Emotion in an alliance rupture and resolution sequence: A theory‐building case study

Aims: Alliance rupture and resolution processes are occasions for the client to have his or her core interpersonal patterns activated in the here and now of the therapy and to negotiate them with the therapist. So far, no studies have been conducted on emotional processing, from a sequential perspective using distinct emotion categories, in alliance rupture and resolution therapy sessions. This is the objective of this theory‐building case study. Method: This client underwent a 34‐session long, psychodynamic psychotherapy within the context of an open trial. An alliance rupture‐resolution sequence of two subsequent sessions, along with a third control session, was selected from this case and these sessions were rated using the Classification of Affective‐Meaning States (CAMS), an observer‐rated method to classify distinct emotions, according to current emotion‐focused models. Results: The results indicate that the rupture session was associated, above all, with core maladaptive fear, evoked in the actual here and now of the therapeutic relationship, whereas the resolution session was associated with the expression and experience of adaptive hurt as regards biographical issues of the client. Discussion: These results are discussed with regard to the alliance rupture and resolution model and the exploration of integrating client's emotional processing in the model.     

Client process in short term dynamic psychotherapy1

In this study, a single case design was used to examine significant client events in a process of short-term dynamic psychotherapy. The Category System of Client Good Moments (Mahrer, 1988) was used as a measure of therapeutic process. Client speaking turns were rated for three sessions (early, middle, and late) of the complete sixteen session treatment conducted according to davanloo's (1978) model of short-term dynamic psychotherapy (STDP), and categories of good moments identified. The results showed that the salient client change-events were related to the client's (a) provision of significant information, (b) exploration of feelings, and (c) insight and understanding across the three sessions. Additionally, the results also showed a statistically significant increase in client-reported behavior change and sense of well-being for the late session. The results suggest that in-session report of behavior change is an important component of therapeutic process. The implications of these results for an atheoretical, data-driven understanding of therapeutic change processes are presented.     

Therapist orientation,supervisor match,and therapeutic interventions: Implications for session quality in a psychotherapy training PRN

Background: Theoretical orientation is a multifaceted construct that is integral to the process of psychotherapy and psychotherapy training. While some research has been conducted on personal identification with particular schools of psychotherapy, techniques used in psychotherapy sessions, and match between trainees and supervisors in training, there is insufficient information regarding how these may interact with one another. Aim: This study, conducted in a practice research network of trainee therapists, was designed to test whether these variables may be related to one another in predicting session quality. Method: The sample comprised 328 sessions from 26 clients and 11 therapists, with the clients completing session quality measures and therapists completing measures of technique immediately post‐session. Results: Using multilevel linear modelling, the data showed varied results. For behavioural therapy and person‐centred therapy, techniques and orientation were unrelated to session quality in the sample. However, process‐experiential, psychodynamic, and cognitive therapy techniques were all involved in interactions with therapist and/or supervisor orientations. Conclusions: These results suggest that the impact of specific psychotherapy techniques sometimes depends on the orientation of the therapist and/or supervisor. For instance, sessions high in cognitive therapy techniques were only associated with positive outcome when both the therapist and supervisor were highly cognitively oriented. Though preliminary, these results suggest that orientation may be an important variable to consider in training and supervision, especially in the context of other variables.     

Reciprocal language style matching in psychotherapy research

Successful coordination of language, that is language style matching (LSM; Gonzales, Hancock, & Pennebaker, 2010) indicated by interdependent use of function words, might be of particular relevance to the psychotherapy process. Empirically, two previous psychotherapy studies indicate that LSM may provide a deeper understanding of the quality of the therapeutic alliance. Theoretically, this process of implicit linguistic coordination may be conceptualised as interpersonal synergy (Riley, Richardson, Shockley, & Ramenzoni, 2011). To illustrate the potential of LSM in psychotherapy research, patterns of LSM per 5 min segments and reciprocal LSM per speaking turn were assessed in a seven‐session treatment demonstration of a narcissistic client. First, LSM predicted observed frequency of ruptures but did not predict observer‐rated working alliance in the corresponding 5 min segments. Second, LSM in these 5 min segments showed a quadratic trajectory of change within session and a stable pattern between sessions. Reciprocal LSM per speaking turn showed that within the majority of this treatment, the client followed the therapist's language style; however, this influence appeared to be bidirectional during the time of a physical altercation in session five. LSM may thus provide a novel way to study some of the more elusive aspects of the therapeutic interaction.     

