Introduction

This article addresses the question of the evaluation of variations in the patient’s capacity for cognitive – affective integration, assessed according to the Referential Activity construct (Bucci, 1997b), with reference to the evolution of transference dynamics, recorded with the Core Conflictual Relationship Theme (CCRT) methodology of Lurborsky (1977) during a psychodynamically oriented psychotherapy process. Bucci’s studies of the process of integration of the representation codes of emotional experience showed that during sessions, Referential Activity (RA) takes a dynamic, cyclical movement.  In particular, the referential process increases when certain affective-cognitive patterns are activated in the therapeutic relationship. Analysing the movement of this variable in relation to the development of transference dynamics can therefore provide useful pointers regarding the interplay of these two aspects in the therapeutic process. It may also be particularly significant to establish which components of the motivational conflict expressed in transference are finally integrated into the new cognitive-affective patterns of interpersonal relationships. The article therefore focuses on the observation and monitoring of a patient’s therapeutic process during his/her psychotherapy treatment, by means of a quantitative empirical analysis. The peculiarity of this study, which is part of a broader line of research called “process research”, is that it creates a constant link between the empirical evidence and the theoretical perspective, and also shows the effective progression of the treatment underway. The tools derive from different theoretical contexts and in this research they are linked to each other, which highlights their specificity and possible integrations.
RA represents the mind’s activity of constructing links between sensorial experience, emotions and thought, which can be expressed through words. The RA variable enables the session transcripts to be scored, indicating the levels of integration between different formal “qualities” of language in communication. This would give an indication of the extent to which non verbal experience, including emotion, is triggered in the speaker’s mind as s/he is speaking, so that corresponding experiences are evoked in the listener or reader. The earliest research already identified the significant differences in individual narration style (Bucci, 1984), which can be measured on a scale of high or low RA. The RA level presents variability both of state and of trait: i.e. it indicates the changes in the subject over time as a result of external or internal events, or more stable inter-individual differences. Observing the progress of RA through the patient’s narratives in the course of a therapeutic session, should make it possible to obtain quantitative data that enable us to interpret the variations in the capacity to connect emotions and words (Bucci, 1997b), and therefore also to bring into focus the more significant narrative passages for that patient in relation to his distinctive emotional patterns (cfr. De Coro & Mariani, 2006). The multiple code model concerns the general function of subjective connection between verbal and non-verbal experience – including emotional experience. In other words, the referential process is the operation that connects the multiple representational formats of non-verbal systems to each other and to words” (Bucci, 1997b). According to Bucci (1997b), there are three basic ways in which human beings represent and elaborate information: sub-symbolic, non-verbal symbolic and verbal symbolic modes. RA is therefore defined as “the capacity to express non-verbal experience, in particular emotional experience, in a verbal form. Emotions are considered the patterns of actions and images in operation both inside and outside the consciousness, and unlike other cognitive patterns they are characterised more by visceral physiological modifications rather than by symbols or images (Bucci, 1997a). In more general terms, emotional patterns can be regarded as being made up of desires, expectations and beliefs about people, which develop through repeated interactions with significant others, particularly with childhood caring figures. In this way, the patterns can include representations of objects or of objects’ characteristics and relations, in which all the components are present: motor, visceral, and somatic. These  emotive structures can be triggered and evoked by autobiographical memories or also by verbal exchanges with other people: recounting an experience or hearing it recounted can therefore reactivate a specific emotional pattern. Passages featuring high RA would therefore be indicative of moments when the patient immerses him/herself in a rich, detailed narrative, managing to convey to the listener a vivid representation of the event and a possible visualisation of the situation recounted. However, unlike methods like CCRT (Luborsky, 1977) which investigate variations on redundant themes in patients’ narratives and the therapist’s ability to see the redundancies, the study of the referential process is based on the formal anlysis of the text, since it aims to identify the structural quality of the language used by the speakers. According to Bucci one can hypothesise an optimal rhythm of the referential process in a session, which would be the expression of the retrieval and repair of a specific dissociated emotional cognitive-affective pattern. In an emotionally charged relational situation like the psychotherapy session, the referential process would be triggered.  The first stage would see the triggering of a set of feelings and neurovegetative transformations that are part of the dominant emotional pattern in the patient’s emotional experience, but which are difficult to express in words.   This first stage is therefore characterised by a low RA. Later, these modifications could be associated to specific memory, thus linking the sub-symbolic level to non-verbal symbolism and raising RA levels.  The third step in an effective process consists of one-on-one reflection on the images and memories that have arisen, which would enable experience to be integrated with language through the verbal exchanges between therapist and patient. This re-elaboration would bring the variable to medium-low levels (Bucci 1997a). The fluctuation just described is identified as the “cycle of the good hour”, supposed to be the optimal rhythm of a session. (Freedman, Lasky & Hurvich, 2002).
The other process analysis tool used in the research traces the patient’s main subjects of conflict by highlighting the repetition of the relational pattern that the patient can re-create. As well as the classic CCRT assessment, here there is a re-adaptation of the tool from a motivational slant. The CCRT method is a measuring tool related to the central relational model that is repeated in every person. The method was  developed from 1976 (Luborsky, 1977), having initially been a tool for measuring the therapeutic alliance. Later, the author focused on the interactions within the sessions studied, and in particular on three categories: the patient’s desires about people, the responses of others and the patient’s reaction to this response.

