Relational psychophysiology: Lessons from mother–infant physiology research on dyadically expanded states of consciousness

Abstract

The authors illustrate how their work on mother–infant “relational psychophysiology” might inform psychotherapy research. They examined psychophysiology in 18 mother–infant dyads (infants' age: 5 months) during normal interaction and a still-face perturbation. They measured respiratory sinus arrhythmia (RSA) as an index of emotion regulation and explored whether skin conductance (SC) concordance, previously linked to therapist empathy, occurs in mothers and infants. During the still-face episode, SC concordance correlated to infant negative engagement. Upon reengagement, when mothers often soothe their infants, concordance instead correlated to behavioral synchrony, an index of maternal sensitivity. Furthermore, maternal RSA became correlated to infant negative engagement. These findings suggest that a mother trying to calm her infant calms herself physiologically and her sensitivity on a behavioral level becomes coherent physiologically. Implications for psychotherapy research are discussed.     

Therapeutic alliance,empathy, and genuineness in individual adult psychotherapy: A meta-analytic review

Objective: Alliance, empathy, and genuineness are each integral parts of the therapeutic relationship. No previous meta-analysis has explored the extent to which therapist empathy and genuineness contribute to the therapeutic alliance. Method: In this meta-analysis, a multifaceted search strategy yielded 53 studies. Forty studies reported alliance/empathy relationships, eight studies reported alliance/genuineness relationships, and five studies reported both. Results: Random effects meta-analyses revealed that therapeutic alliance was significantly related to perceptions of therapist empathy with a mean r?=?0.50 (95% CI?=?0.42, 0.57). Therapeutic alliance was also significantly related to perceptions of therapist genuineness with a mean r?=?0.59 (95% CI?=?0.45, 0.71). Tests of publication bias indicated a low likelihood of publication bias affecting the strength and direction of the results. Potential moderating variables were explored, including rater perspective, measure of therapeutic relationship variables, and client race/ethnicity. Conclusions: Therapeutic alliance has a moderate relationship with perceptions of therapist empathy and genuineness. Of note, there may be reason to believe that when rated by the same person, these constructs have significant overlap and lack discreteness. Future directions for study of the therapeutic relationship are discussed. Implications for practice are provided.     

Interactional synchrony and negative symptoms: An outcome study of body-oriented psychotherapy for schizophrenia

Objective: We sought to assess the efficacy of a manualized body-oriented psychotherapy (BPT) intervention for schizophrenia, by focusing on improvement of negative symptoms and on changes in interactional synchrony. We also explored aspects of a phenomenological theory of schizophrenia, which states that negative symptoms should be understood within an encompassing disturbance of subjectivity and intersubjectivity. Method: Sixteen persons with schizophrenia participated in 10 weeks of BPT. General psychiatric symptomatology and negative symptoms were assessed before and after therapy. Interactional synchrony was assessed via cross-correlations of movements between patient and interviewer in interviews conducted before and after therapy. Results: Psychiatric symptomatology and negative symptoms significantly improved with a medium effect size. We also demonstrated a significant increase in interactional synchrony with a strong effect size. Post hoc analyses showed a significant increase only with open-ended interviews conducted by the same interviewer. Furthermore, we explored the correlation between negative symptoms and interactional synchrony, finding a large inverse relationship. Conclusions: BPT for schizophrenia may effectively reduce patients’ negative symptoms and psychiatric symptomatology. Moreover, it may yield some recovery of pre-reflective social relations. Further evidence of the specific relation between negative symptoms and interactional synchrony would support a phenomenologically informed holistic view of schizophrenia.     

Responding to mentalization invitations in psychotherapy sessions—A conversation analysis approach

Objective: Increase in the capacity to mentalize has been proposed to be an important mechanism of change in psychotherapy. However, mentalization has primarily been studied as an individual skill that people either possess or lack, rather than as an interactional phenomenon. Method: In this study, excerpts from three different sessions in a therapy that aimed at increasing the patients mentalizing capacity were identified and studied using conversation analysis. Results: The analysis indicated that resistance to mentalizing may not only be due to lack of capacity but also may be seen as a linguistic resource in which this resistance demonstrates precisely the ability to mentalize. Conclusions: Consequences for psychotherapy practice and process research are discussed.     

