The process of change in cognitive therapy for depression: Predictors of early inter-session symptom gains

Although cognitive therapy for depression is an efficacious treatment, questions about the aspects of the therapy that are most critical to successful implementation remain. In a sample of 60 cognitive therapy patients with moderate to severe depression, we examined three aspects of therapists’ adherence to cognitive therapy techniques, the patients’ facilitation or inhibition of these techniques, and the therapeutic alliance as predictors of session-to-session symptom improvement across the first five therapy sessions. Two elements of therapist adherence (viz., cognitive methods and negotiating content/structuring sessions) emerged as the strongest predictors of symptom improvement. Patient facilitation or inhibition of therapist adherence also predicted subsequent symptom change. Neither adherence to behavioral methods/homework nor the therapeutic alliance was a significant predictor in parallel analyses. Although alliance scores did not predict subsequent symptom change, they were significantly predicted by prior symptom change. These findings support the model of change that motivates cognitive therapy for depression, and they highlight the potential role of patient facilitation of therapists’ adherence in treatment response.     

Therapeutic action in psychoanalytic therapy with toddlers and parents

Psychotherapy with toddlers and parents can focus on promoting attachment, facilitating development and improving interactions. Some techniques provide guidance to the parents, whereas others interpret to them their unconscious fantasies or ‘ghosts’ contributing to the child’s disorder. A recent paper introduced a psychoanalytically oriented technique, which emphasised the therapist’s interaction with the child in the presence of the parent(s). The child was addressed about his/her unconscious motivations in the session and the feelings towards the therapist. Also, the parent’s transference onto the therapist was seen as a vehicle that might further the therapeutic process and was accordingly addressed. The present paper analyses the therapeutic action in such treatments. Whereas work with the parents resembles that of ordinary psychodynamic therapy, therapeutic action is more difficult to conceptualise regarding the toddler, whose understanding of verbal interpretations and the therapist’s dialogues with the parent is more limited than that of an adult. However, a clinical vignette demonstrates a toddler’s precise and swift reactions to communications from mother or therapist. The paper investigates evidence from neuroscience and psychological research as to which communicative channels – beyond words – toddlers might perceive and comprehend. In addition, it is claimed that the countertransference is key to explaining how the therapist understands such communication.     

Influence of Therapist and Client Behaviors on Therapy Alliance

This study considers the combined effect of therapist behaviors and couples interaction dynamics on therapeutic alliance because it seems to be a significant predictor of successful therapy outcomes. We measured therapeutic alliance using the Working Alliance Inventory, Observer Version (WAI-O), which includes three subscales: goals, tasks, and bond. We investigated the combined effect of therapist behaviors and couples interactions on therapeutic alliance. There were three significant findings: (1) the models better predicted therapeutic alliance for men clients than women clients; (2) combined consideration of partner behaviors and therapist behaviors provided the stronger prediction of therapeutic alliance; and (3) different variables predicted alliance for women clients versus men clients.     

Session-Intersession Sequences in the Treatment of Chronic Anorexic-Bulimic Patients: Following the Model of "Family Games"

In this article, the author presents some technical aspects of a psychotherapeutic approach for treating chronic anorectic patients. Two basic principles underlie the approach. First, the main purpose of the treatment is to improve the patient's relational skills in order to enable her to cope with her family's "game". Second, the therapeutic relationship is considered hierarchically subordinate to her relationships outside the therapeutic context. Mastering the model of families with anorectics is essential if the therapist is to be consistent with these principles. Specialized training in verbal and nonverbal communication is considered a useful tool.     

What do men and women want in a partner? Are educated partners always more desirable?

Previous research has shown that males value a potential partner’s physical attractiveness more than females do, whereas females value a potential partner’s socioeconomic status (SES) more than males do. But are men really so unconcerned about a potential partner’s SES? Five studies revealed that men do integrate information about a woman’s SES into their decisions on whether to consider her as a romantic partner or not. Results consistently demonstrated that male participants preferred women with lower SES. Female participants, in contrast, preferred men with higher SES. These sex differences were more pronounced when a long-term romantic relationship rather than a one-night stand was being considered. In addition, men’s lower reported likelihood of romantic contact with a woman with high SES was due to her high educational level rather than her high income. Mediational analyses showed that men perceived a potential partner with high educational level as less likeable and less faithful, and thus reported less likelihood of romantic contact.     