These categories then became three of the CCRT components:
1. Wish: desires, needs, intentions.
2. RO: responses of others.
3. RS: responses of the self.

The roots of the CCRT method lie in the Freudian conception of the transference model (1912), which over the years has been used as a tool for assessing “case” and “process”, precisely because of its ability to operationalise transference.  The underlying principle presupposes that in every therapeutic session it is possible to identify a certain number of unconscious conflictual themes. The Luborsky method envisages a series of fundamental steps. First of all, it is based on the identification of “Relational Episodes” (RE) in the transcripts of the sessions. Relational Episodes are described as “moments of explicit narration of episodes in which the patient interacts with other people or with the self”. (Luborsky & Crits-Christoph, 1990, p. 31). REs must be subject to a criterion of completeness which excludes espisodes that are fragmentary or incoherent. By definition, they are “Narratives that have a beginning, a middle and an end”. (Luborsky & Crits-Christoph, 1990, p. 32). Through the RE it is possible to trace the three components above. These are monitored until the main components characterising the patient’s central conflicts are identified.  Luborsky & Crits-Christoph (1990) in fact maintain that the three components should be considered as being related to one another and forming a linked “sequence”. In this sequence, wishes and responses make up a pattern in which there is a need that must be satisfied in relation to other people.      Therefore, a conflict is triggered between the needs and responses of others and the self. This concept may overlap the intrapsychic conflict described by Freud between the impulses of the Id and the responses of the Ego.
According to Luborsky, wishes must be satisfied in relation to people and aim to change the nature of the relationship. The adaptation of the CCRT in a motivational key (Dazzi, De Coro & Andreassi, 2003) springs from the gradual transition in the interpretation of the pathology, from a personality pathology to a relational pathology. Above all from the developmental point of view, the disorder is increasingly seen within the context of a relationship, rather than as the disorder of the individual.  In the sphere of  infant research, a particularly useful idea is that of Joseph Lichtenberg (1989) who, by integrating research data with clinical work, put forward a revised psychoanalytical theory of motivation in terms of motivational systems.
A motivational system is a psychological entity based on a fundamental need, which must be satisfied if the cohesion of the self is to be maintained (Stern, 1985).
The needs are:
- Need for physical regulation of physiological requirements
- Need for attachment-affiliation
- Exploratory-assertive need
- Need to react adversely through antagonism and withdrawal
- Need for sensual pleasure and sexual excitement