Research on the alliance: Knowledge in search of a theory

Objectives: The aim of this review paper is to summarize the challenges facing research on the alliance now and going forward. The review begins with a brief overview of the development of the concept of the alliance in historical context. Method: A summary of what has been accomplished both within the psychotherapy research community and in other professions is presented. Current challenges facing this line of research are identified, including the existence of a wide range of operational definitions that results in a diffusion of the identity of the alliance concept. It is argued that the current situation generates risks to incremental growth in several lines of research. Conclusions: A case is made that a lack of clarity regarding how several variables within the broader category of therapeutic relationships fit together, overlap, or complement each other is also potentially problematic. Efforts to resolve the lack of a consensual definition are reviewed, and in conclusion, it is argued that a resumption of a conversation about the relationship in the helping context in general, and the alliance in particular, should be resumed.     

Clients’ experiences of moments of sadness in psychotherapy: A grounded theory analysis

Abstract

Although few studies have examined the experience of depression, no research has been conducted on the experience of sadness in psychotherapy. In this study, clients were interviewed about their experience of sadness using an interpersonal process recall method, these interviews were subjected to grounded theory analysis, and a model of sadness experienced in psychotherapy was derived. The resulting core category—in therapy, the experience of sadness is a struggle against the fear of becoming trapped within the painful, existential question “Who am I?”—captures the essence of the experience of the clients’ sadness and describes the struggle, the causes of sadness, and ways therapists facilitated sadness exploration. The findings are discussed in reference to clinical application and future psychotherapy research.     

Psychotherapy change process research: Realizing the promise

Abstract

Change process research (CPR) is the study of the processes by which change occurs in psychotherapy and is a necessary complement to randomized clinical trials and other forms of efficacy research. In this article the author describes and evaluates four types of CPR. The first three are basic designs and include quantitative process–outcome, qualitative helpful factors, and microanalytic sequential process; the fourth, the significant events approach, refers to methods such as task analysis and comprehensive process analysis that integrate the first three. The strengths and weaknesses of each design are described and summarized using both causal and practical criteria as part of an overall argument for systematic methodological pluralism.     

The Multitheoretical List of Therapeutic Interventions (MULTI): Initial report

Abstract

The Multitheoretical List of Therapeutic Interventions (MULTI) assesses interventions from eight different psychotherapy orientations (behavioral, cognitive, dialectical–behavioral, interpersonal, person centered, psychodynamic, process-experiential, and common factors) and from the perspective of clients, therapists, and observers. The internal consistency for the subscales was moderate to high. Split-half reliability was moderate for clients and low to moderate for therapists and untrained observers. Interrater reliability for the subscales was low for untrained raters but moderate for psychotherapy-knowledgeable raters. A model of the MULTI subscales representing different psychotherapy orientations fit the data adequately but not parsimoniously in a confirmatory factor analysis. MULTI subscale levels successfully predicted sessions of different psychotherapy orientations. The MULTI seems to be a promising tool to investigate the interventions that occur in different psychotherapies.     

Commitment under pressure: Experienced therapists' inner work during difficult therapeutic impasses

Abstract

Interviews were conducted to explore the recall of impasse experiences of 12 highly skilled and experienced therapists. Participants were interviewed in depth individually about a specific impasse from their experience that resolved successfully. The transcribed interviews were analysed using qualitative methodology. The authors found that participants understood their reported impasse experiences as important for their professional development. The category of “helpful subjective presence” describes the mode of being with patients that the participants found therapeutic. The categories of “losing hope” and “difficult feelings in the therapist in the here and now” are processes that threaten the helpful presence. The participants' inner work on the two latter categories is identified as a key to the successful resolution of impasses.     

