The Relationship Between Client Emotional Expressions, Therapist Interventions, and the Working Alliance: An Exploration of Eight Emotional Expression Events

The relationship between client emotional expression and therapist interventions was studied in two working alliance conditions. An events-focused methodology was used to examine a total of 8 events taken from a variety of therapeutic orientations. Results indicated that, in the presence of a good client–therapist relationship, therapists showed higher levels of empathy and effectively focused on the immediately expressed feelings; in turn, their clients were engaged in exploration of feelings. In poor-relationship dyads, clients expressed negative feelings toward the therapists. Interventions rated as effective by clinical judges were characterized by accurate therapist understanding of clients' emotional expressions and working with strains in the therapeutic relationship. Ineffective interventions were associated with inaccurate assessments of clients' emotional states. Intensive analysis of these sessions led to three distinct models of in-session emotional expression events. Theoretical and practical implications of these models will be discussed.     

Exploring In-Session Process with Qualitative and Quantitative Methods in Psychotherapy with an Adolescent

ABSTRACT

There is emerging evidence for the effect of psychotherapy in adolescents with depression. Research indicates that therapists often use techniques from different theoretical models when working with adults. Research on the therapy process in adolescents is scarce. We explore the therapist’s interventions in a time-limited psychodynamic adolescent therapy with Susanna suffering from major depression. Susanna quite suddenly became worse at mid-treatment, with self-harming and suicidal ideations. Rating scales for analyzing in-session relational processes included the Structural Analysis of Social Behavior (SASB), the Adolescent Psychotherapy Q-set (APQ), and the Transference Work Scale (TWS). Self-reports on symptoms, interpersonal problems, and working alliance were obtained before, during, and at the end of and one year after treatment. Different tools seemed to expose different aspects of the process and the patient’s development. Only patient-rated questionnaires revealed the mid-treatment crises. Combining different and pan-theoretical rating scales on here-and-now interventions (TWS and SASB) and whole sessions (APQ), as well as clinician-rated measures and a variety of self-reports, indicated that different psychotherapeutic techniques were integrated in the therapy and seemed beneficial to patient’s outcome. The therapist adhered to the treatment manual. This way of exploring the therapy process may be used for different treatment modalities.     

Love in therapy: A qualitative study of how clients perceive their therapists’ emotions

Relevant literature on attachment theory has explored the importance of emotional experience inside the therapeutic setting, highlighting that the active engagement of the therapist with the client is necessary in the process of change. However, less is known about the clients’ perception of the therapists’ emotional expression during a session. In this qualitative study, we used narrative thematic analysis to examine 10 semi-structured interviews with clients in an enriched systemic therapy approach. Focusing on the similarities of clients’ experiences, what emerged from the interviews were specific ‘perceived emotions’ and the related facial expressions of the therapists that were given attention by the clients. Based on our findings, six emotional themes were identified and are considered prominent: (i) ‘excitement’, (ii) ‘calmness’, (iii) ‘affection’, (iv) ‘empathy’, (v) ‘anger’ and (vi) ‘sadness’. Also, the analysis revealed two distinct functions of the expression of the therapist’s emotions: (i) they are an essential part of the therapeutic relationship and, (ii) they provide clients with alternative ways of experiencing emotions and motivate them to change. Therapists are invited to recognize the importance of their own emotional and facial expression in therapy considering it a form of self-disclosure. Suggestions for further research are also provided.     

A Family Therapist for Life: Observations and Options

“Life” is used here in the chronological sense of years spent as a family therapist and in the existential sense of experiencing “life” in terms of satisfaction, meaning, and vitality in one’s living. In the 1950s, there were few guidelines for professionals recognizing the need for working therapeutically with families. Becoming and being a family therapist are discussed, along with lifetime learning about family and tolerance for ambiguity in understanding family and marital relationships and dynamics; flexibility in implementing therapeutic interventions; functioning in ways that fit with one’s personality, beliefs, and principles; working where one functions best; and what works at what stage for the family therapist and relating these to establishing and maintaining “life” in one’s living.     