A psychotherapeutic computer application: Modification of technological competence

The increasing sophistication of computer technology, combined with increased specification of therapeutic interventions, has facilitated development of computer programs that have achieved marked success in the psychotherapeutic treatment of circumscribed populations. This paper briefly reviews the history of computerized psychotherapy and examines several successful therapeutic computer applications in depth. These applications have attempted to replace the therapist with a computer. Another possible, as yet unexplored, application is the use of the computer as a vehicle for modification of an individual’s perceived competence to effectively operate on his or her environment. Using a computer to successfully manipulate one’s environment can provide a personal mastery experience that has the potential to contribute significantly to an increase in perceived self-competence, an essential component of positive therapeutic change. A study that would provide empirical support for this type of computer application is proposed.     

Women’s physical attractiveness and short-term mating strategies

The current study examined the relationship between women’s physical attractiveness – as rated by themselves and a set of third-party raters – and their mating strategy and sexual experience. Male (N = 105) and female (N = 113) undergraduates rated the attractiveness of face and body photographs of 93 female undergraduates. Attractiveness ratings – particularly bodily attractiveness ratings – were significantly related to women’s mating psychology and behavior. More attractive women reported more sexual experience and a less restricted sociosexual orientation. In addition, some traits better predicted women’s perception of their overall attractiveness, and this pattern was further linked to mating strategy: more sociosexually unrestricted women showed a stronger relationship between bodily traits (i.e., body mass index) and overall attractiveness than less sociosexually unrestricted women. Discussion focuses on the findings that a woman’s mating strategy is linked to both her self-perceived and objective measures of attractiveness, particularly bodily attractiveness.     

Therapist Self-as-Context and the Curative Relationship

This article discusses how the way the therapist relates to his or her personal responses to client material during the session contributes to making the relationship with the client an effective tool for treatment. Ideas from third wave behavior therapy are used to describe aspects of therapist involvement in the relationship and modes of therapist awareness of inner responses. In two vignettes, negative client reactions to an intervention bring problematic therapist material to the fore. Both cases highlight how the stories the therapists spun about themselves as professionals and persons could easily have limited their effectiveness in responding to the material. The vignettes also illustrate how clinicians can overcome personal meanings and judgments to access a more productive mode of interacting with the feelings a critical incident in the relationship evokes in them. It is argued that observing their own content from a psychological distance makes it possible for clinicians to use their feelings without getting caught up in them. These same feelings may then help the therapist perceive how the incident relates to the client’s daily life problems. The therapist’s engagement in a sense of self-as-context is described as a therapeutic stance that provides the psychological distance needed to help overcome alliance ruptures and other potential gridlocks and which may transform the therapist’s inner response to client content into a tool for addressing important client issues.     

A Behavior Analytic Interpretation of the Therapeutic Relationship

The paper examines, from a behavior analytic perspective, the mechanisms through which change occurs within the context of the therapeutic relationship in individual psychotherapy. The analysis focuses upon the therapist’s shaping of the client’s behavior through subtle nonverbal cues and explicit verbal analyses. In the relationship, therapists modify behavior that has created difficulties for the client in the natural environment, and clinical change is dependent upon the extent to which those in the natural environment will reinforce functionally similar response classes. Ferster’s distinction between natural and arbitrary reinforcement and Skinner’s distinction between contingency-shaped and rule-governed behavior are also used to describe the manner through which change occurs. The goal of the paper is to stimulate behavior therapists to look more closely at the therapeutic relationship as a mechanism of clinical change and to help those of other perspectives see how their effectiveness within the relationship can be understood using the principles of learning.

     

Restoring Dyadic Connection in the Face of Multiple Disruptions: Accounting for Vicissitudes in the Therapist’s Capacity for Reflective Functioning

This article describes the working method of our study group comprised of former Chestnut Lodge Hospital therapists and focusing on understanding therapeutic work with severely disturbed adolescents. Using process material from one therapy session, the therapist’s commentary on her feelings and reactions in the session, and the group’s discussion of the work, we explore factors disrupting the therapist’s moment-to-moment capacity to maintain a theory of her own and the patient’s minds. We then discuss what allows her to refind her theory of mind in the face of the patient’s aggressive nihilism and her own sense of loss. Salutary factors included the therapist’s empathy for the patient’s shared sense of grief, the patient’s offering the therapist cues to his inner state, and the dyad’s capacity to tolerate the therapist’s vulnerability in the patient’s presence.     

Perceptions of cotherapists as a function of therapist sex roles and observer sex roles

These two studies examined how therapist sex-role behaviors and subject sex roles influence perceptions of cotherapists conducting marital therapy. As hypothesized, ratings of therapist competence, strength, and impact varied directly with verbal dominance. Contrary to expectations, this effect was not stronger for female therapists than for male therapists. However, verbally dominant females were seen as less in charge than verbally dominant males. Reversal of traditional instrumental and expressive sex-role styles was more salient for male therapists than for females. Nontraditional therapist sex-role styles were seen as providing a greater learning experience than traditional styles. As predicted, androgynous subjects rated male and female therapists equal in competence and strength, and were equally comfortable with each. Sex-typed males and females demonstrated a preference for the female therapist, rating her higher in competence and strength. These studies suggest that cotherapists' attention to the models they present should encompass sex-role behaviors and styles.An earlier draft of this article was presented as a paper at the annual meeting of the American Psychological Association, Toronto, August 1978.     