Psychotherapists' personal identities,theoretical orientations,and professional relationships: Elective affinity and role adjustment as modes of congruence

Abstract

Research shows psychotherapists espousing different theoretical approaches differ in mentality (e.g., cognitive styles, beliefs and epistemologies) and personality (e.g., neuroticism). However, studies have not investigated the association between professional relational style prescribed by therapists' theoretical orientations and therapists' manner of relating in personal life. Analyses of over 4000 therapists of varied nationalities, professions and career levels having different theoretical preferences indicate: (i) therapists' self-experience in close personal relationships was significantly associated with the manner their theoretical orientations prescribed for relating with clients; (ii) therapists were less accepting, less tolerant and more demanding in their personal relationships than with clients; and (iii) therapists adjusted their professional relational manner in practice to meet the specific expectations of their preferred orientations.     

Conceptualization and treatment of personality disorders

Abstract

Résumé

There is an emerging consensus that the essence of personality pathology consists of difficulties with self-identity and chronic interpersonal dysfunction. The nature of normal and abnormal attachment to others, attention control, affect regulation, and the autobiographical self are related developmentally to the early caregiving context. Psychotherapeutic intervention for adults with personality disorders across many schools of psychotherapy is focused on changing the individual's dysfunctional internal models of self and others. Future research will examine how cognitive, cognitive–behavioral, interpersonal, and psychodynamic treatments accomplish this task. Advances in neurobiology, laboratory tasks, and interview techniques will assist in the measurement of personality organization and identification of subgroups of patients for more refined treatments. Our future treatment development must be differentiated and multifaceted, respecting subgroups of patients with severe personality disorders.

Zusammenfassung

Die Konzeptualisierung und Behandlung von Persönlichkeitsstörungen

Die Ansicht, dass Persönlichkeitsstörungen i. A. durch Probleme der Selbstidentität und eine chronische interpersonelle Disfunktion geprägt sind, setzt sich immer mehr durch. Die Art der normalen und anormalen Bindung an andere, der Aufmerksamkeitskontrolle, der Affektregulierung und des autobiographischen Selbst sind im Kontext der frühkindlichen Versorgung zu sehen. Psychotherapeutische Interventionen bei Erwachsenen mit Persönlichkeitsstörungen sind über viele Psychotherapieschulen hinweg darauf konzentriert, die disfunktionalen inneren Modelle vom Selbst und von anderen zu verändern. Zukünftige Forschung wird herausfinden, wie kognitive, kognitiv-verhaltensmäßige, interpersonelle und psychodynamische Behandlungen dieses Ziel erreichen. Fortschritte in der Neurobiologie, bei experimentellen Aufgaben und bei Interviewtechniken werden die Messung von Persönlichkeitsorganisation unterstützen und die Identifikation von Untergruppen ermöglichen und so zu einer Verfeinerung der Behandlung führen können. Die zukünftige Entwicklung von Behandlungen muss, vom Tatbestand von Untergruppen bei schweren Persönlichkeitsstörungen ausgehend, darauf ausgerichtet sein, einen differenzierten und multiperspektivischen Zugang anzustreben .

Conceptualisation et traitement des troubles de personnalité

Un consensus émerge sur le fait que l'essence de la pathologie de la personnalité consiste autour de difficulté de l'identité de soi et des dysfonctions interpersonnelles chroniques. la nature de l'attachement normal et anormal aux autres, le contrôle de l'attention , la régulation affective, et le soi autobiographique sot reliés avec le contexte de soin précoce. Les interventions psychothérapeutiques pour les adultes présentant des troubles de la personnalité sont dans de nombreuses écoles de psychothérapies focalisées sur leurs modèles internes dysfonctionnels de soi et de l'autre. Les recherches futures ont à examiner comment les traitements comportementaux, cognitifs-comportementaux, interpersonnels et psychodynamiques accomplissent cette tâche. Les progrès en neurobiologie, dans les tâches de laboratoire ainsi que dans les techniques d'entretien vont assister la mesure de l'organisation de la personnalité et l'identification de sous-groupes de patients pour des traitements plus affinés. Notre développement du traitement doit être à l'avenir différencié et à multiples facettes, respectant des sous-groupes de patients avec des troubles sévères de la personnalité.

Sommario

Concettualizzazione e trattamento dei disturbi di personalità.

