Process Of Change In Psychotherapy Research Articles

L’attachement du client au thérapeute en psychothérapie : une revue systématique des études empiriques

Attachment theory describes characteristic patterns of relating to close others and has important implications for psychotherapy. Consistent with Bowlby's (1988) secure base conception of attachment in psychotherapy, several instruments have been developed to measure client attachment to therapist. Despite a large number of studies, no review takes into account all published work. The purpose of this systematic review was to compare different measures of client's attachment to therapist, with different groups of client and in different therapeutic contexts. Medline, Embase, Pubmed, PsycInfo, and Web Of Science were searched to identify studies published between 1995 and 2019 reporting on help-seeking client's attachment to therapist. Twenty-five empirical papers met the inclusion criteria. Meta-analyses were conducted for studies that examined client attachment to therapist subscales (Secure, Avoidant–Fearful, Preoccupied–Merger) as correlates of client-rated working alliance (K=11, 892 clients), and general adult attachment (K=11, 752 clients). The results show that the client's secure attachment to therapist is strongly correlated with the therapeutic alliance (mean weighted R=0,71 [95% CI=0.62–0.79]), moderately correlated with the results, and negatively correlated with the avoidance (mean weighted r=−0,12 [IC 95%=−0.06–−0.21]) and anxiety dimensions (mean weighted R=−0,11 [IC 95%=−0.03–−0.17]) of adult attachment. With the Avoidant–Fearful style, results go in the opposite direction, negatively correlated with the therapeutic alliance (mean weighted R=−0.55 [IC 95%=−0.59–−0.50]), negatively correlated with the results, and correlated with the avoidance dimension of adult attachment (mean weighted R=0,16 [IC 95%=0.09–0.23]). The Preoccupied–Merger style shows weak (positive or negative) to zero correlations. In addition, nine studies looked at some dimensions of the psychotherapy process (e.g., resistance, transference, emotions, self-disclosure, and attitude toward psychotherapy), showing that insecurity of attachment to the therapist (both Avoidant–Fearful style and Preoccupied–Merger style) seem to interfere in one way or another with the development of a productive psychotherapy process. Overall, these results are in line with what was expected. They are consistent with Bowlby's conception of a secure base of attachment in psychotherapy. They showed that dysfunction and maladaptive developmental experience interfere with adult's ability needed to establish secure attachments and that psychotherapy may play the role of what has been previously defined as corrective emotional–or intersubjective–experience. In addition, these results do not seem to vary according to the instruments used. Together, the high correlation with therapeutic alliance and the weak correlation with pretherapy adult attachment confirm the relevance of the client's attachment to therapist as a specific variable related to the process of change in psychotherapy.

Transforming emotional suffering into flourishing: metatherapeutic processing of positive affect as a trans-theoretical vehicle for change

ABSTRACTThis paper explores core adaptive emotions, both negative and positive, and investigates their respective roles in the transformation of emotional suffering into flourishing. We do so through the lens of Accelerated Experiential Dynamic Psychotherapy (AEDP), a mind/body, emotion-focused, healing-oriented model of psychotherapy that has articulated a four state phenomenology of the transformational process. Through such a transformational process, energy-consuming negative emotions are transformed into energy-enriching positive emotions, thus describing an arc that organically links the negative emotions of emotional suffering with the positive emotions of flourishing. AEDP achieves this through (i) amplifying the vitality affects that identify positive neuroplasticity through therapist transformance detection; (ii) experientially processing to completion the “gut-wrenching” emotions of trauma, and then, (iii) “turbocharging” the innate affects of healing to expand transformation through metatherapeutic processing, a technique for working with positive emotions to maximize their therapeutic impact. We conclude with thoughts on how metatherapeutic processing might be used by therapists of different orientations to systematically bring flourishing into psychotherapy sessions and on how AEDP’s descriptive phenomenology of affective states can function as a trans-theoretical vehicle of communication to further the exploration of the neurobiological mechanisms underlying change processes in psychotherapy.

