Patient-therapist Interaction Research Articles

Placebo Effects in Psychotherapy: A Framework.

The issue of placebo response and the extent of its effect on psychotherapy is complex for two specific reasons: i) Current standards for drug trials, e.g., true placebo interventions, double-blinding, cannot be applied to most psychotherapy techniques, and ii) some of the “nonspecific effects” in drug therapy have very specific effects in psychotherapy, such as the frequency and intensity of patient–therapist interaction. In addition, different psychotherapy approaches share many such specific effects (the “dodo bird verdict”) and lack specificity with respect to therapy outcome. Here, we discuss the placebo effect in psychotherapy under four aspects: a) nonspecific factors shared with drug therapy (context factors); b) nonspecific factors shared among all psychotherapy traditions (common factors); c) specific placebo-controlled options with different psychotherapy modalities; and d) nonspecific control options for the specific placebo effect in psychotherapy. The resulting framework proposes that the exploration and enumeration of context factors, common factors, and specific factors contributes to the placebo effects in psychotherapy.

Does involving patients in treatment decisions affect perceptions of treatments and therapists?

Psychotherapists may offer patients more or less involvement when deciding on a treatment. The aim of the present research was to examine whether perceptions of the treatment and therapist differ when a therapist uses a paternalistic style in making treatment decisions or a more collaborative approach, in which the patient helps in selecting treatment. In the study, 172 participants, recruited from a university setting and a national sample, listened to a simulated conversation representing either a paternalism or informed-choice model of a therapist-patient interaction. The participants then rated their expectation the treatment would help the patient, their perception of the therapist’s trustworthiness, and their own preference for relying on clinicians for knowledge and decisions. Analysis indicated that among participants preferring to rely on clinicians, perceptions did not differ reliably based on the type of interaction they heard. However, participants wanting more involvement in treatment choices perceived greater treatment effectiveness and clinician trustworthiness for the interaction in which the patient was offered treatment choices. These results suggest that if therapists adopt a collaborative approach, it has the potential to enhance perceptions of individuals preferring the collaborative style without negatively affecting those who prefer less involvement in treatment decisions.

Short-term psychoanalytic psychotherapy with a depressed adolescent with borderline personality disorder: an empirical, single case study

ABSTRACTWhile clinical descriptions of psychotherapy with depressed adolescents with traits of borderline functioning exist, they are not yet supported by empirically-grounded research. This single-case study aims to identify meaningful therapist-patient interaction in the course of short-term psychoanalytic psychotherapy with an adolescent girl who meets diagnostic criteria for both Borderline Personality Disorder (BPD) and Major Depressive Disorder (MDD). Twenty-eight sessions of psychotherapy were coded, using the Adolescent Psychotherapy Q-Set. Five interaction structures were identified, which were distinguished by the nature of the adolescent’s emotional expression during sessions, and how the therapist responded to the young person. Exploration of the clinical and theoretical meaning of these interaction structures suggests that core elements of a young person’s depression and borderline functioning can be identified in sessions, and that the therapeutic process overall shows some significant departures from some of what is usually recognised as a typical psychoanalytic approach. The paper discusses whether these changes in technique can be understood as responses to the clinical challenges associated with working with adolescents with borderline features.

Exploratory analyses of intake sessions in psychodynamic psychotherapy: do processes differ for engager versus non-engager clients?

ABSTRACT We investigated differences in negative indicators and topics discussed during intakes for one engager and one non-engager (i.e. dropout) client for each of 18 therapists in psychodynamic psychotherapy. Results indicated that engager clients had fewer negative indicators (patient-therapist interaction, errors in techniques) and more coverage of client goals for treatment than did non-engager clients. Engager and non-engager clients did not differ in terms of client pathology, therapist countertransference, or order in which they were seen in the clinic. Preliminary findings suggest that therapists should be educated about negative processes and encouraged to discuss client goals to lessen the likelihood of dropout.

