic principles and techniques in short-term dynamic psychotherapy. New York: Spectrum. de Carufel, F. L., & Piper, W. E. (1988). Group psychotherapy or individual psychotherapy: Patient characteristics as predictive factors. International Journal of Group Psychotherapy, 38, 169–188. Diamond, D., Kaslow, N., Coonerty, S., & Blatt, S. J. (1990). Changes in separation-individuation and intersubjectivity in long-term treatment. Psychoanalytic Psychology, 7, 363–397.

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W. E. Piper and S. C. Duncan

Fairbairn, W. R. D. (1952). An object-relations theory of the personality. London: Tavistock. (Original work published in 1944) Fishler, P. H., Sperling, M. B., & Carr, A. C. (1990). Assessment of adult relatedness: A review of empirical findings from object relations and attachment theories. Journal of Personality Assessment, 55, 499–520. Fonagy, P., Leigh, T., Steele, M., Steele, H., Kennedy, R., Matton, G., Target, M., & Gerber, A. (1996). The relation of attachment status, psychiatric classification, and response to psychotherapy. Journal of Consulting and Clinical Psychology, 64, 22–31. Ford, J. L., Fisher, P., & Larson, L. (1997). Object relations as a predictor of treatment outcome with chronic posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 65, 547–559. Freud, S. (1957). An outline of psychoanalysis. In J. Strachey (Ed.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 23, pp. 144–207). London: Hogarth Press. (Original work published 1938) Freud, S. (1957). Instincts and their vicissitudes. In J. Strachey (Ed.), The standard edition of the complete psychological works of Sigmund Freud (Vol. 14, pp. 109–140). London: Hogarth Press. (Original work published 1915) George, C., Kaplan, N., & Main, M. (1984). Adult Attachment Interview. Unpublished manuscript. Greenberg, J. R., & Mitchell, S. A. (1983). Object relations in psychoanalytic theory. Cambridge, MA: Harvard University Press. Høglend, P. (1993a). Transference interpretations and long-term change after dynamic psychotherapy of brief to moderate length. American Journal of Psychotherapy, 47, 494–507. Høglend, P. (1993b). Suitability for brief dynamic psychotherapy: Psychodynamic variables as predictors of outcome. Acta Psychiatrica Scandinavica, 88, 104–110. Høglend, P., & Piper, W. E. (1995). Focal adherence in brief dynamic psychotherapy: A comparison of findings from two independent studies. Psychotherapy, 32, 618–628. Horowitz, M. J.(1979). States of mind: Analysis of change in psychotherapy. New York: Plenum. Horowitz, M. J. (1987). States of mind: Analysis of change in psychotherapy (2nd ed.). New York: Plenum. Joyce, A. S., & Piper, W. E. (1996). Interpretive work in short-term individual psychotherapy: An analysis using hierarchical linear modeling. Journal of Consulting and Clinical Psychology, 64, 505–512. Kernberg, O. (1976). Object relations theory and clinical psychoanalysis. New York: Aronson. Kernberg, O. (1985). Internal world external reality. Northvale, NJ: Aronson. Kernberg, O. (1996). Psychoanalytic object relations theory. In B. Moore & B. Fine (Eds.), Psycho-analysis: The major concepts (pp. 450–462). London: Yale University Press. Krohn, A., & Mayman, M. (1974). Object representation in dreams and projective tests. Bulletin of the Menninger Clinic, 43, 515–524. Last, J. M., & Bruhn, A. R. (1983). The psychodiagnostic value of children’s earliest memories. Journal of Personality Assessment, 47, 597–603. Luborsky, L., & Crits-Christoph, P. (1990). Understanding transference: The Core Conflictual Relationship Theme method. New York: Basic Books. Malan, D. H. (1976). The frontier of brief psychotherapy. New York: Plenum. Mallinckrodt, B., Coble, H. M., & Gantt, D. L. (1995). Working alliance, attachment memories, and social competencies of women in brief therapy. Journal of Counseling Psychology, 42, 79–84. Mallinckrodt, B., Gantt, D. L., & Coble, H. M. (1995). Client patterns in the psychotherapy relationship: Development of the Client Attachment to Therapist Scale. Journal of Counseling Psychology, 42, 307–317. Mann, J. (1973). Time-limited psychotherapy. Cambridge, MA: Harvard University Press. May, P. R. A., & Dixon, W. J. (1969). The Camarillo dynamic assessment scale I: Measurement of psychodynamic factors. Bulletin of the Menninger Clinic, 33, 1–35. McCallum, M., Piper, W. E., & O’Kelly, J. G. (1997). Predicting patient benefit from a group oriented, evening treatment program. International Journal of Group Psychotherapy, 47, 291–314. McLemore, C., & Benjamin, L. S. (1979). Whatever happened to interpersonal diagnosis: A psychological alternative to DSM-III. American Psychologist, 34, 17–34. Moore, B., & Fine, B. (1990). Psychoanalytic terms and concepts. London: Yale University Press. Piper, W. E., Azim, H. F. A., Joyce, A. S., & McCallum, M. (1991). Transference interpretations, therapeutic alliance and outcome in short-term individual psychotherapy. Archives of General Psychiatry, 48, 946–953. Piper, W. E., Azim, H. F. A., Joyce, A. S., McCallum, M., Nixon, G. W. H., & Segal, P. S. (1991). Quality of object relations vs. interpersonal functioning as predictors of therapeutic alliance and psychotherapy outcome. Journal of Nervous and Mental Disease, 179, 432–438. Piper, W. E., Azim, H. F. A., McCallum, M., & Joyce, A. S. (1990). Patient suitability and outcome in shortterm individual psychotherapy. Journal of Consulting and Clinical Psychology, 58, 475–481. Piper, W. E., Boroto, D. R., Joyce, A. S., McCallum, M., & Azim, H. F. A. (1995). Pattern of alliance and outcome in short-term individual psychotherapy. Psychotherapy, 32, 639–647.