PRIVATE THEORIES AND PSYCHOTHERAPEUTIC TECHNIQUE

That if real success is to attend the effort to bring a man to a definite position, one must first of all take pains to find him where he is and begin there. This is the secret of the art of helping others (Kierkegaard [] 1962, p.?27)

The aim of this study is to explore the importance, to the therapeutic process, of the relation between the patient's and the therapist's problem formulations and private theories of pathogenesis and cure. Four cases of young adults in psychoanalytic psychotherapy were compared, two with unequivocally positive and two with more ambiguous outcome at termination. The patients and therapists were interviewed about their private theories initially and at termination of therapy, and a qualitative comparison was made between the cases. In the two more successful cases the therapists had early in therapy perceived obstacles for the therapeutic work in the patients' ways of thinking, feeling, and relating, and made interpretative interventions focusing on these. This was not observed in the less successful cases. In the more successful cases the patient's and the therapist's private theories were more similar at termination than initially, whereas the opposite development was found in the less successful cases. One hypotheses generated is that the therapeutic process can be facilitated by a therapist listening to the patient's private theories, making interpretative interventions focusing on obstacles to the therapeutic work, including contradictions between their private theories, and monitoring the patient's reactions to these interventions.     

Cathodal transcranial direct current stimulation of the right Wernicke's area improves comprehension in subacute stroke patients

Previous studies have shown the appearance of right-sided language-related brain activity in right-handed patients after a stroke. Non-invasive brain stimulation such as transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS) have been shown to modulate excitability in the brain. Moreover, rTMS and tDCS have been found to improve naming in non-fluent post-stroke aphasic patients. Here, we investigated the effect of tDCS on the comprehension of aphasic patients with subacute stroke. We hypothesized that tDCS applied to the left superior temporal gyrus (Wernicke’s area) or the right Wernicke’s area might be associated with recovery of comprehension ability in aphasic patients with subacute stroke. Participants included right-handed subacute stroke patients with global aphasia due to ischemic infarct of the left M1 or M2 middle cerebral artery. Patients were randomly divided into three groups: patients who received anodal tDCS applied to the left superior temporal gyrus, patients who received cathodal tDCS applied to the right superior temporal gyrus, and patients who received sham tDCS. All patients received conventional speech and language therapy during each period of tDCS application. The Korean-Western Aphasia Battery (K-WAB) was used to assess all patients before and after tDCS sessions. After intervention, all patients had significant improvements in aphasia quotients, spontaneous speech, and auditory verbal comprehension. However, auditory verbal comprehension improved significantly more in patients treated with a cathode, as compared to patients in the other groups. These results are consistent with the role of Wernicke’s area in language comprehension and the therapeutic effect that cathodal tDCS has on aphasia patients with subacute stroke, suggesting that tDCS may be an adjuvant treatment approach for aphasia rehabilitation therapy in patients in an early stage of stroke.     

Cognitive effects of language on human navigation

Language has been linked to spatial representation and behavior in humans, but the nature of this effect is debated. Here, we test whether simple verbal expressions improve 4-year-old children’s performance in a disoriented search task in a small rectangular room with a single red landmark wall. Disoriented children’s landmark-guided search for a hidden object was dramatically enhanced when the experimenter used certain verbal expressions to designate the landmark during the hiding event. Both a spatial expression (“I’m hiding the sticker at the red/white wall”) and a non-spatial but task-relevant expression (“The red/white wall can help you get the sticker”) enhanced children’s search, relative to uncued controls. By contrast, a verbal expression that drew attention to the landmark in a task-irrelevant manner (“Look at this pretty red/white wall”) produced no such enhancement. These findings provide further evidence that language changes spatial behavior in children and illuminate one mechanism through which language exerts its effect: by helping children understand the relevance of landmarks for encoding locations.     

