Neurodynamics inside therapeutic interaction: a case study with simultaneous EEG recording / La neurodinámica en el contexto de la interacción terapéutica: un estudio de caso con una grabación simultánea de EEG

Recent research on processes of psychotherapy has focused on the study of patient-therapist regulation. Evidence concerning verbal and nonverbal coordination as predictors of therapeutic alliance and outcome in psychotherapy has been cumulating. These, along with others results in the field of social neuroscience, suggest that behavioural coordination may have neurophysiological correlates, which play a role in the regulatory process in psychotherapy. Here we introduce an observational paradigm and analytic method to assess the joint neurodynamic activity of patient and therapist. Additionally we report results from ongoing psychotherapy sessions. Our work highlights the involvement of brain activity in the psychotherapeutic process and provides novel insights on how psychotherapy works, in order to further the understanding of the embodied characteristic of the therapeutic interaction.     

Psychotherapists' attitudes towards and observations of nonverbal communication in a greeting situation: II. Relationships to background variables.

An interview study of 79 Swedish psychotherapists was performed to investigate their attitudes towards and observation of nonverbal communication in a reference situation in relation to background factors such as gender, length of professional experience, and theoretical approach. The greeting situation, i.e., the first time a therapist and patient meet in a waiting-room, was chosen as the reference situation. Face communication in that greeting situation was significantly less achieved by male psychotherapists with relatively short experience than by female therapists. However, this sex difference was not significant among therapists whose psychotherapeutic experience was longer than 13 years. Attaching great importance to nonverbal communication in psychotherapy was related to an intention to be well-kept and to perform correctly in front of the patient, to establish direct communication in the greeting situation, and to background factors such as frequent work in psychotherapy and an eclectic psychotherapeutic approach.     

Clinical commentary by David Trevatt,Clinical Manager of ‘Hear and Now’ Adolescent Counselling Service,Redbridge and Manager of Open Door's Parenting Teenagers Project,Haringey

Leading the charge to link intervention research with clinical practice is the development of process research, which involves a detailed analysis of specific therapeutic processes over the course of treatment. The delineation of interaction structures – repetitive patterns of interactions between patient and therapist over the course of treatment – can inform therapists of what may be expected from patients with particular patterns of symptoms or behaviours in their clinical practice and how interactions change over time. Using the Child Psychotherapy Q-Set, this study aims to compare the different interaction structures that emerged in the two-year psychotherapy of a six-year-old child conducted, for one year each, by two doctoral-student therapists in a university-based community mental health clinic. The study allows for exploration of the independent role of the therapist in the psychodynamic therapy of a child diagnosed with Asperger's disorder. The results suggest that four distinct interaction structures between child and therapist could be identified in this psychotherapy and that the interaction structures differed between the two therapists and also differed over time within each treatment. The implications of these findings for training and clinical practice are discussed.     

Die Wiederherstellung der Zeit in der ambulanten Psychotherapie mit Psychosekranken

In psychoanalytic psychotherapy with psychotic patients, a disturbance in time experience quite frequently turns out to be central to the psychotic experience as a whole. These patients experience disruptions in the flow of time that lead to a loss of temporal continuity. This loss of temporal structures causes damage in thinking functions: Relations like causality, finality and others which imply a temporal dimension, cannot be established any more. Parts of treatment histories serve to demonstrate the reconstruction of temporal continuity by the patient in psychotherapy. Object-relation-theory and Piaget’s experimental psychology provide the frame of reference for the understandig of the mental processes involved. At the beginning of the psychotherapy the patient experiences being together with the therapist and being separated from him as two discrete conditions of existing which have no links. The periodical reappearance of being together in combination with the awareness of the therapist’s continuous ongoing care encourages the patient to remember and to envisage the meetings with the therapist. The reliability of the alternation seems to stimulate a specific mental activity which creates connections allowing for transitions between the different conditions — in the sense of Winnicott’s transitional phenomena. Transitional phenomena which sometimes are quite concrete things bridge the gap between presence and future. Narrating serves as a link to the past. Through these creative ego-activities temporal continuity is regained providing the basis for strucured thinking and — very important — for the perception of one’s own personality and its continuity over time, thus generating a sense of identity. This process of reconstructing time is interesting in itself, because it sheds light on the psychodynamics of the restitutional processes after a psychotic illness. Moreover, it allows for hypotheses about the development of the inner time dimension in early childhood.     

