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.     

Cognitive errors,coping patterns,and the therapeutic alliance: A pilot study of in‐session process

Aim: This exploratory study examined the association between clients’ assessment of the therapeutic alliance and their cognitive errors (CE) and coping action patterns (CAP). Method: Selected therapy sessions of clients (N = 26) were rated for cognitive errors and coping action patterns using the CERS and CAPRS methods (Drapeau, Perry, & Dunkley, 2008; Perry, Drapeau, & Dunkley, 2005). The therapeutic alliance was assessed using the Working Alliance Inventory (WAI; Horvath & Greenberg, 1989). Results: Following Bonferroni corrections, no significant relationship was found between clients’ CEs and their ratings of the WAI. However, the ‘Negotiation’ CAP was associated with the total alliance score, and with the Task and Goal subscales. Implications: A better understanding of the cognitive processes presented by clients in session can enable clinicians to address these factors early on when the alliance is most critical.     

The Psychology of Crime by David Abrahamsen

Abstract

This study investigated the relationships between initial level of alliance, pattern of alliance over sessions, and outcome in a sample of 107 patients who completed short–term group therapy for complicated grief. Both patient–rated alliance and therapist–rated alliance were studied. For patient–rated alliance, both the initial level of alliance and the linear pattern of alliance were directly and significantly related to favorable outcome. For therapist–rated alliance, no significant direct relationships with outcome were found. Instead, significant interaction effects were found. For patients with relatively high initial alliance, the greater the increase in alliance over sessions, the better the outcome. For patients with relatively low initial alliance, the greater the decrease in alliance over sessions, the better the outcome. Explanations for the findings are considered as well as possible clinical implications.     

Negotiating ending: A qualitative study of the process of ending psychotherapy

Objectives: When psychotherapy is open-ended, the question of termination is a matter for negotiation. A model based on both content and the process of ending may explain how ‘good enough’ psychotherapies can be brought to ‘good enough’ endings.

Design: Twelve processes of ending were explored through a combination of audio recordings made during therapy sessions and post-therapy interviews with clients and therapists. Therapies had been tailored to the needs of the clients and were based on a broad spectrum of theoretical affiliations.

Methods: A procedure for systematic text condensation was used on a case-by-case basis. Issues surrounding the initiation and negotiation of ending were pointed out in each case and were then compared across cases.

Results: The initiation of ending and exchanges concerned with when and how to end therapy unfolded as a concerted process because both parties seemed to be aware that the theme of ending contained a potential challenge to the alliance. Dual affect regulation, implicit communication and a future-oriented perspective were important features. Structural elements such as schedule changes and temporary breaks served several psychological functions. Therapies seemed to reach ‘good enough’ endings when the client and therapist joined in their efforts to resolve basic ambivalences embedded in the decision to terminate contact with the affirmation of a continuing emotional bond.     

Psychological support needs of patients with head and neck cancer and their caregivers: A qualitative study

Objective: The aim of this study was to explore the psychological support needs of patients with head and neck cancer (HNC) and their caregivers. The appropriate timing, length, format and content of sessions were also investigated.

Design: Eighty-three patients with HNC and 73 of their caregivers completed questionnaires at diagnosis. Follow-up questionnaires were mailed to patients six months later.

Main outcome measures: Free text-comments to open-ended questions in the questionnaires were analysed using an inductive thematic approach with coding and theme development directed by the content of responses. This was used to determine psychological support needs both at diagnosis and at six month follow-up.

Results: Patients described ‘just being there’, empathy, maintaining normality and practical support as helpful from family/friends. They desired information, honesty, positivity and empathy from clinical staff. Formal psychological support was desired by approximately 40% of patients and caregivers, particularly early after diagnosis and during treatment. Most participants desired face to face sessions, providing individualised information and coping strategies.

Conclusion: The results of this study suggest that psychological interventions for patients with HNC and their caregivers should be delivered early after diagnosis in face to face sessions, presenting honest and factual information about the disease and coping strategies.     