What Differentiates Poor and Good Outcome Psychotherapy? A Statistical-Mechanics-Inspired Approach to Psychotherapy Research

Statistical mechanics investigates how emergent properties of macroscopic systems (such as temperature and pressure) relate to microscopic state fluctuations. The underlying idea is that global statistical descriptors of order and variability can monitor the relevant dynamics of the whole system at hand. Here we test the possibility of extending such an approach to psychotherapy research investigating the possibility of predicting the outcome of psychotherapy on the sole basis of coarse-grained empirical macro-parameters. Four good-outcome and four poor-outcome brief psychotherapies were recorded, and their transcripts coded in terms of standard psychological categories (abstract, positive emotional and negative emotional language pertaining to patient and therapist). Each patient-therapist interaction is considered as a discrete multivariate time series made of subsequent word-blocks of 150-word length, defined in terms of the above categories. “Static analyses” (Principal Component Analysis) highlighted a substantial difference between good-outcome and poor-outcome cases in terms of mutual correlations among those descriptors. In the former, the patient’s use of abstract language correlated with therapist’s emotional negative language, while in the latter it co-varied with therapist’s emotional positive language, thus showing the different judgment of the therapists regarding the same variable (abstract language) in poor and good outcome cases. On the other hand, the “dynamic analyses”, based on five coarse-grained descriptors related to variability, the degree of order and complexity of the series, demonstrated a relevant case-specific effect, pointing to the possibility of deriving a consistent picture of any single psychotherapeutic process. Overall, the results showed that the systemic approach to psychotherapy (an old tenet of psychology) is mature enough to shift from a metaphorical to a fully quantitative status.

Therapist and clinic effects in psychotherapy: A three-level model of outcome variability.

The study aimed to (a) investigate the effect of treatment location on clinical outcomes for patients receiving psychological therapy (a clinic effect, akin to the concept of a therapist effect) and (b) assess the impact of explanatory individual and aggregate demographic and process variables on the clinic and therapist effects. The sample comprised 26,888 patients, seen by 462 therapists, across 30 clinics. Mean patient age was 38 years (69% female, 90% White, 92% planned ending). The dependent variable was patients' posttherapy score on the Clinical Outcomes in Routine Evaluation-Outcome Measure. An incremental 3-level multilevel model was constructed. Markov Chain Monte Carlo estimation created 95% probability intervals for the clinic and therapist effects. A 3-level model with no explanatory variables detected a clinic effect of 8.2%, significantly larger than the therapist effect of 3.2%. Adding explanatory variables significantly reduced the clinic effect to 1.9% but did not significantly alter the therapist effect (3.4%). Patient-level symptom severity and employment status, and clinic-level percentage of White patients and health care sector, explained the most clinic outcome variance and overall outcome variance. Substantial variability in clinical outcomes was found between clinics providing psychological therapy. Socioeconomic mix of patients explained significant proportions of variability at the clinic level but not the therapist level. Clinical implications include the need to go beyond the therapist-patient interaction to deliver effective psychological therapy. Future research is also needed to identify the mechanisms by which clinic and/or area-level factors impact on clinical outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

How We Do What We Do: The Therapist, EMDR, and Treatment of Complex Trauma

This article discusses strategies for working with patients who present with the specific psychological deficits associated with complex trauma. In order to maintain the patient's stability, safety, and capacity for adaptive information processing (AIP) during sessions, these treatments require an extremely active therapist who is able to help regulate the pace of therapy and the patient's participation in it. Attunement to both patient's and therapist's experience is a core therapeutic process that enables the treatment. Eye movement desensitization and reprocessing (EMDR) therapists must set the frame of the therapy, help to build and then utilize the capacity for AIP, and establish a relationship capable of coregulating the patient's state during both resource development and trauma processing. All of these functions can be enhanced using bilateral stimulation (BLS). They are accomplished via specific therapist actions during sessions: assessing and supporting the capacity for AIP, looking for opportunities to strengthen resources and competencies, and staying attuned to empathic resonances and countertransference. Decisions that shape the treatment process and affect its pacing evolve from an integration of multiple factors: the therapist's attunement to self, patient, and the therapy relationship; and an understanding of complex trauma, dissociation, therapeutic process, and EMDR. Examples of patient–therapist interaction during two EMDR sessions are provided to illustrate therapy process and the use of the treatment relationship in clinical decision-making and coregulation.