Integrating clients' moment‐to‐moment ratings into psychotherapy research: A novel approach

Counselling and psychotherapy researchers have considerably advanced the field's understanding of psychotherapy processes and how they relate to treatment outcomes. Despite these advances, little is known about the client's perspective of changes in psychotherapy processes that occur throughout a given session (i.e. micro‐processes). To address this gap, this article describes the novel application of methods that assess participants' moment‐to‐moment ratings to psychotherapy research. This method entails recording psychotherapy session content that clients and other potential raters (e.g. therapists, researchers) later review while simultaneously providing continuous ratings of psychotherapy processes (e.g. helpfulness, alliance). In addition, moment‐to‐moment ratings can facilitate significant events research by prompting researchers to elicit client feedback about the moments that are rated the most and least positively. However, few studies have used these methods in the context of psychotherapy research. Studies incorporating these methods may yield findings that advance psychotherapy research, training efforts and clinical practice. For example, studies may examine how the magnitude and timing of clients' moment‐to‐moment ratings of psychotherapy processes are associated with treatment outcomes, therapist ratings and physiological processes (e.g. heart rate variability). Trainee therapists and their supervisors may also use clients' moment‐to‐moment ratings to facilitate attunement to verbal and non‐verbal indicators of moments perceived more positively and negatively. Last, these methods can produce findings that are highly relevant to clinical practice, where therapists routinely navigate fluctuations in psychotherapy processes (e.g. alliance ruptures) that can be assessed using moment‐to‐moment ratings.     

How Therapy Helps When the Culture Hurts

SUMMARY

The purpose of psychotherapy is movement toward relational healing. However, the practice itself is embedded in a culture where relational disconnection and power-over arrangements are normative. The purpose of this article is to examine the impact of cultural disconnections on the therapy relationship. Because they embody multiple social identities within a power-over paradigm, both client and therapist are “carriers” of cultural disconnections. The article examines the shifting vulnerabilities associated with those identities that may lead to impasse and violation or contribute to possibilities for growth. Scenarios from clinical practice illustrate how conflict becomes a pathway to deeper connection when embraced with such processes as empathic attunement, authentic responsiveness, and mutuality.     

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.

     

Warum nachhaltige therapeutische Veränderungen im Gehirn Zeit brauchen

Successful psychotherapy requires structural and functional changes in limbic brain centers; however, these differ in manner, effectiveness and dynamics. One primary factor is the therapeutic alliance, i.?e. the mutual trust between patient and therapist. This factor reduces the level of stress hormones via release of the “bonding hormone” oxytocin and increases the production of serotonin and endogenous opioids. As a consequence, a rapid improvement of the mental emotional state of the patient often occurs; however, this is not accompanied by the deeper and longer lasting neuronal changes necessary to treat severe mental illnesses. This occurs only when dysfunctional habits of feeling, thinking and acting residing primarily in the basal ganglia (striatopallidum and nucleus accumbens) and amygdala are reorganized. Rather than being an explicit cognitive process this represents an implicit procedural process, which after an extensive search for resources requires a sufficient length of time and frequent rehearsal of more adaptive emotional attitudes and patterns of behavior. Apparently, this is promoted by the generation of new nerve cells from neural stem cells induced by oxytocin and neurotrophins, such as brain-derived neurotrophic factor (BDNF), taking place in the hippocampus and the basal ganglia. All these facts are in favor of a long-term psychotherapy at least in cases of severe mental diseases.     

The Use of Teaching Stories in Conjoint Family Therapy

Two general factors have been singled out as being held in common by all types of psychotherapy: an educational, rational factor (often called "content") and a factor operative in the relationship between the therapist and his patient (often called "process"). In the field of family therapy, the non-educational aspects of intervention are sometimes presented in the form of "therapeutic, paradoxical communications" (Haley, Bateson, Jackson, Weakland) or the 'therapy of the absurd" (Whitaker, Malone). In the present paper, I wish to present a form of therapeutic communication, the teaching story, that embodies a unique mixture of both the educational and the paradox, or absurd.     