Esiste un consenso emergente che l'essenza della patologia di personalità consista in difficoltà con l'identità di sè e la disfunzione interpersonale cronica. La natura di un normale ed anormale attaccamento agli altri, il controllo dell'attenzione, la regolazione affettiva ed il sé auto autobiografico sono relativi all'accrescimento iniziale nel contesto di cure parentali. L'intervento psicoterapeutico per gli adulti con i disturbi di personalità attraverso molte scuole della psicoterapia si focalizza sul cambiare i modelli interni disfunzionali dell'individuo e degli altri. La ricerca futura esaminerà come i trattamenti cognitivi, cognitivo-comportamentale, interpersonale ed i trattamenti psicodinamici compiono questa operazione. Gli avanzamenti nella neurobiologia, nei compiti e tecniche di interviste aiuteranno nel misurare l'organizzazione di personalità e nell'identificazione dei sottogruppi di pazienti per trattamenti più raffinati. Il nostro sviluppo futuro di trattamento deve essere differenziato e sfaccettato, rispettando i sottogruppi di pazienti con gravi disturbi di personalità.

Resumen

Conceptualización y tratamiento de los desórdenes de personalidad

Existe un consenso progresivo acerca de que la esencia de la patología de la personalidad consiste en dificultades con la propia identidad y con disfunciones crónicas en las relaciones interpersonales. La naturaleza del apego tanto normal como anormal, el control de la atención, la regulación del afecto y el self autobiográfico están relacionados con el contexto de cuidados tempranos. La intervención psicoterapéutica de adultos con desórdenes de la personalidad según diversas escuelas de psicoterapia está focalizada en cambiar los modelos internos disfuncionales del self y de los otros. La investigación futura examinará cómo los tratamientos cognitivo, cognitivo-comportamental, interpersonal y psicodinámico pueden lograrlo. Los avances en la neurobiología, los trabajos de laboratorio y las técnicas de entrevista ayudarán en la evaluación de la organización de la personalidad y en la identificación de subgrupos de pacientes asignables a tratamientos más refinados. Nuestro desarrollo terapéutico futuro debe ser diferenciado y multifacético respecto de los subgrupos de pacientes con desórdenes severos de la personalidad.

     

20/20 Hindsight: A 25-year programme at the Anna Freud Centre of efficacy and effectiveness research on child psychoanalytic psychotherapy

Objective: This paper describes the evolution of methods of enquiry—through 25 years of work, with Professor Peter Fonagy and many other colleagues—of research and theorizing about child and adolescent therapy outcomes. Method: The work has focused on measuring psychoanalytic outcomes, but with an increasing interest in discovering therapeutic elements across treatment modalities. Results: Headline findings are described, with lessons from the ups and downs of developing (a) retrospective, follow-up, and prospective outcome studies, and (b) measures of child and family functioning. Issues of manualizing and measuring treatment process are discussed, together with the fruitfulness of mixed-method (quantitative and qualitative) process and outcome research with young people and families. Conclusions: Using the dilemmas, experiences, and findings ??of our group as examples, growing points and well as growing pains for the field are suggested.     

A mathematical model of psychotherapy: An investigation using dynamic non-linear equations to model the therapeutic relationship

Abstract

Mathematical models, such as the one developed by Gottman et al. (1998, 2000, 2002) to understand the interaction between husbands and wives, can provide novel insights into the dynamics of the therapeutic relationship. A set of nonlinear equations were used to model the changing emotional state of a therapist and client. The results suggest: (1) The person that is most responsive to the other achieves the most positive state, (2) the emotional state of the client oscillates before reaching its final state, (3) therapy is least successful when the therapist starts from a negative state, and (4) there is an inverse relationship between models that change only the influence parameter and models that change only the inertia parameter, creating a series of four basic models to work with. These theoretical models require further, empirical investigation to test the derived parameters. If validated, or revised based on observations of therapist-client relationships in development, they could provide specific direction in creating successful therapeutic relationships for training clinicians and those already in practice.     