Therapeutic agency, in-session behavior, and patient-therapist interaction.

The aim of this study was to investigate associations between patients' subjective agency, their observable in-session behavior, and the patient-therapist interaction during the early phase of psychotherapy. The sample included 52 depressed patients in psychodynamic psychotherapy. After Session 5, the patients' agency and the quality of the therapeutic alliance were assessed. Based on session recordings, two independent observers rated the patients' involvement, their interpersonal behavior, and the therapists' directiveness. Higher agency was associated with stronger therapeutic alliances. Patients who indicated higher agency in their therapy participated more actively in the session and showed less hostile impact messages. Patients' agency was not related to therapists' directiveness. Patients' sense of agency in psychotherapy was associated with more active involvement and affiliative interaction. The findings support the idea that patients need to feel capable of acting within and having an influence on their therapy to benefit from it.

Quantitative metaphor usage patterns in Chinese psychotherapy talk.

The study of metaphor in psychotherapy is undergoing a 'contextual turn', shifting emphasis from global mechanisms underlying metaphors and therapeutic change to their naturally occurring properties in therapist-patient interaction. While there have been rich qualitative and contextual descriptions of metaphors in psychotherapy, complementary quantitative accounts of metaphor usage patterns over larger amounts of talk have been less forthcoming. This paper reports metaphor usage patterns as associations between key contextual variables which characterize metaphors in a dataset of Chinese psychotherapy talk. A total of 2893 metaphor vehicle terms from 29.5 hours of talk were coded for SPEAKER, FUNCTION, TARGET, PHASE OF THERAPY, and DYAD. A loglinear analysis revealed significant higher order associations (DYAD*TARGET*FUNCTION*PHASE; DYAD*FUNCTION*PHASE*SPEAKER; TARGET*FUNCTION*SPEAKER), discussed as usage patterns which bear implications for the psychotherapeutic application of metaphor. Limitations and future research directions are discussed.

Cooperative modalities in robotic tele-rehabilitation using nonlinear bilateral impedance control

A nonlinear model reference adaptive bilateral impedance controller is proposed that can accommodate various cooperative tele-rehabilitation modes for patient–therapist interaction using a multi-DOF tele-robotic system. In this controller, two reference impedance models are implemented for the master and slave robots using new model reference adaptive control laws for the nonlinear bilateral teleoperation system. “Hand-over-hand” and “adjustable-flexibility” are two modes of patient–therapist cooperation that are realized using the proposed strategy. The Lyapunov-based stability proof guarantees the patient’s and the therapist’s safety during the cooperation and interaction with robots, even in the presence of modeling uncertainties of the multi-DOF teleoperation system. The performance of the proposed bilateral impedance controller is experimentally investigated for upper-limb tele-rehabilitation in the two mentioned cooperation modes.

Design of a pressure sensitive matrix for analyzing direct haptic patient-therapist interaction in motor rehabilitation after stroke

Abstract: Robot based therapy is one of the prevalent therapeutic approaches in motor stroke rehabilitation. It is often used in hospitals in combination with conventional therapy. In order to optimize human-robot interaction, we aim to investigate how a therapist physically supports patients during motor training of the upper extremities. This paper presents the design of a flexible textile sensor matrix, which measures the pressure exerted between therapist and patient during direct haptic interaction as well as the hand position and orientation in space. The matrix contains 144 sensors which enables measuring pressure intensity and localization of areas where the pressure is applied. The measurement matrix was evaluated with four healthy participants.