Solving distant analogies reduces belief-based responding in transitive inference

ABSTRACT

Previous research demonstrated that relational processing in transitive inference problems can be disrupted by belief-based content. Given the premises, The horse is larger than the goat, and The goat is larger than the elephant, accepting the valid conclusion, The horse is larger than the elephant suggests use of relational processing whereas accepting the invalid conclusion The elephant is larger than the horse indicates belief-based responding. This research examined whether solving analogies influenced participants’ reliance on belief-based or relational processing. Participants generated solutions to either distant analogies (e.g. nose:scent::antenna: ______) or near analogies (e.g. nose:scent::tongue:______) before evaluating the conclusions of transitive inference problems that were valid (V) or invalid (I) and believable (B), unbelievable (U) or neutral (N). Solving distant analogies eliminated belief-based responding (possibly reflecting improved inhibitory control) and facilitated relational responding on VU problems.     

Early attachment quality moderates eating disorder risk among adolescent girls

Objective: There is growing evidence that children’s early relational environment has lasting implications for physical and mental health. In this paper, we test whether attachment insecurity in early childhood is associated with increased responsivity to risk factors for eating disorders (EDs; e.g. pubertal weight gain, maternal negative affect) during adolescence.

Design: Hypotheses were tested with longitudinal data from 447 girls (final mean age?=?15.1?years) over a 12-year period. Tests of direct effects, moderation and moderated mediation were conducted using nested structural equation models and bootstrapped estimates of direct and indirect effects.

Results: Early attachment quality was not directly associated with disordered eating attitudes and behaviours (DEABs), but did moderate relations between adolescent ED risk factors and DEABs. Specifically, among girls with an insecure attachment history, higher BMI at age 15 directly predicted more DEABs, while maternal negative affect and pubertal weight gain indirectly predicted DEABs via greater preoccupation with parental relationships. These same direct and indirect paths did not emerge among adolescent girls with a secure attachment history.

Conclusion: Results delineate one way early attachment quality may contribute to EDs among some adolescent girls, and support recent efforts to incorporate relational components into obesity and ED prevention programmes.     

The concept of the 50-minute hour: Time forming a frame for the unconscious

Abstract

The 50-minute hour is a feature of psychoanalytic work that is most commonly discussed in the context of case reports. This paper examines it as a concept. The author starts by describing the origin of the 50-minute hour and its development as an element of the psychoanalytic setting or framework. Next, he considers the significance of the clock as a relational factor in the session and reflects on the alienness of the time of day to the unconscious, and the consequences of this alienness. He then uses a clinical example to illustrate the phenomenon of the stretching effect of time in analytic sessions. Finally, the author demonstrates how cleverly the 50-minute hour excises the time needed for unconscious processes from our accelerated present; he shows that it challenges the social convention of time, and has a structuring effect in that it “times” psychic processes.     

Face It Head On

SUMMARY

This article focuses on key clinical ideas to help couples face directly the painful issues brought about by infidelity. The author discusses key relational processes related to infidelity along with desired outcomes. The emphasis is on helping couples change key relational dynamics that facilitate the healing process. Couples are encouraged to engage in the healing process head on, and not avoid or skirt around the issues. The article illustrates these desired changes by means of a case Study.     

Childhood Sexual Abuse

Abstract

Childhood sexual abuse is a problem that leads to serious psychological disturbances evidenced through the symptoms of post-traumatic stress disorder (PTSD). This article discusses the treatment of sexual abuse survivors within a psychoanalytic framework. Different theoretical perspectives including classical Freudian, ego-psychological, object-relational and self-psychological are presented. Several relational treatment models, including feminist psychodynamic approaches, are offered. Themes include the importance of developing a strong therapeutic alliance and analyzing transference responses.     

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.     