How to Help a Thin-Skinned Person: Commentary on Paper by Stephen Seligman

Stephen Seligman's treatment of Harriet illustrates the typical challenges and basic technical principles in working with narcissistically sensitive people. Often, with such patients there are struggles around the frame, especially issues of payment and cancellation policies. Sometimes the therapist must be flexible in negotiations with the patient. In the early phases of therapy interpretations of defense, especially the interpretation of projected aggression, are not helpful. Interventions that recognize the patient's response to something the therapist has done or failed to do are more effective and set the stage for later work focused on the patient's recognition of her self-states. A willingness to respect Harriet's identification with Joan of Arc, and to work in displacement, rather than pathologizing her preoccupation was also essential. Finally, Seligman utilized the concept of mentalization in actively discussing with Harriet the mental processes of other people in her life. All these techniques enabled Harriet to move from being dominated by a sense of grievance to becoming capable of experiencing grief.     

Engaging reluctant adolescents in family therapy: an exploratory study of in‐session processes of change

Informed by a trans‐theoretical model of the therapeutic alliance in conjoint family therapy, this exploratory study was the initial stage in a task analysis of critical shifts in adolescent engagement. Specifically, we compared sessions in which a resistant adolescent either did or did not shift from negative to positive engagement during the session. Two successful and two unsuccessful change events were selected from an archival data set based on SOFTA ratings of the therapeutic alliance. The results suggested that one parent element (support) and five therapist elements (structuring therapeutic conversations, fostering autonomy, building systemic awareness, rolling with resistance and understanding the adolescent's subjective experience) seemed critical for successfully facilitating adolescent engagement. The qualitative results were informed by the adolescent's self‐reported target complaints pretreatment, which suggested varying reasons for the teenagers’ active or passive disengagement. Implications for practice and recommendations for future research are offered to continue this line of inquiry.     

The Child Rating Scale and its use with middle school-age students

The Child Rating Scale is a socioemotional self-report rating scale design for elementary school children. This study examined the Child Rating Scale with a middle school-age sample (Grades 5 to 8) of 240 students. The Child Rating Scale's four scales have shown moderate to high coefficients alpha. Factor analysis yielded the 4 underlying factors consistent with the current subscales. Supportive convergent validity was found based on the Child Rating Scale subscales' predicted association with the Self-perception Profile for Children and the Psychological Sense of School Membership-Brief. Consistent with current research, decline over grades in rule compliance/acting out and school interest was documented as well as the expected mean sex differences on these two subscales. Possible areas of study are indicated, and the present study's limitations are described. The Child Rating Scale seems to be a promising self-report measure for middle school-age youth.     

Defense Mechanisms in Mania,Bipolar Depression and Unipolar Depression

The present study compared the use of defense mechanisms in ten bipolar manic, ten bipolar depressed and ten unipolar depressed patients. The defense mechanisms were assessed by two methods: TAT stories scored by Defense Mechanism Manual and Defense Mechanism Rating Scale ratings of psychodynamic interviews. The severity of symptoms was assessed by Beck Depression Inventory for depressed patients and Young’s Manic Rating Scale for manic patients. Both bipolar manic and depressed groups used the defense mechanism of denial, borderline level defenses and immature defenses significantly more than the unipolar depression group. The manic group showed greater dependence on narcissistic level defenses as compared to the other two groups. Positive relationships were found between severity of manic symptoms and the defense mechanisms of denial as well as the narcissistic level defenses. The bipolar depression group also used more action level defenses as compared to the unipolar depression group. The unipolar depression group scored higher on the defense mechanism of identification and adaptive level defenses as compared to the manic group. A negative correlation was found between the severity of depressive symptoms for unipolar depression group and the defense mechanism of identification. The neurotic level defenses were used most frequently by unipolar depression group, followed by the bipolar depression group and manic group. Some of these findings are in consonance with the psychoanalytic understanding of mania and depression.     