Object Relations Theory

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Piper, W. E., Debbane, E. G., Bienvenu, J. P., & Garant, J. (1984). A comparative study of four forms of psychotherapy. Journal of Consulting and Clinical Psychology, 52, 268–279. Piper, W. E., de Carufel, F. L., & Szkrumelak, N. (1985). Patient predictor of process and outcome in shortterm individual psychotherapy. Journal of Nervous and Mental Disease, 173, 726–733. Piper, W. E., Joyce, A. S., McCallum, M., & Azim, H. F. A. (1993). Concentration and correspondence of transference interpretations in short-term psychotherapy. Journal of Consulting and Clinical Psychology, 61, 586–595. Piper, W. E., Joyce, A. S., McCallum, M., & Azim, H. F. A. (1998). Interpretive and supportive forms of psychotherapy and patient personality variables. Journal of Consulting and Clinical Psychology, 66, 558–567. Piper, W. E., McCallum, M., & Joyce, A. S. (1993). Manual for assessment of quality of object relations. Unpublished manuscript. Piper, W. E., Rosie, J. S., Azim, H. F. A., & Joyce, A. S. (1993). A randomized trial of psychiatric day treatment. Hospital and Community Psychiatry, 44, 757–763. Rapaport, D., & Gill, M. (1959). The points of view and assumptions of metapsychology. The International Journal of Psychoanalysis, 40, 153–162. Robbins, L. L., Wallerstein, R. S., Sargent, H. D., & Luborsky, L. (1956). The psychotherapy research project of The Menninger Foundation: Orientation, rationale, design, concepts, sample use of method. Bulletin of the Menninger Clinic, 20, 221–278. Sandler, J., & Rosenblatt, B. (1962). The concept of the representational world. Psychoanalytic Study of the Child, 17, 285–296. Satterfield, W. A., & Lyddon, W. J. (1995). Client attachment and perception of the working alliance with counselor trainees. Journal of Counseling Psychology, 42, 187–189. Sifneos, P. E. (1972). Short-term psychotherapy and emotional crisis. Cambridge, MA: Harvard University Press. Smith, T. E. (1993). Measurement of object relations: A review. Journal of Psychotherapy Practice and Research, 2, 19–37. Stricker, G., & Healey, B. J. (1990). Projective assessment of object relations: A review of the empirical literature. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 2, 219–230. Strupp, H., & Binder, J. (1984). Psychotherapy in a new key: A guide to time-limited dynamic psychotherapy. New York: Basic Books. Urist, J. (1977). The Rorschach test and the assessment of object relations. Journal of Personality Assessment, 41, 3–9. Weiss, J., Sampson, H., & the Mount Zion Psychotherapy Research Group. (1986). The psychoanalytic process: Theory, clinical observations, and empirical research. New York: Guilford. West, M. L., & Sheldon-Keller, A. E. (1994). Patterns of relating: An adult attachment perspective. New York: Guilford. Westen, D., Lohr, N., Silk, K. R., Gold, L., & Kerber, K. (1990). Object relations and social cognition in borderlines, major depressives, and normals: A TAT analysis. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 2, 355–364.