Chapter 6 Developmental Perspectives in Brief Treatment of Gay Youth

Abstract

This report explores representative dilemmas of gay youth in the transition from late adolescence to young adulthood and shows how brief treatment may facilitate efforts to work toward greater authenticity in sense of self and identity, revise maladaptive relational patterns, and strengthen coping capacities. It presents the case of an 18-year-old male who was seen in supportive psychodynamic treatment for 13 sessions in a university counseling service. Developmental and relational deficits, rooted in a stigmatized identity, perpetuated problems in functioning. The relational functions and supportive elements of the therapeutic process are emphasized in discussion of curative factors. Establishment of the selfobject bond with the therapist strengthened self, facilitated coping, and improved social functioning. The author emphasizes the importance of considering the impact of internalized homophobia and self-alienation in assessment of functioning and establishment of treatment goals.     

Sexual quality of life in patients undergoing coronary artery bypass graft surgery

Objectives: Despite improvements in many domains of functioning, sexual quality of life often remains impaired following coronary artery bypass graft (CABG) surgery. This study examined associations among sexual quality of life, fear of sexual activity and receiving information from providers about sexual activity in CABG patients.

Methods: Participants completed a survey assessing sexual activity, mental health and physical health at baseline (3–5-day post-surgery; n?=?60) and 2-month post-surgery (n?=?42).

Results: Sexual quality of life showed moderate difficulties at baseline and did not improve by follow-up (p values ≥0.09). At follow-up, greater patient fear was associated with lower sexual quality of life in some domains; receiving information was related to lower fear (p values ≤0.03) and greater sexual satisfaction and interest (p values ≤0.04). Suggestive of mediation, there was a significant indirect effect of information on patient fear and of patient fear on sexual interest (p?=?0.05).

Conclusions: Though data were cross-sectional, findings suggest that fears of sexual activity may play a role in lowering CABG patients’ motivation for sexual activity and that receiving information from a medical provider may assist in hastening sexual rehabilitation. Prospective and intervention studies are needed to support findings.     

Experiential avoidance in adolescents with borderline personality disorder: comparison with a non-BPD psychiatric group and healthy controls

ABSTRACT

Previous research has identified experiential avoidance (EA) as related to a host of adolescent internalizing and externalizing problems, as well as borderline personality disorder, suggesting that it is a crosscutting factor for adolescent psychopathology. It remains unclear whether EA differs among adolescents with BPD compared to adolescents with other psychiatric disorders and healthy adolescents. The aims of this study were to 1) examine EA in adolescents with BPD compared to non-BPD inpatient adolescents and healthy adolescents, and 2) to evaluate whether EA has a unique relationship to borderline pathology over and above internalizing and externalizing. Self-report measures of BPD features, EA, and psychopathology were completed by 692 adolescents (64.5% female, M_age= 15.20). This sample included a group of psychiatric inpatient youth (n = 197 BPD; n = 403 non-BPD) and a group of healthy adolescents (n = 92). Results revealed that EA differed significantly across all three groups, with the highest level of EA evidenced in adolescents who had BPD. Furthermore, there was a significant, unique association between BPD symptoms and EA over afnd above internalizing and externalizing pathology. These findings pinpoint EA as an important risk marker and possible target of prevention or intervention for adolescent BPD.     

Parental Marital Quality and Well-Being,Parent-Child Relational Quality,and Chinese Adolescent Adjustment

The linkages between parents’ report of marital quality and parental well-being and children’s report ofparent-child relational quality and adolescent psychological well-being in 378 Chinese families over 2 years were examined. Results revealed that (a) marital quality predicted parental well-being; (b) fathers’ marital quality and well-being predicted parent-child relational quality but mothers’ did not; (c) paternal influence appeared to be stronger than maternal influence on adolescent adjustment; and (d) both direct and indirect paths were found for the linkages between parental marital quality and well-being and adolescent psychological well-being.     