Clinical Validity of a Dimensional Assessment of Self- and Interpersonal Functioning in Adolescent Inpatients

The Social Cognition and Object Relations Scale–Global Version (SCORS–G) is a clinical rating system assessing 8 domains of self- and interpersonal relational experience that can be applied to narrative response data (e.g., Thematic Apperception Test [TAT; Murray, 1943], early memories narratives) or oral data (e.g., psychotherapy narratives, relationship anecdotal paradigms). In this study, 72 psychiatrically hospitalized adolescents consented and were rated by their individual and group therapist using the SCORS–G. Clinicians also rated therapy engagement, personality functioning, quality of peer relationships, school functioning, global assessment of functioning (GAF), history of eating-disordered behavior, and history of nonsuicidal self-injury. SCORS–G composite ratings achieved an acceptable level of interrater reliability and were associated with theoretically predicted variables (e.g., engagement in therapy, history of nonsuicidal self-injury). SCORS–G ratings also incrementally improved the prediction of therapy engagement and global functioning beyond what was accounted for by GAF scores. This study further demonstrates the clinical utility of the SCORS–G with adolescents.     

Using Motivational Monitoring to Evaluate the Efficacy of Self-disclosure and Self-involving Interventions

Self-disclosures and self-interventions are generally considered useful, although their role remains controversial. This is mainly due to the heterogeneity of research findings on this topic, characterized by the lack of a clear definition of self-disclosure and of systematic and effective methods to evaluate the short- and long-term effects of such interventions. To clarify the concept of self-disclosure, it is essential to understand whether its definition comprehends different interventions, which may have different effects. An accurate and reliable evaluation of such effects may allow clinicians and researchers to differentiate among different kinds of self-disclosures. In this theoretical article, we propose a method to evaluate the clinical efficacy of self-disclosures interventions. This method is based upon the monitoring of motivational systems (Liotti, 2005), which allows therapists to assess the cooperative attunement between patient and therapist in real-time. Our central assumption is that the evaluation of the cooperative attunement between patient and therapist, as well as the patient’s metacognitive functioning, is primary to assess the use of clinical interventions. Indeed, these factors – either acting on their own or synergistically – are the mark, the essence, and the reflection of the therapeutic alliance, which is the strongest predictor of treatment’s outcome.

     

Confirmatory Factor Analysis of the Behavioral and Emotional Rating Scale–2 (BERS-2) Parent and Youth Rating Scales

We confirmed the factor structure of the Behavioral and Emotional Rating Scale – 2nd Edition (BERS-2) with a normative parent and youth sample. The BERS-2, based on the Behavioral and Emotional Rating Scale (BERS), is a standardized instrument that assesses children's emotional and behavioral strengths. The original BERS was renormed to create a separate parent scale (Parent Rating Scale) and a youth self-report scale (Youth Rating Scale). In this study, we investigated whether the five-factor structure of the original BERS (i.e., interpersonal strengths, family involvement, intrapersonal strengths, school functioning, and affective strengths) could be replicated with normative parent and youth respondents. A total of 927 parents of students with and without disabilities and 1301 youth with and without disabilities volunteered to participate in the study. Confirmatory factor analysis was used to determine the extent to which the normative parent and youth data fit the original five-factor BERS structure. Results indicated that the five-factor structure demonstrated an acceptable fit with the normative parent and youth samples. Practical implications and future research ideas are discussed.     