Knowing,Influencing, and Healing: Paranormal Phenomena and Implications for Psychoanalysis and Psychotherapy

The serious consideration of paranormal phenomena, or psi, has not been scientifically respectable in modern intellectual discourse. A skeptical attitude persists despite robust evidence demonstrating the reality of nonlocal phenomena such as telepathy and the impact of mind from a distance. A major obstacle to the thoughtful consideration and integration of this evidence is the fact that paranormal phenomena do not fit within generally accepted models of how the universe works. Newer constructs and research findings in quantum physics, however, demonstrate the reality of nonlocal effects and help provide a conceptual framework that encompasses the research documenting psi. Paranormal phenomena have relevance for the fields of psychotherapy and psychoanalysis in the consideration of nonverbal communication and mutual influence between therapist and patient.     

Passt oder passt nicht?

Differential indication in psychotherapy should be a process of decision making, that takes multiple factors into account, and not just the assignment of a particular disorder to the adequate therapeutic method. Unspecific characteristics of the patient, instead of disorder-specific features, as well as personality characteristics of the therapist having therapeutic relevance are important factors either. In this way decisions for an indication then turn into the crucial question of matching between patient and therapist. The receptivity of the patient is a central component. As a result of successful maching, the therapeutic relationship will improve which has a positive influence on the outcome of psychotherapy. According to the generic model of psychotherapy 4 levels of the decision-making process are defined. They serve as orientation for a differential indication taking into account both persons and methods. The realization of this indication model in in-patient treatment has some preconditions. Obligatory is the availability of a variety of therapists differing in therapeutic methods and personal characteristics. The mostly applied principles of matching decisions are listed in tabular form and illustrated by a case report.     

Soft Prosody and Embodied Attunement in Therapeutic Interaction: A Multimethod Case Study of a Moment of Change

This study focused on a moment of weeping in one psychotherapy case. The overall aim was to explore the role of “soft prosody” in psychotherapy interaction—that is, the participants’ use of pauses, a lower volume, slower rhythms, and softer intonation than in the surrounding speech. A mixed-method, micro-analytic perspective was applied to investigate (a) social interaction, including its verbal and nonverbal elements; (2) the participants’ bodily responses, including autonomic nervous system (ANS) measurements; and (3) the participants’ thoughts and feelings during the therapy session, as reported in subsequent individual interviews. Soft prosody was observed to be an important conversational tool. It was used in conveying affiliation and offering therapeutic formulations, and it appeared to contribute both to emotional attunement between the participants and to the therapeutic change that occurred during the interaction under study. Two differing bodily synchronization tendencies in the arousal levels were observed among the participants: (a) a complementary tendency—that is, when the client's arousal increased, the therapist's decreased (occurring during the active therapeutic processing); and (b) a tendency to concurrent decreased arousal in all of the participants.     

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.     

Tele‐analysis: the use of media technology in psychotherapy and its impact on the therapeutic relationship

A growing number of approaches in psychotherapy make use of internet‐ and other media‐based interactions. This paper discusses the impact on the therapist‐client relationship of using media technology and gives an overview of the current state of the debate. It is suggested that the technical conditions of internet‐based interactions produce new forms of social relationships that differ significantly from face‐to‐face‐interactions and that unconscious, nonverbal cues get lost. Research on the therapeutic interaction making use of ‘discourse linguistic’ methods is presented. The loss of nonverbal cues has implications for psychotherapy in general and especially for the treatment of patients who have difficulties relying on a secure therapeutic relationship. Emotional security in interactional relationships is transmitted to a much greater extent by nonverbal cues than by verbal content; psychoanalytic methods are specialized to refer to this level of interaction. Two alternative scenarios are discussed based on the psychoanalytic theories of Winnicott and Lacan: the risk of an illusionary, idealized image of the other and the possibility that cyberspace can be used for psychological development as a transitional space.     