The process of change in psychotherapy with a pregnant patient following perinatal losses: An analysis of a case study

Despite research suggesting increased anxiety and depressive symptoms after a perinatal loss and during future pregnancies, little knowledge exists to guide clinicians treating pregnant women after perinatal loss. This case study explores processes that facilitated therapeutic change for a pregnant patient with major depressive disorder (MDD) and posttraumatic stress disorder after perinatal losses. The study integrated quantitative and narrative analyses in a single case derived from the pilot phase of a randomized controlled trial on supportive-expressive therapy for MDD. The quantitative and narrative analyses suggest that an improvement in maladaptive interpersonal patterns toward the therapist, in the form of attachment avoidance, made it possible to form a strong alliance, which in turn led to a successful outcome. The findings highlight the importance of improving maladaptive interpersonal patterns as a prerequisite to enable patients after pregnancy losses to develop and maintain a corrective therapeutic experience.

Therapist empathy and client outcome: An updated meta-analysis.

Put simply, empathy refers to understanding what another person is experiencing or trying to express. Therapist empathy has a long history as a hypothesized key change process in psychotherapy. We begin by discussing definitional issues and presenting an integrative definition. We then review measures of therapist empathy, including the conceptual problem of separating empathy from other relationship variables. We follow this with clinical examples illustrating different forms of therapist empathy and empathic response modes. The core of our review is a meta-analysis of research on the relation between therapist empathy and client outcome. Results indicated that empathy is a moderately strong predictor of therapy outcome: mean weighted r = .28 (p < .001; 95% confidence interval [.23, .33]; equivalent of d = .58) for 82 independent samples and 6,138 clients. In general, the empathy-outcome relation held for different theoretical orientations and client presenting problems; however, there was considerable heterogeneity in the effects. Client, observer, and therapist perception measures predicted client outcome better than empathic accuracy measures. We then consider the limitations of the current data. We conclude with diversity considerations and practice recommendations, including endorsing the different forms that empathy may take in therapy. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Alexithymia and emotional processing: a longitudinal mixed methods research.

Alexithymia has been associated with poor outcomes in psychotherapy. This association has been attributed to a difficulty in patients processing emotions and engaging in emotional tasks. The possibility of alexithymia being modified by psychotherapy remains a topic of great debate but with little empirical research. In this study a mixed methods longitudinal design was used to better understand alexithymia, emotional processing and change process in psychotherapy. Twelve clients, five with alexithymia, were studied considering the development of alexithymia, emotional awareness, differentiation, regulation and severity of symptoms. The reliable change index was used to interpret the evolution of those emotional variables’ scores for each case and thematic analysis was used to analyze individual interviews. Thematic analysis generated several themes, organized in two broad domains: i) perception of emotions and ii) description of change. The three alexithymic patients that changed in alexithymia also changed in at least one of the emotional variables – lack of emotional awareness, emotion differentiation or emotion regulation. Generally, alexithymic patients were able to accomplish change in psychotherapy although they had a tendency to focus on physical complaints, describe changes in a more rational rather than emotional way and present vaguer descriptions of their problems. These results point that alexithymia may change through therapy and reinforces that those changes are associated with improved emotional processing.

Mechanisms of Change in Treatments of Personality Disorders: Introduction to the Special Section.

The present introduction to the Special Section on Mechanisms of Change in Treatments of Personality Disorders explains the value of research focusing on processes of change in psychotherapy by referring to a variety of methodologies. Whereas outcome for these treatments has been repeatedly demonstrated, it remains an open question what the core psychobiological features of change are. Taking a radically empirical perspective, this introduction focuses on patient and therapeutic relationship variables, such as emotional and socio-cognitive processing. The six empirical articles of the Special Section are introduced, as are the three discussions of the Special Section.