Relational interventions in psychotherapy: development of a therapy process rating scale

BackgroundIn psychodynamic psychotherapy, one of the therapists’ techniques is to intervene on and encourage exploration of the patients’ relationships with other people. The impact of these interventions and the response from the patient are probably dependent on certain characteristics of the context in which the interventions are given and the interventions themselves. To identify and analyze in-session effects of therapists’ techniques, process scales are used. The aim of the present study was to develop a simple, not resource consuming rating tool for in-session process to be used when therapists’ interventions focus on the patients’ relationships outside therapy.MethodsThe present study describes the development and use of a therapy process rating scale, the Relational Work Scale (RWS). The scale was constructed to identify, categorize and explore therapist interventions that focus on the patient’s relationships to family, friends, and colleges Relational Interventions and explore the impact on the in-session process. RWS was developed with sub scales rating timing, content, and valence of the relational interventions, as well as response from the patient. For the inter-rater reliability analyzes, transcribed segments (10 min) from 20 different patients were scored with RWS by two independent raters. Two clinical vignettes of relational work are included in the paper as examples of how to rate transcripts from therapy sessions with RWS.ResultsThe inter-rater agreement on the RWS items was good to excellent.ConclusionRelational Work Scale might be a potentially useful tool to identify relational interventions as well as explore the interaction of timing, category, and valence of relational work in psychotherapies. The therapist’s interventions on the patient’s relationships with people outside therapy and the following patient-therapist interaction might be explored.Trial registrationFirst Experimental Study of Transference-interpretations (FEST307/95)Registration number: ClinicalTrials.gov Identifier: NCT00423462.Electronic supplementary materialThe online version of this article (doi:10.1186/s12888-016-1021-4) contains supplementary material, which is available to authorized users.

Meeting report of the 2nd German dialectical behavior therapy for adolescents network meeting

Over the past 30 years, dialectical behavior therapy has been shown to be an effective treatment for adult borderline personality disorder. The adaptation of DBT for adolescents (DBT-A) in different patient groups has also led to some promising improvements of the respective psychopathology. During the second German DBT-A network meeting in 2015 in Mainz, Germany, a need for further research and innovative approaches in treatment of adolescents became apparent and resulted in controversial discussions. Main issues were enlarging evidence of effectiveness of DBT-A strategies with regard to family interaction, i.e. involving caregivers in treatment. In general, there seems to be a dire need for disentangling different therapeutic strategies and resulting treatment outcomes, especially concerning the needs of different patient groups. Additionally, the implementation of smartphone-based real life assessment and intervention into DBT-A was discussed extensively. Providing time congruent skills within an application, decreasing aversive tension and reducing dysfunctional behavior could lead to an enhanced therapist-patient interaction. This meeting report presents the core issues raised during the network meeting and discusses their implications for further research.

The Importance of Early Attachment Relationships in Current Psychoanalysis

Both psychoanalysis and psychoanalytic psychotherapy are psychiatric modalities for investigating the human mind, especially the unconscious mind. The therapist helps his patients by understanding them through conversation and interpreting their unconscious mind based on their free associations. Therefore, both psychoanalysis and psychoanalytic psychotherapy have emphasized the interpretation of therapist and the insight of patient. However, the patient-therapist interaction is an important factor of therapy in addition to the therapists’ interpretation. We defined the meaning and concept of mental development and reviewed the Freud’s epigenesist theory, the Klein’s position theory and the development theory on post-adolescence. We summarized the ontological motives of mental development and the correlation between the development theory and the psychoanalysis theory. We indicated that the patient-therapist relationship is especially important to children and lower-level personality disorder patients. Therefore, we focused the similarities between the child-mother and the patient-therapist relationships and the development of interaction. We concluded that mental development is the process that brings about new functions and transformation of the individual and continues through his entire life. We suggested that mutual interactions concurrently lead to mental development of individual and the interaction itself. From this point of view, we discuss why the patient’s first experience of containing achieved through the patient-therapist relationship serves as a therapeutic factor of psychoanalysis. Finally, we suggest that therapist’s rephrasing and summary of their interaction to the patient during the psychoanalysis is one of the key factors of psychoanalysis.