Becoming a Telepathic Tuning Fork: Anomalous Experience and the Relational Mind

Although we tend to regard telepathic communication as anomalous or uncanny, outside the range of scientific explanation, many paranormal experiences can be understood scientifically as the type of unconscious affective communication about which there is a growing body of scientific research and evidence. An information-processing model illuminates how a patient’s dissociated attempts to communicate through sensory experiences may be converted to the verbal symbolic via the analyst’s use of evoked images in the dissociative process. Understanding projective identification as a dissociative process of communication by which the patient projected his own unacceptable emotions into the analyst, who could then know experientially what the patient was feeling, can be understood scientifically as telepathic communication. When a patient experiences the effects of severe trauma and is very dissociative, as in the case presented, it is difficult to track and reflect upon these processes as they occur, making it virtually impossible to become and remain empathically attuned to his many self states. In the dissociative attunement deconstructed here, the therapist–patient dyad resonated increasingly in a telepathic attunement, despite much discord and confusion.     

心理治疗中共同要素理论的历史发展

从共同要素的角度,分理论模式化与研究实证化两条线索,追溯了心理治疗中共同要素理论的思想渊源,并自Saul Rosenzweig开始,综述了Carl Rogers、Jerome Frank、Marvin Goldfried、Michael Lambert、Bruce Wampold等学者的观点,探讨了共同要素理论的历史演进、内涵结构、理论模式及当代研究进展。认为它在不久的未来,将与特殊技术说逐步走向整合,加深对心理治疗过程与改变机制的认识,共同提升心理治疗的效果。     

Development through interruptions and reparations – A case study of a dual challenging psychotherapy

The aim of this study was to understand how relational difficulties in psychotherapy may be handled to represent possibilities for change. Temporary interruptions and subsequent reestablishment of contact were chosen as the strategic focus in one severely challenging case of long term psychodynamic psychotherapy where outcome was known to be good. Interruptions and reestablishments were conceptualised by how the informants gave meaning to them. The choice of focus represented a strategic selection of events in the course of therapy where the regulation of the alliance by the therapist as well as by the patient was at stake. A detailed case record was studied and interviews with patient and therapist were conducted. A hermeneutical-phenomenological approach was used to analyse the material. The narrative dimension was important in structuring and interpreting the data. It was shown how important relational difficulties, such as mutual incompatible expectations and demands was handled both on a structural and interpersonal level, and some important steps and hallmarks of the healing process was identified. Close inspection of the course of events in psychotherapies is seen as a promising method for bringing a better understanding of how change processes unfold.     

Evidence-Based Therapist Responsivity to Disruptive Clinical Process

Although a historically prominent model of evidence-based practice (EBP) privileges the faithful delivery of single empirically supported treatment (EST) packages, psychotherapy research demonstrates that therapist adherence to an EST is often unrelated to patient outcome. Additionally, perseverative adherence when facing disruptive clinical process can relate to worse outcomes. In contrast, unmanipulated within-case variability in adherence, or the natural incorporation of theoretically “off-brand” interventions into an EST, can associate with more improvement. Further supporting the value of therapist flexibility, treatments that intentionally integrate theory-informed departures (away from the foundational EST) vis-à-vis specific disruptive clinical processes can outperform the standard EST without such departures. Thus, responsively adjusting treatments, such as cognitive-behavioral therapy (CBT), to patients’ contextualized pathology, characteristics, and momentary interactions with the provider may represent a more empirically well-supported form of EBP. Consistent with these ideas, we present an overview of context-responsive psychotherapy integration (CRPI), an approach to EBP in an if-then key. CRPI frames common factors as typical and potentially disruptive clinical “if” situations that therapists will encounter and to which they “then” need to be responsive beyond strict adherence to any EST. Notably, such departures can be temporary, thereby supporting vs. replacing the primary EST interventions. To illustrate CRPI’s application to practice, we focus on one example of patient resistance to CBT as a contextual process marker and motivational interviewing as a theory- and evidence-informed departure response. We also discuss clinical, cultural, empirical, and training considerations from the CRPI perspective.