Each of the five motivational systems, made up of an interrelated group of needs and desires, is present right from birth and lasts one’s whole life. They are initially characterised by innate responses and later they develop and are organised so as to deal with the environment, interactions with carer figures and with the degree of neurophysiological development.
The development of motivational systems proceeds alongside the development of the sense of self; there is therefore the transition from the perception of regularity and change in the outside world (typical of the sensation of emergence of the self), to the feeling of separation and recognition of the other with the nuclear self, through to the awareness that the mental contents of the subjective self can be accepted. With the exception of the aversive system, which is triggered and characterised by feelings of malaise and danger, the satisfaction of needs related to other systems will lead to experiences marked by positive affects.  These are experiences that later the child, and then the adult, will be motivated to recreate. Every motivational system is organised independently, but at the same time can play the dominant role of organiser, inducing others to acquiesce, at certain points in life. Motivational systems intertwine to ensure order in overall motivation, the ultimate purpose of which is survival. The term “system” has been chosen to emphasise the concepts of organisation, change and plasticity. Unlike the concept of structure, that of system allows development to be conceptualised as a product of a complex set of interactions which is in constant change and which moves towards well-coordinated organisational levels. Dazzi, De Coro & Andreassi (2003) proposed a new organisation of the CCRT “wish” component, in terms of motivational systems. This reorganisation led  to the creation of a coding system applied to session transcripts of patients with different diagnoses, which proved able to discriminate between the diagnoses themselves. With the application of the CCRT adaptation, according to the motivational systems, it is possible to give an operationalised reading of cognitive-affective models, revealing the motivational systems that are active moment by moment during the psychotherapy. Research on a single case (Ortu, Andreassi, Scanu & Dazzi, 2004) applied this coding system based on the reformulation of Wishes in terms of the five motivational systems to clinical case sessions proposed by Lichtenberg, Lachman, & Fosshage, (1996). This case was used by the authors to illustrate the “movement” of motivational systems in the course of psychotherapy. The case was related to psychoanalysis that lasted nine years, presented and discussed through the exposition of five weeks’ work, one every two years. Comparing the results produced by the authors (Lichtenberg, Lachmann & Fosshage, 1996) to the results of motivational-CCRT, along with the analyst’s comments, showed congruence between the motivational systems  recorded with the motivational-CRRT categories and case assessment by Lichtenberg, Lachmann e Fosshage, (1996). The authors expressed their clinical comments on the emerging system, with particular reference to Model Scenes: “Model scenes graphically and metaphorically illuminate and encapsulate experiences that represent salient motivational themes, constructed and reconstructed as unconscious fantasies and pathogenetic beliefs” (Lichtenberg, Lachman, & Fosshage, 1996, p. 3). They organise the patient’s narratives and associations so as to capture important transference configurations and role updating and to bring into sharper focus the explorations of the patient’s experience and motivations. Lichtenberg and colleagues believe that the analytic process can be considered an elaboration of the model scene. 

The research of Ortu, Andreassi, Scanu and Dazzi (2004), shows that during the therapeutic process the aversive motivational system, capable of undermining joint exploration, becomes less dominant in favour of the motivational system of attachment, which can sustain the therapeutic alliance and the exploration of problem areas.
The integration of these three tools applied to a single-case study should enable us to identify the significant passages in the patient’s narration, and within them the dominant cognitive-affective patterns, if and how they can be dissociated and if and how they can be pervasive for the subject, being recursive and redundant in the patient. The studies that compared CCRT data with RA data on the same psychotherapy sessions show a constant relation between the positive RA peaks and the presence of Relational Episodes including all or part of the CCRT components. High RA levels in patients’ narratives therefore seem to identify the central models of the relational dynamics, and along with them the major moments of the patient’s malaise (Bucci, 2002; De Coro, Mariani, Pazzagli, Andreassi, Ortu & Caviglia, 2004; Ortu, Pazzagli, Calcioli, Lingiardi, Williams & Dazzi, 2001). In other research work, aimed at investigating the qualities of the narration in depressed patients,  the Referential Activity in stories of early memories was linked to the revelation of Relational Episodes and to the self-assessment of clinical depression (with the Beck Depression Inventory). This confirmed the correspondence between CCRT and high RA in revealing significant object relations in the various subjects; low RA levels were also found to be significantly linked to episodes marked by negative emotions. Lastly, the RA measurement proved to be discriminating, in the group of non-depressed subjects, to identify those who recounted very few Relational Episodes (as in the group of depressed subjects), thus highlighting the possibility of considering a low RA as a risk factor for the presence of non self-perceived latent depression  (Ben-Meir & Bucci, 2004). By means of this study one therefore expects to demonstrate this correspondence between RA and classic motivational CCRT in a case featuring low functioning dictated by the clinical diagnosis.

Specific Research Questions

The integrated study of different tools for psychotherapy process analysis allows us to explore the correspondence between theoretical constructs and practical application. The studies cited above direct research investigations towards certain hypotheses. A correspondence between RA, classic-CCRT and motivational-CCRT would underline the relation between the conflictual transference configuration versus the dissociated cognitive-affective emotional pattern. The investigation therefore sets out to:

- Test whether there is any correspondence between peaks and REs, whether the RA peaks correspond to the narration of Relational Episodes (RE), from which peculiar transference patterns can be extrapolated. If such a correspondence were systematically found, this would highlight the usefulness of using CCRT and RA constructs in the early identification, within the therapeutic process, of the patient’s salient relational patterns (and this would enable the salient points and main conflictual transference patterns to emerge rapidly in the therapeutic process);
- Test whether a higher number of REs corresponds to a “cycle of the good hour”, characterised by an RA variable movement following this pattern: low RA in the initial phase,  high RA in the central phase and low RA in the concluding phase;
- Test whether there is a correspondence between the identification of the referential process movement called “cycle of the good hour” and the emergence of a motivation system of attachment directed towards a better therapeutic alliance. 