Integrating Sociological and Psychoanalytic Concepts by Otto Pollak

The total data set for this study consisted of 958 critical incidents from high and low cohesion sessions in person-centered group psychotherapy. These incidents were typically noted on a group climate questionnaire at the end of each session. Altogether 211 clients and students participated in twenty-six groups.

The high cohesion sessions were dominated by the following cohesion dimensions in rank order: self-disclosure and feedback (24.0%); attraction and bonding (20.2%); listening and empathy (20.0%); process performance and goal attainment (15.0%); and support and caring (10.6%). The corresponding rank order for the low cohesion sessions was strikingly different: avoidance and defensiveness (43.5%); conflict and rebellion (22.2%); and selfdisclosure and feedback (8.9%).

Apparently then, there are very different patterns of critical incidents in high and low cohesion sessions of group psychotherapy.     

The Lonely Crowd: A Study of Changing American Character by David Riesman; in collaboration with Reule Denny and Nathan Glazer

This paper describes a form of combined psychotherapy in which the individual sessions are used as an adjunct to group therapy. Each group member is seen regularly in individual sessions to focus primarily on the member's ongoing group work. The individual sessions are scheduled on a rotating basis. Typically, each group member is seen in an individual session once every four weeks. Additional individual sessions are available only when immediate attention is appropriate and necessary. The group is viewed as the primary therapeutic component. A cost-effective therapeutic approach that uses both individual and group methods, this modality lends itself well to a clinic and to a private practice setting.     

A Pilot Study of Psychotherapist Trainees' Alpha-Amylase and Cortisol Levels During Treatment of Recently Suicidal Clients With Borderline Traits

Psychotherapists often experience stress while providing psychotherapy, in particular when working with difficult presentations such as suicidality. As part of a larger study on the treatment of recently suicidal college students with borderline traits, 6 therapists in training collected their own salivary samples for alpha-amylase (AA) and cortisol (C) analyses immediately before and after sessions with 2 selected clients. On average, samples were collected for the same therapist-patient dyad throughout the year-long study to ensure that data reflected therapist responses across stages of treatment. Therapists also completed a working alliance questionnaire and rated perceived session difficulty immediately after each selected session. Contrary to expectations, therapists demonstrated elevated levels of stress as measured by AA and C at presession relative to postsession levels. Greater session difficulty was related to more pronounced declines in AA, whereas a stronger working alliance was linked to more pronounced reductions in C. Results suggest that physiological stress responses while working with recently suicidal clients with borderline traits occur primarily in terms of session anticipatory anxiety, whereas AA and C changes may be affected differently by factors such as session difficulty and working alliance. This is a pilot study, limited by its sample size, but the design, findings, and inclusion of physiological measures present an initial step in an essential line of research.     

Linguistic Reflections on Psychotherapy: Change in Usage of The First Person Pronoun in Information Structure Positions

Aim of present study was to understand changes in speech of clients with regard to certain linguistic features from 5th to 15th session of psychotherapy. First person pronoun use in information structure positions were analyzed in speech of clients. Participants of this study were 11 psychotherapists (clinical psychology master and doctorate students) and 16 clients (applicants to AYNA Psychotherapy Unit). In present study word count results of clinets’ speeches were analyzed by ANOVA method. According to results, use of first person pronoun changed significantly in preverbal position from 5th to 15th sessions of psychotherapy. Findings of this study suggest that, psychotherapy leads to certain linguistic changes, and these changes discussed to be means of understand change of clients during psychotherapy     

The different patterns of group climate critical incidents in high and low cohesion sessions of group psychotherapy

The total data set for this study consisted of 958 critical incidents from high and low cohesion sessions in person-centered group psychotherapy. These incidents were typically noted on a group climate questionnaire at the end of each session. Altogether 211 clients and students participated in twenty-six groups. The high cohesion sessions were dominated by the following cohesion dimensions in rank order: self-disclosure and feedback (24.0%); attraction and bonding (20.2%); listening and empathy (20.0%); process performance and goal attainment (15.0%); and support and caring (10.6%). The corresponding rank order for the low cohesion sessions was strikingly different: avoidance and defensiveness (43.5%); conflict and rebellion (22.2%); and self-disclosure and feedback (8.9%). Apparently then, there are very different patterns of critical incidents in high and low cohesion sessions of group psychotherapy.     

