Promoting an Empathic Dialectic for Therapeutic Change: An Integrative Review

This integrative review is focused on a formulation of therapeutic empathy. We describe the “empathic dialectic” as therapists’ capacity to emotionally resonate with patients’ internal states, such as during ruptures, and to coregulate their own and the patients’ states through mentalization. The first aim was to provide a theoretical framework for the empathic dialectic, by summarizing background literature on the empathic process, intersubjectivity, rupture repair, relational psychoanalysis, and attachment. The second aim was to conduct an integrative review of peer-reviewed articles published between the years of 2016 and 2021. After conducting a review of 28 articles, we sought to identify (1) research that supports the existence of an empathic dialectic, (2) evidence that therapists’ attachment influences the empathic dialectic, and (3) implications of the empathic dialectic for training and supervision. Results pointed to the central role of therapists’ attachment security in the empathic dialectic, and the negative repercussions of therapists’ insecurity when mentalization is underdeveloped. Results also highlighted the role of supervision as a means of enhancing trainees’ self-awareness of their attachment, and its impact on the alliance. As the American Psychological Association embraces a clinical competencies model in its accreditation of clinical psychology doctoral programs, the importance of attaining an integrative understanding of therapeutic empathy has become increasingly imperative. To this end, we conclude by promoting the empathic dialectic as a key clinical competency, and providing further recommendations for training and supervision.

     

Assessing Interpersonal Subtypes in Depression

The context-free diagnoses outlined by the Diagnostic and Statistical Manual of Mental Disorders might not provide enough information to represent the heterogeneity observed in depressed patients. Interpersonal factors have been linked to depression in a mutually influencing pathoplastic relationship where certain problems, like submissiveness, are related to symptom chronicity. This study evaluated interpersonal pathoplasticity in a range of depressive presentations. We examined archival data collected from 407 participants who met criteria for major depressive disorder (MDD), dysthymic disorder (DD), or subthreshold depression (sD). Latent profile analysis (LPA) identified 5 interpersonal subtypes (vindictive, intrusive, socially avoidant, exploitable, and cold). Apart from gender, the subtypes did not differ significantly on demographic characteristics, psychiatric comorbidity, or self-report depression severity. Socially avoidant participants were more likely to meet criteria for a clinical depression diagnosis (MDD or DD), whereas vindictive participants were more likely to have sD. Our results indicate that interpersonal problems could account for heterogeneity observed in depression.