Therapeutic Immediacy in Psychodynamic Psychotherapy for Depression: A Mixed-Method Study

This exploratory study assesses the use and quality of therapeutic immediacy in short-term psychodynamic psychotherapy for depression. We aimed to identify what constitutes effective here-and-now discussions of the therapeutic relationship by examining a sample of four treatment cases drawn from a previous randomized clinical trial for depression. Transcripts of 16 treatment sessions (four time points per treatment) were analyzed using the consensual qualitative research for case study method. The therapists' contributions to therapeutic immediacy were assessed qualitatively by independent judges and then quantitatively analyzed in relation to immediate session outcome as well as overall treatment outcome (reduction in depressive symptoms). A total of 41 immediacy events were identified across 16 sessions, of which 35 were therapist-initiated and subsequently organized into 18 discrete categories. High-quality immediacy events (as assessed by the judges) were associated with higher patient involvement. Two immediacy categories were significantly different between good and poor outcome cases. Therapists "acknowledged their patient's progress in therapy" more often in good outcome cases, whereas they "assessed patients' feelings about the overall progress of therapy" more often in poor outcome cases. No significant relationship was found between frequency, rated quality of immediacy events, and treatment outcome. Four immediacy events rated by the judges as high- and low-quality are presented as clinical examples illustrating positive and negative therapists' contributions to therapeutic immediacy. Therapist behaviors that may improve the effectiveness of therapeutic immediacy are discussed. Clinical Impact Statement Question: What characterizes successful therapeutic immediacy in psychodynamic therapy for depression? Findings: Effective immediacy interventions are characterized by keeping the patients highly involved by encouraging them to express feelings about the treatment and the therapist. No relationship was found between frequency, rated quality of immediacy events, and treatment outcome. Meaning: The results illustrate what constitutes a successful immediacy intervention in the context of a session and identifies different types of immediacy interventions associated with good and poor treatment outcomes. Next Steps: Our results suggest several hypotheses about possible effective and ineffective therapist behaviors within therapeutic immediacy that may be tested in larger scale research and could potentially lead to clinical implications for psychodynamic treatments for depression.