The manifestation of transference during early psychotherapy sessions: Exploring an alternate data source for therapist narratives in transference research

Introduction: Previous transference studies have compared in‐session client narratives about significant others to in‐session client narratives about the therapist, limiting data to the information that clients are willing to share with the therapist. Method: The first three sessions of 30 therapies with high‐functioning individuals were examined using the Core Conflictual Relationship Theme (CCRT) method. Client narratives about others were drawn from the psychotherapy sessions and client narratives about the therapist were drawn from a Participant Critical Event (PCE) interview conducted after the third session of therapy. Results: Factor analyses of the CCRT components indicated several relational patterns: a complementary pattern of relating characterised by a devaluation of the therapist and idealisation of others; a concordant relational transfer where clients feel bad with both the therapist and others; and as clients experience control issues with significant others, they wish to adopt a submissive stance toward the therapist. The results suggest that the source of therapist narratives may influence the results of transference research.     

Change in action: how infants learn to walk down slopes

A critical aspect of perception–action coupling is the ability to modify ongoing actions in accordance with variations in the environment. Infants’ ability to modify their gait patterns to walk down shallow and steep slopes was examined at three nested time scales. Across sessions, a microgenetic training design showed rapid improvements after the first session in infants receiving concentrated practice walking down slopes and in infants in a control group who were tested only at the beginning and end of the study. Within sessions, analyses across easy and challenging slope angles showed that infants used a ‘braking strategy’ to curb increases in walking speed across increasingly steeper slopes. Within trials, comparisons of infants’ gait modifications before and after stepping over the brink of the slopes showed that the braking strategy was planned prospectively. Findings illustrate how observing change in action provides important insights into the process of skill acquisition.     

Brief crisis group psychotherapy versus the initial sessions of long-term group psychotherapy: An exploratory comparison

An attempt was made to specify the therapist behaviors characteristic of the brief crisis group (BCG) approach, to assess how patients experience BCG on dimensions of session impact and group climat, and to describe the changes possible from BCG on measures of outcome by contrasting this modality with the initial sessions of traditional long-term therapy groups in a preexperimental design. Data obtained from four eight-session BCGs and three beginning long-term groups (LTG) were used for analyses. Patients were administered the Session Evaluation (SEQ) and Group Climate (GCQ) Questionnaires at the end of each group session. Two judges sat in on each session and coded the types of therapist interventions using the Therapist Behavior Categories (TBC) system. Aspects of self-esteem and symptomatology were assessed as indices of change over the 8-week period in a pre-post fashion. Therapists in BCG evidenced a distinct pattern of interventions during midpoint group sessions (sessions 3–6), placing a greater emphasis on challenging patient perceptions and providing information than their LTG counterparts. The therapists' use of self as an issue in BCG increased as termination approached and apparently served a more limited function than in LTG. Patients in BCG reported a more rapid development of a working group and experienced greater session benefit. Patients in BCG also reported lower levels of conflict and avoidance and a greater decrease in these resistance behaviors. As expected, BCG patients reported substantially greater improvement on most outcome dimensions at the end of the 8-week period. Results are considered as clarifying the approach to and impact of BCG psychotherapy.An earlier version of this paper was presented at the 15th Annual Meeting of the Society for Psychotherapy Research, Lake Louise, Alberta, June 19–23, 1984.     

Mapping Good Therapy Sessions: A Pilot Study of Within-Session Client Affect

The purpose of the present study was to measure client affect over small timescales within therapy sessions, in order to identify affective patterns that might distinguish good versus poor sessions. Toward this end, patterns of affect were observed across 15-s intervals throughout one therapy session for each of four different clients being treated for generalized anxiety disorder using cognitive-behavioral therapy. The primary hypothesis was that during “good” therapy sessions (as defined by high session alliance scores and good therapy outcomes), clients would exhibit a pattern of positive–negative–positive (PNP) affect during the course of the session, reflecting prolonged periods of negative affect consistent with productive therapeutic work, situated between periods of positive feeling. Clients in “poor” sessions were not expected to show this pattern. The findings were consistent with predictions. There was also a non-significant trend suggesting that clients in good sessions demonstrated a greater frequency of very small PNPs—as brief as 45 s—suggesting a potentially greater number of “micro-episodes” of therapeutic work. Implications of the findings are discussed.     