Confessions of a New York rupture researcher: An insider’s guide and critique

Objective: The study of alliance rupture has become quite prevalent since 1990 and especially in the past 10 years where we have seen a noticeable surge in empirical publications on the subject. This honorary paper attempts to provide a critical review of this literature from the perspective of someone who has contributed to it in his collaborative work on a research program designed to investigate ruptures and to develop intervention and training models to resolve them. Method: This paper is organized into three topics or sections: (1) alliance rupture, (2) rupture resolution, and (3) alliance training; and it addresses definitions, findings, questions, and lessons with regard to each topic. Results/Conclusions: It suggests some clinical conceptualizations (concerning agency and communion as well as mutual recognition), training implications (regarding emotion regulation and deliberate practice), and methodological considerations (promoting pluralism and contextualism), along with future directions.Clinical or methodological significance of this article: The paper provides a critical review of research on a possible risk factor and potential change process in psychotherapy, including related training strategies, that has important implications for treatment outcome and professional development.

The role of emotion in psychotherapeutic change for medically unexplained symptoms

Objectives: Evidence of the contribution of emotional processes to the emergence, maintenance, and experience of medically unexplained symptoms (MUS) suggests that clinical approaches which target these processes could be beneficial. In this study, qualitative methods were used to examine patients’ perspectives and subjective experiences of emotional processes in the context of a psychotherapy assessment and treatment service for MUS provided in a hospital emergency department (ED). Methods: Seven semi-structured interviews were conducted with ED patients presenting with MUS who received a course of intensive short-term dynamic psychotherapy treatment. Results: Interpretative phenomenological analysis was employed with three superordinate themes emerging: Barriers to examining emotional processes; reflections on the therapeutic process; psychological change; and improved well-being. Obstacles to clinical engagement in treatment for MUS were described in relation to patients’ and therapists’ ability to identify, address, and utilize emotion processes. Specific elements of this work were identified as integral components of the psychotherapy change process for MUS. Conclusions: Directly observing the physical effects of emotional experiencing in MUS provides sensory evidence that can enable patients to make mind–body connections. Psycho-emotional processes warrant further study to explore the applicability to other conceptual models for assessing and treating MUS.Clinical and methodological significance: In this article, we highlight that Medically Unexplained Symptoms (MUS) are a priority area for both physical and mental health care services. We present findings relevant to the effectiveness of a novel psychotherapy innovation within a hospital emergency department (ED). The use of interpretative phenomenological analysis to study the experiences of ED clients with MUS offers an established qualitative method for exploring the processes underlying therapeutic change. The results provide new insights around obstacles to engagement alongside potential solutions when addressing the psychological needs of clients with MUS. Although emotion processes have been described as a potentially important change process for MUS and in psychotherapy more generally, little empirical research has studied these two areas collectively.

Attachment Theory and Group Psychotherapy

ABSTRACTThis article presents an integration of attachment theory and affective neuroscience that helps inform a complementary conceptual framework from which the contributions of the neurosciences can be applied to group psychotherapy. One overarching aim of attachment theory is to understand the neural basis of emotional disorders and the facilitation of affect regulation with the goal of developing more effective treatment interventions. Missing from more traditional models of group therapy has been a cogent articulation of the implicit neural mechanisms involved in explaining how and why interpersonal emotional engagement accounts for the majority of the change process in psychotherapy. The neurosciences now provide us with such an articulation focused on the crucial importance that recurring authentic face-to-face social interaction have on neural processes. Attachment theory has utilized neuroscientific evidence to promote the creation of an enriched group environment that enhances opportunities for authentic engagements among group members.

Narratives from therapists regarding the process of psychotherapeutic change in children and adolescents who have been victims of sexual abuse / Narrativas de terapeutas sobre el proceso de cambio psicoterapéutico en niños, niñas y adolescentes que han sido víctimas de agresiones sexuales

The purpose of this study is to understand how psychotherapists perceive the process of change in psychotherapy in children and/or adolescents who have been victims of sexual abuse and the influence therapeutic alliance has on this treatment. A qualitative research study was carried out through 24 in-depth interviews with psychologists, analysed from a narrative analysis framework. The results of this study highlight that the change in psychotherapy is gradual and progressive and develops in different stages: an initial one of connection with the therapeutic space, an intermediate stage of giving new meanings to their abusive experience and a final stage consolidating the changes. In each of these stages, the therapeutic alliance influences in different ways; it is essential in the process of psychotherapeutic change. The implications of these findings for child and adolescent clinical work are stressed by highlighting therapists’ narratives.