The Functional Analytic Psychotherapy Rating Scale: a Replication and Extension

Few theories of psychotherapy give direction to the therapist on a moment-to-moment level or make predictions about how specific therapist techniques change client behavior in session. Functional analytic psychotherapy (FAP, Kohlenberg and Tsai in Functional analytic psychotherapy: a guide for creating intense and curative therapeutic relationships. Plenum, New York 1991) provides this direction and prediction. Specifically, FAP claims that client problem behaviors will be displayed in the therapeutic relationship and that the therapist can improve client in-session behavior through differential, contingent responding. Further, it is assumed that these improvements in session can be generalized to out of session relationships. The FAP rating scale (FAPRS) was developed for the purpose of coding in-session client and therapist behaviors in an effort to test FAP’s purported mechanism of change. The current study seeks to replicate and extend initial FAPRS findings (Callaghan et al. in J Contemp Psychother 33:321–339, 2003) regarding mechanism of change and to address transportability. FAPRS coding data from a single successful case of an individual diagnosed with Borderline Personality Disorder and treated with FAP is presented. Results indicate that the FAPRS system is transportable and are generally supportive of the claim that therapist contingent responding leads to client improvement.     

Individually-tailored, Internet-based treatment for anxiety disorders: A randomized controlled trial

Previous studies on Internet-based treatment with minimal to moderate therapist guidance have shown promising results for a number of specific diagnoses. The aim of this study was to test a new approach to Internet treatment that involves tailoring the treatment according to the patient’s unique characteristics and comorbidities.A total of 54 participants, regardless of specific anxiety diagnosis, were included after an in-person, semi-structured diagnostic interview and randomized to a 10 week treatment program or to a control group. Treatment consisted of a number of individually-prescribed modules in conjunction with online therapist guidance. Significant results were found for all dependent measures both immediately following treatment and at 1 and 2 year intervals. Mean between-group effect size including measures of anxiety, depression and quality of life was Cohen’s d = 0.69 at post-treatment, while the mean within-group effect size was d = 1.15 at post-treatment and d = 1.13 and d = 1.04 at 1 and 2 year follow-up respectively.The tentative conclusion drawn from these results is that tailoring the Internet-based therapy can be a feasible approach in the treatment of anxiety in a homogeneous population.     

When Time Stands Still: The Non-Interactive Interaction in the Psychoanalytic Encounter

This paper strives to shed light on the patient–therapist encounter at times and places where emotional life has stopped, both within the patient and in the therapeutic dyad. The term non-interactive interaction is coined to describe a manner of being together that does not possess the essential features of interaction: movement, encounter, and change. The paper explores the characteristics and effects of such dead areas in one’s soul and the various motivations for the therapist’s willingness to surrender himself to such areas, both those of his patient’s and of his own. Among these, the paper suggests, are the therapist’s love and dedication to his or her patients; his deep-rooted struggle to cope with and give life to some of his own deadened and traumatic self-states; and, perhaps most important, a mythical, hubris-like, valiant, and perennial urge to fight death. Two clinical examples are presented.     

Simultaneous Semipermeable Groups for Mothers and Their Early Latency-Age Boys

Abstract

Bonding is an ongoing aspect of intersubjective experience, a type of mental relationship to oneself and others. As a behavioral mode, bonding utilizes verbal and nonverbal communication primarily to establish a basic feeling of connection between individuals. Bonding is the floor, a cognitive-affective state that precedes and prepares the way for the complex processes underlying identification. The concept relates to Bion’s early theory of basic assumptions, and takes on new and different meanings according to his later ideas regarding social communication. Bonding is also a therapeutic posture or technique, an element in the establishment of group cohesion, the positive transference, and therapeutic and group alliance. Case examples illustrate how the therapist and other group members bring a complex of bonding needs and anxieties that must be negotiated to establish and maintain bonding, which is a necessary condition for successful therapeutic work.     

Bringing ethics into focus: How regulatory focus and risk preferences influence (Un)ethical behavior

In four laboratory studies, we find that regulatory focus induced by situational cues (such as the framing of an unrelated task) or primed influences people’s likelihood to cross ethical boundaries. A promotion focus leads individuals to be more likely to act unethically than a prevention focus (Studies 1, 2, and 3). These higher levels of dishonesty are explained by the influence of a person’s induced regulatory focus on his or her behavior toward risk. A promotion focus leads to risk-seeking behaviors, while a prevention focus leads to risk avoidance (Study 3). Through higher levels of dishonesty, promotion focus also results in higher levels of virtuous behavior (Studies 2 and 3), thus providing evidence for compensatory ethics. Our results also demonstrate that the framing of ethics (e.g., through an organization’s ethics code) influences individuals’ ethical behavior and does so differently depending on an individual’s induced regulatory focus (Study 4).     

Do 10-month-old infants understand others' false beliefs?

As adults, we know that others’ mental states, such as beliefs, guide their behavior and that these mental states can deviate from reality. Researchers have examined whether young children possess adult-like theory of mind by focusing on their understanding about others’ false beliefs. The present research revealed that 10-month-old infants seemed to interpret a person’s choice of toys based on her true or false beliefs about which toys were present. These results indicate that like adults, even preverbal infants act as if they can consider others’ mental states when making inferences about others’ actions.