Group Session Rating Scale: Preliminary psychometrics in substance abuse group interventions

Background: Although ultra‐brief outcome and process measures have been developed for individual therapy, currently there are no ultra‐brief alliance measures for group therapy. Method: The current study examined 105 clients in group therapy for issues related to substance abuse or with issues related to the substance abuse of a significant other. We tested whether a newly developed group therapy alliance measure – the Group Session Rating Scale would be related to other commonly used group process measures (Working Alliance Inventory, Group Cohesion, Group Climate) and early change (change over the first four sessions of group therapy). Results: The findings provided support for reliability based on Cronbach alphas and test‐retest coefficients. Additionally, the GSRS was a one‐factor measure that was related to other group process measures as well as predicted early change. Discussion: Clinical implications for how to utilise ultra‐brief outcome and alliance measures are provided.     

Relational Aggression in Women during Emerging Adulthood: A Social Process Model

Two studies investigated potential mediators of the association between relational victimization and relational aggression. Self-report measures of aggressive behavior among peers, exclusivity, hostile attribution biases, and borderline personality disorder (BPD) symptoms were collected. In study 1, participants were 180 female emerging adults (M = 18.82, SD = 1.18). Both exclusivity and hostile attribution biases for relational provocations were found to partially mediate the association between relational victimization and relational aggression. In study 2, participants were 54 female emerging adults (M = 19.16, SD = 1.11). Symptoms of BPD were not found to mediate the association between relational victimization and relational aggression, yet unique associations with relational aggression were observed. The results add to recent research guided by a social process model in which links between victimization and aggression are more clearly understood. Copyright © 2011 John Wiley & Sons, Ltd.     

How do therapists ally with adolescents in family therapy? An examination of relational control communication in early sessions

Sequential analyses examined associations between the working alliance and therapist-adolescent communication patterns in 10 Spanish cases of brief conjoint family therapy. Early sessions with strong versus problematic alliances, rated by observers, were selected for coding of relational control communication patterns. No differences were found in the frequency of exchanges, but competitive responding by the therapists (reflecting an interpersonal struggle for control) was significantly more likely in problematic alliance sessions than in strong alliance sessions. Cases in which the adolescent's alliance with the therapist remained positive from Session 1 as compared with Session 3 showed a decrease in the likelihood of competitive symmetry. Notably, when the quality of the alliance deteriorated over time, the therapists were increasingly more likely to respond to the adolescents' domineering messages in a competitive manner. Results underscore the need to avoid competitive responding in order to ally with adolescents in conjoint family treatment.     

Spontaneous Moments and the Domain of Non-Verbal Communication

Abstract

This paper investigates the impact of non-verbal interactions and spontaneous encounters on the therapeutic process and on a client's structural and behavioral patterns. The following case vignette concerns a client who presents with a pattern of non-verbal relational schemas based on his early traumatic experiences. The non-verbal and verbal role reenactments that unfold between client and therapist will be examined from an intersubjective, dialogical and self psychological perspective. Finally, the paper will explore how important therapeutic shifts may occur by attending to and working through these non-verbal aspects of the treatment, leading to new relational structures.     

An expert consensus on the most effective components of cognitive behavioural therapy for adults with depression: a modified Delphi study

ABSTRACT

Designing new approaches to delivering cognitive behavioural therapy (CBT) requires an understanding of the key components. This study aimed to establish an expert consensus on the effective components of CBT for depressed adults. An international panel of 120 CBT experts was invited to participate in a modified Delphi study. Thirty-two experts participated in round 1; 21 also provided data in round 2. In round 1, experts rated the effectiveness of 35 content and process components. A priori rules identified components carried forward to round 2, in which experts re-rated items and final consensus items were identified. Consensus was achieved for nine content components (ensuring understanding; developing and maintaining a good therapeutic alliance; explaining the rationale for CBT; eliciting feedback; identifying and challenging avoidant behaviour; activity monitoring; undertaking an initial assessment; relapse prevention methods; homework assignments); and three process components (ensuring therapist competence; scheduling sessions flexibly; scheduling sessions for 45–60 mins). Five of the twelve components identified were generic therapeutic competences rather than specific CBT items. There was less agreement about the effectiveness of cognitive components of CBT. This is an important first step in the development of novel approaches to delivering CBT that may increase access to treatment for patients.