Methodologies

Tools:

Referential Activity
Operatively, referential activity is a variable made up of 4 sub-variables, defined as concreteness, specificity, clarity, imagination.

• Concreteness measures the level of sensorial and/or perceptive quality of the words used, including references to all the sensorial modes, to movement and to bodily experience.
• Specificity shows the quantity of details present in the transcript and therefore measures the degree of specification in the description of characters, places and objects in an episode, or in the various elements of a series of thoughts and/or moods.
• Clarity refers to how comprehensible the scenes, events and/or thoughts appear when expressed in language; in particular, it assesses the clarity of focus on the theme and organization of passages, determining how easy it is for the listener or reader to follow the discourse.     
• Imagination is understood as the activity of producing images. It measures the evocativeness of the language used, that is, how far the words and the overall story manage to arouse emotional resonance in the listener through images (Bucci, 2000).

The four sub-variables aim to measure language features that can be defined and quantified by judges speaking the same language. The variables are relatively independent from each other and as such, can be measured separately on a 0 -10 scale; at the same time they are interrelated in that they estimate the quality and intensity of the communication of emotional experience in language. The average of the four scores given becomes the RA value. The texts are firstly broken down into passage-segments which depend on the length and structure of the text. Each segment is defined as an “Ideational unit” and is characterised by a story that introduces a shift in the narrative focus, or a new subject. It is usually possible to recognise these points of transition intuitively, often without being able to establish the explicit elements underlying this judgement. For ideational units in a psychotherapy session, the segmentation must take into account not only the shift of focus, but also the therapist’s possible interventions aimed at setting boundaries. Interpretative or major interventions by the therapist can be considered a boundary point between one ideational unit and the beginning of another.  The judges need to agree on the segmentation carried out and to discuss ambiguous situations. Two or more trained judges express their impression of the narrative material. The opinion is based on the four dimensions, assessing only the narrative form of the text. The Imagination and Concreteness scales measure the sensorial features, while the Specificity and Clarity scales reflect the degree of organization and the communicative quality. Scoring the ideational units is done in double blind by experienced judges, and later the reliability is calculated with the ICC (index of intraclass correlation) as well as Crinbach’s alpha coefficient. The RA score given to a specific segment is the average of the RA scores given by the judges.

The Core Conflictual Relationship Theme (CCRT)
This is a method for the measurement of repetitive disadaptive relational patterns. The Central Conflictual Relational Theme method is based on the identification of narrative units called “relational episodes” (RE) which patients typically recount and which they may implement with the therapist during psychotherapy sessions. Relational Episodes correspond “to a part of the session that appears to be a relatively separate, explicit narration of episodes in which the patient interacts with other people or with the self” (Luborsky & Crits-Christoph, 1992, p. 31).  The practical application of the CCRT envisages two stages in assessment for narratives: one of segmentation of the psychotherapy session into narrative units (Relational Episodes) and one of coding these episodes in terms of their components, using specific interpretative categories established by Luborsky. “The central relational pattern, script or schema that each person follows in establishing his relationships can be derived by considering the unchanging elements of the narrations made by people about their own relationships” (Luborsky, Crits-Cristoph, 1998, p. 31). The RE must respect a criterion of completeness which leads to the exclusion of the parts in a patient’s narration that do not include at least the following components: Wish (the original motivational component of the patient’s central conflict), the Response of the Other (expectation about the response that the Wish will receive from the other).  By definition, they are “Narratives that have a beginning, a middle and an end” (Luborsky & Crits-Christoph, 1992, p. 32). The second phase consists of identifying, in the REs, the 3 components:
Others’ responses and the self’s responses are subdivided into positive and negative categories.
1. Wish: desires, needs, intentions.
2. RO: responses of others.
3. RS: responses of the self.
Negative: responses that imply that the patient has suffered, or is expected to suffer, some interference in the satisfaction of his desires.
Positive: refers to the non-interference in the satisfaction of desires and/or a feeling of mastery in the management of wishes.
Each of the components of relational episodes is now classed in the respective standard category. After assessing the most recurrent types of components, one can proceed with the formulation of the CCRT. The most frequently occurring W, RO and RS categories, in fact, go to make up the CCRT of the patient who expresses his/her central conflict, generally between desires (W) and responses from others (RO) or from the self (RS).  (cfr. Ortu, 2006). A study carried out by Luborsky, Crits-Christoph et al. (1992) on 33 patients taken from the broader sample of the Penn Psychotherapy Project showed that, also in successful treatment, some aspects of the Central Conflictual Relational Theme may remain unchanged: a person’s desires, needs and intentions in fact tend to remain stable in different situations and over time (Luborsky & Crits-Christoph, 1990, cap. 9). The patient, however, usually achieves greater awareness of his/her own relational models, which become more flexible. Consequently, s/he is able to react better to conflictual situations and s/he expects more positive responses from others.