Attachment characteristics and treatment outcome following inpatient psychotherapy: Results of a multisite study

Abstract

Existential suffering may contribute to treatment-resistant depression. The “VITA” treatment model was designed for such patients with long-standing depression accompanied by existential and/or religious concerns. This naturalistic effectiveness study compared the VITA model (n = 50) with a “treatment as usual” comparison group (TAU; n = 50) of patients with treatment-resistant depression and Cluster C comorbidity. The TAU patients were matched on several characteristics with the VITA patients. The VITA model included existential, dynamic, narrative and affect-focused components. The VITA group had significantly greater improvement on symptom distress and relational problems during treatment and from pre-treatment to 1-year follow-up. Patients in the VITA, at follow-up, were more likely to be employed and less likely be using psychotropic medications.     

Sexual satisfaction in Chinese gay and bisexual men: relationship to negative sexual minority identity and sexual role preference

The present study explored the relationships among sexual satisfaction, sexual minority identity, and sexual role preference (top, bottom, and versatile) in a sample (N = 403) of Chinese men who self-identified as either gay or bisexual. Participants completed online the New Scale of Sexual Satisfaction, Lesbian and Gay Identity Scale, and a survey of sexual role preference. The New Scale of Sexual Satisfaction comprises two factors: (1) personal experiences and sensations (ego focused), and (2) participants’ perceptions of partner reactions and sexual activity in general (partner/activity focused). The hierarchical multiple regression model revealed that internalized homonegativity (the degree of negativity the participant associates with their sexual minority identity) significantly predicted ego-focused and partner/activity-focused sexual satisfaction. There were significant differences in ego-focused sexual satisfaction among sexual role preference groups (top, bottom, and versatile). Participants in the top (preferring the insertive position) and versatile (preferring either position) groups scored higher on ego-focused sexual satisfaction compared to those in the bottom (preferring the receptive position) group (M_tops = 3.12, M_versatiles = 3.23, M_bottoms = 2.98, p < .05). These findings indicated that reducing internalized homonegativity could be a complementary treatment for sexual satisfaction in gay and bisexual men.     

Patient affect experiencing following therapist interventions in short-term dynamic psychotherapy

Abstract

The aim of this research was to examine the relationship between therapist interventions and patient affect responses in Short-Term Dynamic Psychotherapy (STDP). The Affect Experiencing subscale from the Achievement of Therapeutic Objectives Scale (ATOS) was adapted to measure individual immediate affect experiencing (I-AES) responses in relation to therapist interventions coded within the preceding speaking turn, using the Psychotherapy Interaction Coding (PIC) system. A hierarchical linear modelling procedure was used to assess the change in affect experiencing and the relationship between affect experiencing and therapist interventions within and across segments of therapy. Process data was taken from six STDP cases; in total 24 hours of video-taped sessions were examined. Therapist interventions were found to account for a statistically significant amount of variance in immediate affect experiencing. Higher levels of immediate affect experiencing followed the therapist's use of Confrontation, Clarification and Support compared to Questions, Self-disclosure and Information interventions. Therapist Confrontation interventions that attempted to direct pressure towards either the visceral experience of affect or a patient's defences against feelings led to the highest levels of immediate affect experiencing. The type of therapist intervention accounts for a small but significant amount of the variation observed in a patient's immediate emotional arousal. Empirical findings support clinical theory in STDP that suggests strategic verbal responses promote the achievement of this specific therapeutic objective.     

Compassion in psychotherapy: The perspective of therapists nominated as compassionate

Abstract

Fourteen therapists nominated by peers as compassionate defined compassion in psychotherapy as connecting with the client's suffering and promoting change through action. They indicated that compassion was broader and deeper than empathy, helps clients feel understood, and relieves symptoms. Although indicating that compassion was innate, therapists felt it could be further awakened. Factors facilitating compassion in therapy were therapists feeling clients’ suffering, understanding client dynamics, identifying with and liking clients, client involvement, and a good therapy relationship. Hindering factors included clients being resistant, being aggressive, having serious pathology, or violating boundaries; therapists having interfering personal issues, feeling incompetent, or having negative reactions to or not liking clients; and a poor therapy relationship. A theory regarding compassion in psychotherapy is proposed.