Strategies to Engage Underrepresented Parents in Child Intervention Services: A Review of Effectiveness and Co-occurring Use

The purpose of this review was to estimate the impact of parent engagement strategies tested with underrepresented families of young children with social, emotional, or behavioral disorders, and describe the combinations in which these strategies are commonly used together. We conducted a systematic review using the PracticeWise Engagement Coding System to identify which strategies had the strongest empirical support for engaging underrepresented (i.e., minority race or ethnicity, or low income) families receiving psychosocial services for their children. Social network analyses were used to identify the frequency of strategy use and how strategies were combined to engage underrepresented families. Linear regression was used to estimate the impact of each strategy on parent engagement, using attrition as a proxy for non-engagement. Thirty-five studies met inclusion criteria. Parent attrition was predicted by larger sample sizes, lower maternal education, interventions that were more community or home-based, less therapist monitoring, positive reinforcement from therapists, and more pairing families with peers. Social network analyses suggested that more effective strategies were more frequently implemented alone and less effective strategies were commonly combined with each other. Our findings suggest that researchers and practitioners require guidance in selecting engagement strategies to reduce attrition of underrepresented families in treatment. Although we identified promising strategies for improving parent engagement in treatment for underrepresented children with social, emotional, or behavioral disorders, the frequent combining of engagement strategies in research means that there is little data on the independent effects of interventions to increase parent engagement for this population.     

The Moderating Effects of Mindfulness on Psychological Distress and Emotional Eating Behaviour

Current evidence and theory suggests that emotional eating resulting from attempts to manage psychological distress, such as anxiety, depression, and stress, is considered to be a major contributor to obesity. Mindfulness has been shown to be related to disordered eating behaviours. Employing a non‐clinical sample of 42 males and 115 females, the present study investigated the contribution of mindfulness as a potential moderator between psychological distress and engagement in emotional eating, while controlling for the effects of gender and general nutrition knowledge. Consistent with predictions, psychological distress was positively associated with engagement in emotional eating, while mindfulness was found to share an inverse relationship. Moreover, after controlling for gender and general nutrition knowledge, the interaction between psychological distress and mindfulness was found to significantly predict the tendency to engage in emotional eating over and above the individual effects of these variables. The findings from the current study add to the current literature supporting the use of mindfulness‐based interventions for treatment of emotional eating practices in individuals experiencing anxiety, stress, and lower levels of depression.     

Autonomic stress reactivity and executive functions in successful and unsuccessful criminal psychopaths from the community

A significant gap in the psychopathy literature is the lack of studies comparing "successful," nonconvicted psychopaths with "unsuccessful," convicted psychopaths. This study tested the hypothesis that successful psychopaths show increased autonomic stress reactivity and better neuropsychological function compared with unsuccessful psychopaths. A total of 26 controls, 16 unsuccessful psychopaths, and 13 successful psychopaths were assessed on psychophysiological measures recorded during an emotional manipulation, the Wisconsin Card Sorting Test (WCST), Wechsler Memory Scale--Revised subtests, and childhood stressors. Compared with controls, unsuccessful psychopaths showed reduced cardiovascular stress reactivity. In contrast, successful psychopaths showed heightened reactivity, better WCST performance, and more parental absence than unsuccessful psychopaths and controls. The implications of these findings and the generalizability of existing psychopathy research are discussed.     

P3 event-related potentials and childhood maltreatment in successful and unsuccessful psychopaths

Although P3 event-related potential abnormalities have been found in psychopathic individuals, it is unknown whether successful (uncaught) psychopaths and unsuccessful (caught) psychopaths show similar deficits. In this study, P3 amplitude and latency were assessed from a community sample of 121 male adults using an auditory three-stimulus oddball task. Psychopathy was assessed using the Psychopathy Checklist-Revised (Hare, 2003) while childhood physical maltreatment was assessed using the Conflict Tactic Scale (Straus, 1979). Results revealed that compared to normal controls, unsuccessful psychopaths showed reduced parietal P3 amplitudes to target stimuli and reported experienced more physical abuse in childhood. In contrast, successful psychopaths exhibited larger parietal P3 amplitude and shorter frontal P3 latency to irrelevant nontarget stimuli than unsuccessful psychopaths. This is the first report of electrophysiological processing differences between successful and unsuccessful psychopaths, possibly indicating neurocognitive and psychosocial distinctions between these two subtypes of psychopathy.     