Motivational CCRT
After the identification of the REs according to the classical method described earlier, there comes coding, in a modality similar to that used for Luborsly’s CCRT:

• Identification of Relational Episodes
• Identification of Wish components using the 5 motivational systems
• Identification of the pervasive components.

The motivational CCRT only takes into consideration the Wish component, excluding the responses of Self and of the Object.  The wishes of the classic CCRT cluster were redefined on the basis of the motivational theory of Lichtenberg (1989) (cfr. De Coro, Mariani, Pazzagli, Andreassi, Ortu & Caviglia, 2004).
The systems referred to are:

• Motivational system of the physical regulation of physiological needs
• Motivational system of attachment-affiliation
• System of exploratory-assertive motivation
• Aversive  motivational system
• Sensual/sexual motivational system

The examiner then records the frequency of the wish component and indicates the prevailing motivational system and whether there is also a secondary system.

Sample

The study was carried out on 4 psychodynamic psychotherapy sessions at a University Clinical Centre that had been going on for 5 years, with twice-weekly sessions. The first two years of treatment were studied, with a choice of transcriptions of 4 audio-recorded sessions, 6 months apart:   n. 2 – 12 – 41 – 82. Clinical assessment with DSM-IV, AXIS I General Anxiety Disorder; AXIS II Significant Histrionic and Narcissistic traits, AXIS IV with the experience of a serious recent death.  The structural assessment was of borderline functioning.

Results

Referential Activity in the course of the Therapeutic Process

The scoring was done in double blind by two experienced judges, resulting in the following scores:

The average values of RA remain constant in the various sessions, showing a narrative style characterised by a poor referential process. A constant level of RA in the different sessions indicates a trait characteristic in the patient, which could be linked to the seriousness of the patient’s clinical diagnosis. A greater s.d. in found in sessions 41 and 82 where the variable’s breadth of fluctuation increases.
RA movement in the sessions shows a limited fluctuation of the referential process in sessions 2 and 12, while for sessions n. 41 and 82 there is greater fluctuation and range of scores. Session 82 presents a specific fluctuation of the variable responding to the characteristic hypothesised by the “cycle of the good hour”, Low RA > High RA > Low RA (Bucci, 2002; Freedman, Lasky & Hurvich, 2002). The session in which all the scores of the single ideational units are below the scales’ average score is session 12, where there are no peaks over 5 on the RA scale.

Analysing the CLASSICAL CCRT

The task of identifying the RE and the three main components was given to two experienced judges. The level of agreement between the two judges was 95% (K= .90) as regards the identification of the RE, while as regards the three components it was respectively, Wish: 95% (K= .90), RO 87% (K= .75), RS: 82.5% (K = .65).

Motivational CCRT
The task of identifying the RE was given to two experienced judges. The agreement between the two judges was 95% (K= .90) as regards the identification of the E; as regards the Wish, it was 95% (K= .90).

During the first three phases the dominant motivational system was the aversive system, which expresses the need to react in a withdrawn or antagonistic way. Session 12 saw the appearance of wishes related to the system of needs and physiological regulation, alongside the aversive system. This aspect would indicate a greater somatic activation, inducing high levels of aspects of concrete thought and references to the body, both in the form of symptoms and of facets of physiological functioning. In session 82 there is a transformation of the secondary motivational system. While the aversive system remains a dominant organiser, a secondary role is played by an Attachment system. This aspect is in relation to the RS and RO components indicated in the classic CCRT in the same session. In the fourth phase, there is greater willingness on the part of the patient to enter a bond of trust which will foster the therapeutic alliance.

Relation between CCRT and AR

The AR peaks in the sessions fall within the complete and/or partial REs, found more in sessions 41 and 82. There is an increased overlapping of the AR peaks in the RE in the course of the treatment. This aspect signals a development in the narrative capacity, i.e. a greater integration of emotional patterns activated in relation to specific significant relational episodes.  