Topic change processes in psychotherapy: a case study approach

ABSTRACTA method for the analysis of transcripts from individual psychotherapy sessions is presented. The method, Topic Change Process Analysis (TCPA), is a qualitative and exploratory approach focusing on therapist-client interaction, on how such interaction influences topic changes during the therapy, and the possible contribution of the changes to the final therapeutic outcome. The method is descriptive. This makes it possible to explore the therapeutic processes in therapies with different theoretical orientations and to interpret the findings from different theoretical angles. The material from the analysis can be used to construct case stories covering topic changes occurring during a psychotherapy process.

Changes in symptom intensity and emotion valence during the process of assimilation of a problematic experience: A quantitative study of a good outcome case of cognitive-behavioral therapy

The assimilation model describes the change process in psychotherapy. In this study we analyzed the relation of assimilation with changes in symptom intensity, measured session by session, and changes in emotional valence, measured for each emotional episode, in the case of a 33-year-old woman treated for depression with cognitive-behavioral therapy. Results showed the theoretically expected negative relation between assimilation of the client's main concerns and symptom intensity, and the relation between assimilation levels and emotional valence corresponded closely to the assimilation model's theoretical feelings curve. The results show how emotions work as markers of the client's current assimilation level, which could help the therapist adjust the intervention, moment by moment, to the client's needs.

Innovative Moments in Humanistic Therapy I: Process and Outcome of Eminent Psychotherapists Working with Bereaved Clients

This project entailed an intensive qualitative analysis of six-session psychotherapies conducted by three eminent humanistic psychotherapists working with bereaved clients. The Innovative Moments Coding System (IMCS), rooted in narrative therapy, is designed to measure change across therapy orientations. Research using the IMCS suggests that the psychotherapy change process occurs through the emergence, elaboration, and expansion of identifiable change moments for a client—innovative moments (IMs)—which present as exceptions to a client's presenting problematic narrative. There are five identified types of IMs: action, reflection, protest, reconceptualization (RC), and performing change (PC). The current study aimed to inform theory regarding the patterns of IMs across three humanistic approaches—constructivist, person-centered, and existential—when working with bereaved clients, while linking these patterns to observable change in each client's functioning. The alliance between each client and therapist was also assessed across the therapy process, showing consistently strong alliances across the three cases. Findings from the current study reinforce the salience of reflection, RC, and PC IMs in successful grief therapy cases, and also suggest the importance of meaning-making interventions in grief therapy. Clinical implications and suggestions for future research are also addressed.

A dynamic systems approach to psychotherapy: A meta-theoretical framework for explaining psychotherapy change processes.

Notwithstanding the many methodological advances made in the field of psychotherapy research, at present a metatheoretical, school-independent framework to explain psychotherapy change processes taking into account their dynamic and complex nature is still lacking. Over the last years, several authors have suggested that a dynamic systems (DS) approach might provide such a framework. In the present paper, we review the main characteristics of a DS approach to psychotherapy. After an overview of the general principles of the DS approach, we describe the extent to which psychotherapy can be considered as a self-organizing open complex system, whose developmental change processes are described in terms of a dialectic dynamics between stability and change over time. Empirical evidence in support of this conceptualization is provided and discussed. Finally, we propose a research design strategy for the empirical investigation of psychotherapy from a DS approach, together with a research case example. We conclude that a DS approach may provide a metatheoretical, school-independent framework allowing us to constructively rethink and enhance the way we conceptualize and empirically investigate psychotherapy. (PsycINFO Database Record