Clients' Experiences of Obstructive Silence: Integrating Conscious Reports and Analytic Theories

The psychodynamic literature has associated clients' silences in psychotherapy sessions with a variety of processes. These processes include wishes to merge with the therapist, to gain control in session, to communicate the unsayable, to express helplessness and, most frequently, the intertwined processes of resistance and regression. Experiences of obstructive silence—that is, moments in which clients detached from the process of therapeutic inquiry—were examined in this study. A grounded theory analysis was used to explore clients' experiences of silences in psychotherapy across psychotherapeutic modalities. Two types of obstructive pausing processes, Disengaged pauses and Interactional pauses, were identified. The implications of delineating conscious aspects of these complex experiences are stressed and techniques are suggested for therapeutic intervention in moments of experienced threat.     

Developing the matrix representation grid (MRG): A method for observing group processes. Findings from time-limited group psychotherapy for alcohol-dependent patients

The MRG was published 1988 in order to support developments in group psychotherapy methods as one of the all too few process observation research methods for studying group-as-a-whole. After 9 years of what pilot studies have labeled successful clinical trials, this study aims at validating the MRG against the established SAVI: Structural Analysis of Verbal Interaction (Agazarian & Simon 1989). Videotaped group sessions from short-term groups for alcohol dependent patients conducted along two therapy methods, one behaviorally oriented and the other group analytic, are used as material. The MRG is validated in the study, confirmed to be clinically valuable, and some interesting comparisons between the two treatment modalities are also made.     

Emotional Reactions Before Examinations: II. Results of a Questionnaire

To evaluate the effect of session replication and the effect of the duration of the interval between sessions on CFF, three groups different in the methods of spacing sessions were tested for 10 sessions. A significant interaction effect was observed between interval durations and session replications. The group that was tested daily for five consecutive days showed a consistent elevation in threshold after the first two sessions, while the other two groups showed relatively uniform threshold scores over the 10 sessions.     

Outcome in short-term group psychotherapy

This study examines the effectiveness of planned dynamic short-term group psychotherapy in a health maintenance organization setting. The groups, conducted by experienced short-term psychodynamically trained therapists, focused on common life-stage issues. A pretest/posttest design was employed; group participants completed a battery of self-report measures before, after, and 4–6 months after treatment. Group participants made statistically (and clinically) significant positive changes on the majority of change measures. They saw themselves as improved on target problems, became far less symptomatic, and reported considerable growth in interpersonal functioning.     

A Patient Who Does Not Look: A Collaborative Treatment with Video Feedback

We describe a collaborative treatment of a woman in face-to-face psychoanalytic psychotherapy (with Larry Sandberg), whose persistent gaze aversion was a symptom immune to interpretive efforts. After many years of treatment, the patient agreed to engage in video feedback sessions (with Beatrice Beebe), which have occurred for the past decade. The face of Dr. Beebe, but not the face of the patient, was videotaped during psychotherapy sessions. Dr. Beebe and the patient then reviewed segments of the videotaped session, collaboratively observing and thinking together, translating between the verbal dialogue and the therapist’s implicit action dialogue. We examine the impact of this intervention on the psychotherapy process.     

Therapist Interventions and Skills as Predictors of Dropout in Outpatient Psychotherapy

The current study employed machine learning to investigate whether the inclusion of observer-rated therapist interventions and skills in early sessions of psychotherapy improved dropout prediction beyond intake assessments. Patients were treated by postgraduate clinicians at a university outpatient clinic. Psychometric instruments were assessed at intake and therapeutic interventions and skills in the third session were routinely rated by independent observers. After variable preselection, an elastic net algorithm was used to build two dropout prediction models, one including and one excluding observer-rated session variables. The best model included observer-rated variables and was significantly superior to the model including intake variables only. Alongside intake variables, two observer-rated variables significantly predicted dropout: therapist use of feedback and summaries and treatment difficulty. Although not retained in the final prediction model, the observer-rated use of cognitive techniques was also significantly correlated with dropout. Observer ratings of therapist interventions and skills in early sessions of psychotherapy improve predictors of dropout from psychotherapy beyond intake variables alone. Future research could work toward personalizing dropout predictions to the specific dyad, thereby improving their validity and aiding therapists to recognize and react to increased dropout risk.