Discussion

The results enabled a close relation to be traced between referential process, central conflictual theme and prevailing motivational system. It was seen in fact that the movement of the different variables in the four stages of treatment showed a  transformation between the second and the third stage. Through the classic CCRT the course of the process can be subdivided into two session subgroups. In the last two there is a transformation that introduces the presence of positive object responses to arrive at session 82, with positive responses from both the object and the self. The motivational CCRT, too, highlights a process of change found in the variation of the secondary motivational system. In the fourth stage, in fact, a second motivational system of attachment emerges, signalling a transformation in the organisation of the patient’s experience. The AR movement at the same time signals a process of transformation deriving from the increase in standard deviation of the scores; moreover, the progress of session 82 is congruent with the ‘cycle of the good hour’.
The process represented in this way, integrating the theoretical models examined, indicates that the patient’s cognitive-affective patterns start to be activated in the first and second stage. However, dissociative mechanisms of functioning, which can be seen in the patient’s narration from the presence of aversive physiological systems still do not allow experience to be elaborated and integrated. It is only in the third stage, when narrative processes appear to be more integrated between the different coding systems, that there can be a possibility of change, in the form of the introduction of additional relational experiences.  These new cognitive-affective patterns do not replace the previous patterns, but provide an alternative, useful for the reorganisation of experience and the representation of reality. Responding with precision to the hypotheses formulated, one can state that:

- The hypothesis of the correspondence between AR peaks and REs is partially confirmed. When the RE tend to be fragmentary and partial, in the first two stages of treatment, the correspondence is not significant. In the last two stages, when the relational narration becomes more integrated, the relation between the two variables is significant.

-The number of relational episodes is not correlated to the presence of “cycle of the good hour”, but instead the fact that there is an higher co-occurrence of AR peaks falling into relational episodes signals the presence of a “cycle of the good hour”: it could be said that when there is greater correspondence between RE and RA peaks, the RA seems to follow a course typical of the “cycle of the good hour”.

-Confirmation is given of the hypothesis that the course of the referential process defined as “cycle of the good hour” corresponds to the emergence of a motivational system of attachment which allows the therapeutic alliance to improve and which could  enable the patient’s cognitive-affective patterns to be transformed.

In conclusion, with a patient whose relational and motivational situation prevents an adequate connection with the therapist, central disadaptive patterns are not completely integrated in the CCRT narrations. The possibility of monitoring the movement of RA, seen both as the capacity for interpersonal connection and as cognitive-affective integration, alerts the therapist to the point at which the CCRT narrations best reflect the activation of disadaptive relational patterns.  This may indicate that the referential process can be a significant variable in directing the clinician’s focus and in drawing attention to the sessions where the disadaptive patterns appear more clearly. This would allow a precise analysis of the salient interactions and a full understanding of the patient’s organisational systems, needed for the introduction of functional change. A further consideration comes from the possibility of linking the seriousness of the patient’s diagnosis, associated to a structural assessment of borderline functioning, with constantly low RA levels and the presence of mainly negative Responses of the self and of the Other. Such results are in line with the research of Ben-Meir and Bucci (2004), where low AR and scarce REs, as in the first two phases of the process, can signify the presence of latent, non self-perceived depression, as well as a significant relation between low levels of AR and episodes marked by negative emotions.
More in general, we would like to underline that the multi-tool assessment of the therapeutic process that we have put forward offers a useful perspective for research into clinical change at different levels.  
Firstly, this approach makes it possible to compare some of the assumptions of psychodynamic theories about the therapeutic process factors needed for clinical change with the empirical data derived directly from the treatment context.
Secondly, this research approach allows for the heuristic-clinical validity of operationalizing psychodynamic constructs on the therapeutic process. Constructs like CRRT and RA, in fact, seem to offer a grid for the interpretation of psychotherapeutic change which a) guarantees a prompt, adequate formulation of the salient clinical dynamics  of the individual treatment, easy to apply also in the immediate experience of the clinic; b) prescinds from the specific orientations of the different clinical schools, improving the chances of communication between operators; c) allows us to follow the process of clinical change according to the assumptions accepted by the various schools with a psychodynamic approach.

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Notes

* Specialist in Clinical Psycology. Top

** Specialist in Clinical Psychology. Top

*** PhD Student in Dynamic Clinical Psychology – “La Sapienza” University of Rome - Italy. Top

**** Researcher – University of Aosta - Italy. Top