On the present situation in psychotherapy and its implications - A critical analysis of the facts

The currently dominating research paradigm in evidence-based medicine is expounded and discussed regarding the problems deduced from so-called empirically supported treatments (EST) in psychology and psychotherapy. Prevalent political and economic as well as ideological backgrounds influence the present dominance of the medical model in psychotherapy by implementing the randomized-controlled research design as the standard in the field. It has been demonstrated that randomized controlled trials (RCTs) are inadequate in psychotherapy research, not the least because of the high complexity of the psychotherapy and the relatively weak role of the treatment concept in the change process itself. All major meta-analyses show that the Dodo bird verdict is still alive, thereby demonstrating that the medical model in psychotherapy with its RCT paradigm cannot explain the equivalence paradox. The medical model is inappropriate, so that the contextual model is proposed as an alternative. Extensive process-outcome research is suggested as the only viable and reasonable way to identify highly complex interactions between the many factors regularly involved in change processes in psychotherapy.

Ambivalence and innovative moments in grief psychotherapy: The cases of Emily and Rose.

Several studies have suggested that the process of narrative change in psychotherapy occurs through the emergence and expansion of moments of novelty, known as innovative moments (IMs), that allow changes in the problematic self-narrative responsible for the client's suffering. However, as these IMs challenge typical (and problematic) ways of acting, feeling, and thinking, they may also generate discrepancy or uncertainty. Clients may reduce uncertainty by returning to the problematic self-narrative immediately after the emergence of an IM, thus ensuring the homeostasis of the previous meaning system. This cyclical movement is a form of ambivalence, which can maintain problematic stability across therapy and lead to therapeutic failure. In this study, we identified return to the problem markers (RPMs), which are empirical indicators of the ambivalence process, for all IMs in two cases of constructivist grief psychotherapy. Both cases evidenced a high percentage of IMs with RPMs, and the evolution of IMs and RPMs along treatment was significantly correlated. We suggest that stability of the ambivalence process in grief psychotherapy may represent a form of self-protection from the anxiety or guilt of releasing pain as a disconnection from the deceased.

Memory reconsolidation, emotional arousal, and the process of change in psychotherapy: New insights from brain science.

Since Freud, clinicians have understood that disturbing memories contribute to psychopathology and that new emotional experiences contribute to therapeutic change. Yet, controversy remains about what is truly essential to bring about psychotherapeutic change. Mounting evidence from empirical studies suggests that emotional arousal is a key ingredient in therapeutic change in many modalities. In addition, memory seems to play an important role but there is a lack of consensus on the role of understanding what happened in the past in bringing about therapeutic change. The core idea of this paper is that therapeutic change in a variety of modalities, including behavioral therapy, cognitive-behavioral therapy, emotion-focused therapy, and psychodynamic psychotherapy, results from the updating of prior emotional memories through a process of reconsolidation that incorporates new emotional experiences. We present an integrated memory model with three interactive components-autobiographical (event) memories, semantic structures, and emotional responses-supported by emerging evidence from cognitive neuroscience on implicit and explicit emotion, implicit and explicit memory, emotion-memory interactions, memory reconsolidation, and the relationship between autobiographical and semantic memory. We propose that the essential ingredients of therapeutic change include: (1) reactivating old memories; (2) engaging in new emotional experiences that are incorporated into these reactivated memories via the process of reconsolidation; and (3) reinforcing the integrated memory structure by practicing a new way of behaving and experiencing the world in a variety of contexts. The implications of this new, neurobiologically grounded synthesis for research, clinical practice, and teaching are discussed.

