Trajectories and Mediators of the Change in Psychotherapies

2009–2015 / Project Head: Prof. Dr. Dr. Dorothea Huber

Financed by: Steger-Stiftung foundation, Munich, and the Research Advisory Board of the International Psychoanalytical Association (IPA)

Project Description
The aim of this investigation is to record trajectories of the change on a symptoms based and interpersonal level during the therapy ("How is the course of the change?"), in addition to examining whether the working relationship and a positive introject (positive handling of the self with the self) are mediators of the change.

The data comes from the Munich Psychotherapy Study (MPS, Huber et al., 2012, 2013), a prospective quasi experimental, i.e. partly randomised, process-outcome study which examined the effectivity and the therapeutic processes of psychoanalytical (PA), depth psychology-based (DP) and cognitive-behavioural therapy (CBT) in the treatment of depressive patients. The process is recorded on a six-monthly basis. In order to measure the trajectories, the Beck Depression Inventory (BDI) and the Global Severity Index (GSI) of the Symptom Checklist from Derogatis (SCL-90-R) are applied on the symptom level and the Inventory of Interpersonal Problems (IIP) on the interpersonal level. The mediators are recorded with the INTREX, introject positive, and the working relationship with the Helping Alliance Questionnaire (HAQ).

In order to answer the two research question (trajectories and mediation), the data was statistically evaluated with Multilevel Models (MLM). So as to respond to the question about the potential mediators, in addition an extended Multilevel Growth Model was applied that permits the recording of parallel changes in an outcome and in a potential mediator.

The trajectories of the symptomatology (BDI and GSI) decreased dramatically in the early phase (six months) of the treatment and to a lesser extent in the later phase (six months to the end of the treatment) without any significant differences between the three forms of therapy under investigation. The latter finding can be interpreted to mean that the differing intensity of the three forms of therapy is not yet a fundamental effective factor and that, in accordance with an array of empirical evidence, the unspecified therapeutic working alliance and other general effective factors play a fundamental role in the symptomatic improvement. However after the end of the treatment, the trajectories of the symptomatology continued to decline further in the PA, but not in the DP and the CBT. This differing development can be understood as a change to the structures forming the basis for the symptoms caused by the more intensive PA process, which effects a greater stability of the symptomatic improvement. In comparison to this, the trajectories of the interpersonal problems decline significantly faster in the DP compared to the other two therapies, presumably because the DP concentrates more on the interpersonal problems from the beginning; in the later therapy phase and after the treatment, the change process came to a standstill in the DP and the CBT, while it continued in the PA and thus a significant difference developed to the DP and the CBT. This finding indicates that in the later therapy phase in the PA, specific therapeutic effective factors can become active and initialise permanent changes in the interpersonal problems.

The result of the mediator analysis was that the positive introject was not a mediator for the differential therapy effect, which we traced back to the methodical deficiency of the measuring instrument which is not able to record the unconscious dimension of the introject, as well as to the small group sizes and the low number of measurement time points. The working alliance is also not a mediator of the differential therapy effect which, except for the limitations caused by the study design mentioned above, also indicates that on a conceptual level that the working alliance is to be understood as a "vehicle" for potential mediators of the therapeutic process, to be considered as a "workspace" for observing the symptoms and problems of the patients from a new perspective.

Dorothea Huber, International Psychoanalytic University Berlin; email: dorothea.huber(at)
Klinik für Psychosomatische Medizin und Psychotherapie/Clinic for Psychosomatic Medicine and Psychotherapy, Klinikum München-Harlaching Clinic

Günther Klug, Klinik und Poliklinik für Psychosomatische Medizin und Psychotherapie, Klinikum rechts der Isar, TU München/Clinic and Polyclinic for Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar Clinic, TU Munich University

Johannes Zimmermann, PhD, Psychologische Hochschule Berlin university


  • Huber, D., Zimmermann, J., Henrich, G., & Klug, G. (2012). Comparison of cognitive-behaviour therapy with psychoanalytic and psychodynamic therapy for depressed patients - a three-year follow-up study. Zeitschrift für Psychosomatische Medizin und Psychotherapie 58: 299-316.
  • Huber, D., Henrich, G., Clarkin, J., & Klug, G. (2013). Psychoanalytic versus psychodynamic therapy for depression – A three-year follow-up study. Psychiatry 76:132-149.
  • Klug, G., Henrich, G., Filipiak, B. & Huber, D. (2012). Trajectories and mediators of change in psychoanalytic, psychodynamic, and cognitive behavioral therapy. Journal of the American Psychoanalytic Association, 60: 598-605.
  • Klug, G., Zimmermann, J. & Huber, D. Outcome trajectories and mediation in psychotherapeutic treatments of major depression. Journal of the American Psychoanalytic Association, JAPA accepted.