Zilcha-Mano, S., Fisher, H., Dolev-Amit, T., Keefe, J. R., & Barber, J. P. (2023). A systematic review of the association between interpretations and immediate, intermediate, and distal outcomes. Psychotherapy. Advance online publication. https://doi.org/10.1037/pst0000479
Interpretation is a therapeutic technique that refers to a psychotherapist who recognizes and seeks to raise the patient’s awareness and understanding of recurrent maladaptive patterns. An interpretation goes beyond what the patient says or recognizes consciously and gives a new meaning or explanation for behaviours, thoughts, or feelings so that the patient sees their problems in a new way. In other words, the effect of an interpretation is to raise a patient’s insight into their problems. Interpretation is a transtheoretical technique, although it is often associated with psychodynamic therapies. Some interpretations are interpersonal in nature (focused on maladaptive relationship patterns inside and outside of the therapeutic relationship), and some are intrapersonal in nature (e.g., focused on the conflict between ones wishes/desires and how one ideally sees oneself). In this systematic review of the research on interpretation, Zilcha-Mano and colleagues included 18 studies that tested the association between interpretation and outcomes. Previous reviews found a mixed association between interpretation and outcomes possibly because of the different methods of assessing interpretation and different way of conceptualizing outcomes. What is unique about this review is that it categorized outcomes as immediate (e.g., in-session alliance, disclosure, emotional expression), intermediate (e.g., next-session alliance strength, session depth), and distal (e.g., change in symptoms from pre- to post-treatment). Since there were so few studies in each of these outcome categories (6 studies of immediate, 4 studies of intermediate, and 12 studies of distal outcomes), the authors did not conduct a meta-analysis, but rather counted studies that supported or did not support the use of interpretation for each of these categories of outcomes. For immediate outcomes, half of the studies reported a positive association with interpretation (whereas half of studies showed a neutral or negative association). That is, on average patients in those studies tended to react positively to therapist interpretations during the session with increased therapeutic alliance or emotional processing. For intermediate outcomes, half the studies reported a positive association with interpretation (as opposed to neutral or negative association). That is, on average the results suggested that interpretation in in a previous session was associated with patients experiencing a better alliance and session depth in the subsequent session. For distal outcomes, there was mixed evidence with most studies reporting a neutral effect of interpretation on pre- to post-symptom change.
It is challenging to draw explicit practice implications from a research area that is complex and not yet large enough to allow for a meta-analysis. However, using a mixture of these research findings and clinical experience, Zilcha-Mano and colleagues suggest some therapeutic practices that may be helpful. They suggest, for example that therapists (1) observe the immediate and intermediate outcomes of an interpretation (i.e., does the patient rejected it or does it deepen the therapeutic work?), (2) check with patients about how they feel about the interpretation, (3) prioritize accurate and experience-near interpretation (those that the patient can immediately recognize and understand), (4) monitor the strength of the alliance before, during, and after an interpretation, (5) consider that an interpretation may be more beneficial for patients with poorer quality of relationships and self-concepts than for those with better relationship and self-functioning, and (6) be aware that interpretations may not be beneficial and could be harmful if delivered at the wrong time or if not attuned to the patient’s needs and capacities