An exploration of the therapeutic process while using computerised cognitive behaviour therapy

Background: Modern technologies that offer an alternative to face‐to‐face therapy have gained ground in the NHS. Critics have argued that some of the important elements of the therapeutic change process necessarily require a human therapist. Yet, the traditional understanding of the change process in psychotherapy is challenged by evidence that some computerised cognitive behaviour therapy (cCBT) programs may be as effective as face‐to‐face therapy, suggesting that in certain cases the interaction between user and a cCBT product satisfies sufficient criteria for personal change without the need for actual human contact. Aim: This study used the cCBT package Blues Begone as a means of investigating the process by which a computer‐mediated program helped adults with mild depression help themselves. Method: Seven qualitative interviews were conducted with mildly depressed users who had completed Blues Begone in their own homes without any additional human help or support. Findings: Interpretive phenomenological analysis (IPA) was performed with four main themes emerging. These were: the meaningful relationship; shape from confusion; stimulation and empowerment. This study illustrates some of the ways that some depressed users make use of cCBT self help.

AS08-01 - A taxonomy and synthesis of common factors in psychotherapy

A large number of meta-analyses demonstrates that psychotherapy is beneficial for most forms of psychopathology. Yet, there is considerable disagreement as to what makes psychotherapy effective. Currently, there are two major assumptions: the specific ingredients assumption and the common-factor model. However, this dichotomy is based on conceptual inaccuracies. The presented Taxonomy Project attempts to contribute to a clearer definition and conception of common psychotherapeutic factors by analyzing their differential associations to psychotherapeutic techniques. A comprehensive literature search was performed to identify the common factors discussed in psychotherapy research. 22 common factors were extracted from the literature and defined. Psychotherapy experts then rated the degree of associations of different common factors to a set of psychotherapeutic standard techniques in a web-based survey. Hierarchical regression analyses using mixed models, principal component and cluster analyses were performed to analyze these associations. Mixed-effects models indicate that common factors differ by their differential associations to specific psychotherapeutic techniques. Common factors, therefore, could be defined by their idiosyncratic profiles of associated techniques. In addition, based on these differential associations 4 superior classes of common factors operating in effective psychotherapy can be identified by principal component and cluster analyses. At present, research addressing therapeutic change processes in psychotherapy is suffering from a terminological “jungle” and fundamental misconceptions. It is likely that this conceptual impreciseness hinders the exact analysis of the psychotherapeutic change processes and, thus, progress in psychotherapy. The presented taxonomical endeavor is a promising first step towards a clarification of the important construct ‘common factors’.

Qualitative research methods in mental health and psychotherapy: a guide for students and practitioners

About the Contributors. Acknowledgements. PART I Getting Started. 1 Introduction (Andrew R. Thompson and David Harper). 2 Identifying and Synthesizing Qualitative Literature (Rachel L. Shaw). 3 Ethical Issues in Qualitative Mental Health Research (Andrew R. Thompson and Eleni Chambers). 4 Participation and Service User Involvement (Alison Faulkner). 5 Qualitative Data Collection: Asking the Right Questions (Hannah Frith and Kate Gleeson). 6 Qualitative Methods for Studying Psychotherapy Change Processes (Robert Elliott). 7 Choosing a Qualitative Research Method (David Harper). PART II Methods. 8 Interpretative Phenomenological Analysis in Mental Health and Psychotherapy Research (Michael Larkin and Andrew R. Thompson). 9 Existentialist-Informed Hermeneutic Phenomenology (Carla Willig and Abigail Billin). 10 Grounded Theory Methods for Mental Health Practitioners (Alison Tweed and Kathy Charmaz). 11 Discourse Analysis (Eugenie Georgaca and Evrinomy Avdi). 12 Narrative Psychology (Michael Murray and Sally Sargeant). 13 Ethnomethodology/Conversation Analysis (Mark Rapley). 14 Q Methodological Research in Mental Health and Psychotherapy (Wendy Stainton Rogers and Phillip O. Dyson). 15 Thematic Analysis (Helene Joffe). PART III Establishing Good Quality Qualitative Research in Mental Health. 16 In Pursuit of Quality (Liz Spencer and Jane Ritchie). 17 Emerging Issues and Future Directions (David Harper and Andrew R. Thompson). Index.