Supportive interventions and nonsymbolic mental functioning

The author aims to show how supportive interventions are the analyst's most relevant therapeutic means to helping patients with a feeble symbolic system transform nonsymbolic episodes and reestablish symbolic mental functioning. Symbolic and nonsymbolic modes of mental functioning are first outlined. Supportive interventions are redefined as an analyst's effort at improving a patient's nonsymbolic mental functioning, by using principally pragmatic or interactive aspects of communication to deal with her or his patient's nonsymbolic in-session experiences. These interventions are psychoanalytic when transference focused, in so far as they foster the symbolization and transformation of more primitive (nonsymbolic) layers of the transference. Some probable mechanisms underlying the effect of supportive interventions on nonsymbolic functioning include the modification of mental procedures. Supportive interventions also help restore symbolic mental elaboration through the gratification of a basic ego or self-need, bringing about a temporary relief from psychic pain, with increased affect tolerance and a renewed capacity to use symbols. This soothing effect accounts for a missing link in Bion's model of the elaborative effect of the analyst's reverie.     

Defense use and defense understanding in children

This study investigated the relation between children's use of defense mechanisms and their understanding of those defenses. We hypothesized that, once a child understands how a particular defense functions, the use of that defense will no longer be successful and will be replaced by another defense mechanism that is not yet understood. Defense use was assessed from the Thematic Appreception Test (TAT) stories told by 122 children; defense understanding was determined from the children's understanding of stories portraying defenses. The results indicated that younger children (mean age = 7-8) used the defense of denial more than the older children (mean age = 9-11). Older children understood the functioning of denial and projection better than the younger children. A comparison of children who did and did not understand a defense showed that younger children who understood the functioning of denial were less likely to themselves use denial. Likewise, older children who understood the functioning of projection were less likely to use this defense.     

Therapist Factors Matter: A Systematic Review of Parent Interventions Directed at Children’s Behavior Problems

The present review systematically explored research examining the relationship between therapist‐related factors and the outcomes of parent interventions directed at children’s behavior problems. A systematic search of the literature was conducted with online scientific databases, parenting programs, web sites, and bibliographic references of the selected articles, according to PRISMA guidelines. A total of 24 quantitative studies met the inclusion criteria. Although some methodological limitations were identified with respect to the measurement of therapist factors, the reviewed research strongly suggests that the therapist plays a critical role in parent interventions directed at behavior problems. In particular, many parent outcomes are found to be related to the parent–therapist alliance, the therapist’s fidelity to the intervention, specific therapist’s in‐session actions, and the therapist’s personal variables. The parent–therapist alliance and therapist fidelity to the intervention consistently relate to changes in parenting practices, and alliance additionally relates to fewer perceived barriers to participation in treatment, more treatment acceptability, and greater parenting satisfaction and self‐efficacy. In addition, specific in‐session therapist interpersonal actions relate to parents’ engagement and satisfaction, while both the therapist’s interpersonal actions and more active skills relate to parent change. Therapist’s personal variables have been scarcely or poorly studied to date, but the results found justify the need to develop further research in this area. In conclusion, more attention should be given to the role of the therapist when implementing parenting programs directed at behavior problems, and more and better research is needed that can overcome the methodological limitations identified.     

Motor vehicle accidents and adolescents: An empirical study on their emotional and behavioral profiles,defense strategies and parental support

Background: Research has limitedly focused on adolescents’ emotional–behavioral functioning preceding road collisions and on the role of family support. Objective: To verify whether the rates of motorbikes collisions among adolescents are associated with their emotional–behavioral functioning, their use of specific defense strategies and family support. Method: N = 150 adolescents who visited an emergency department for road accidents were selected and completed self-report questionnaires assessing emotional–behavioral functioning, difficulty in identifying and describing emotions, use of defense strategies and perceived family support. Results: Higher rates of motorbike collisions are associated with more maladaptive emotional–behavioral functioning. Higher perceived family support is associated with lower rates of collisions. Conclusions: Recidivism of motor vehicle collision among adolescents can be considered as a form of acting-out caused by their psychological difficulties.