Long-term weight loss maintenance for obesity: a multidisciplinary approach.

The long-term weight management of obesity remains a very difficult task, associated with a high risk of failure and weight regain. However, many people report that they have successfully managed weight loss maintenance in the long term. Several factors have been associated with better weight loss maintenance in long-term observational and randomized studies. A few pertain to the behavioral area (eg, high levels of physical activity, eating a low-calorie, low-fat diet; frequent self-monitoring of weight), a few to the cognitive component (eg, reduced disinhibition, satisfaction with results achieved, confidence in being able to lose weight without professional help), and a few to personality traits (eg, low novelty seeking) and patient–therapist interaction. Trials based on the most recent protocols of lifestyle modification, with a prolonged extended treatment after the weight loss phase, have also shown promising long-term weight loss results. These data should stimulate the adoption of a lifestyle modification-based approach for the management of obesity, featuring a nonphysician lifestyle counselor (also called “lifestyle trainer” or “healthy lifestyle practitioner”) as a pivotal component of the multidisciplinary team. The obesity physicians maintain a primary role in engaging patients, in team coordination and supervision, in managing the complications associated with obesity and, in selected cases, in the decision for drug treatment or bariatric surgery, as possible more intensive, add-on interventions to lifestyle treatment.

Do Patient Characteristics Predict Outcome of Psychodynamic Psychotherapy for Social Anxiety Disorder?

ObjectivesLittle is known about patient characteristics as predictors for outcome in manualized short term psychodynamic psychotherapy (PDT). No study has addressed which patient variables predict outcome of PDT for social anxiety disorder.Research Design and MethodsIn the largest multicenter trial on psychotherapy of social anxiety (SA) to date comparing cognitive therapy, PDT and wait list condition N = 230 patients were assigned to receive PDT, of which N = 166 completed treatment. Treatment outcome was assessed based on diverse parameters such as endstate functioning, remission, response, and drop-out. The relationship between patient characteristics (demographic variables, mental co-morbidity, personality, interpersonal problems) and outcome was analysed using logistic and linear regressions.ResultsPre-treatment SA predicted up to 39 percent of variance of outcome. Only few additional baseline characteristics predicted better treatment outcome (namely, lower comorbidity and interpersonal problems) with a limited proportion of incremental variance (5.5 to 10 percent), while, e.g., shame, self-esteem or harm avoidance did not.ConclusionsWe argue that the central importance of pre-treatment symptom severity for predicting outcomes should advocate alternative treatment strategies (e.g. longer treatments, combination of psychotherapy and medication) in those who are most disturbed. Given the relatively small amount of variance explained by the other patient characteristics, process variables and patient-therapist interaction should additionally be taken into account in future research.Trial RegistrationControlled-trials.com/ISRCTN53517394

What Influences Patient-Therapist Interactions in Musculoskeletal Physical Therapy? Qualitative Systematic Review and Meta-Synthesis.

Musculoskeletal physical therapy involves both specific and nonspecific effects. Nonspecific variables associated with the patient, therapist, and setting may influence clinical outcomes. Recent quantitative research has shown that nonspecific factors, including patient-therapist interactions, can influence treatment outcomes. It remains unclear, however, what factors influence patient-therapist interaction. This qualitative systematic review and meta-synthesis investigated patients' and physical therapists' perceptions of factors that influence patient-therapist interactions. Eleven databases were searched independently. Qualitative studies examining physical therapists' and patients' perceptions of factors that influence patient-therapist interactions in musculoskeletal settings were included. Two reviewers independently selected articles, assessed methodological quality using the Critical Appraisal Skills Programme (CASP), and performed the 3 stages of analysis: extraction of findings, grouping of findings (codes), and abstraction of findings. Thirteen studies were included. Four themes were perceived to influence patient-therapist interactions: (1) physical therapist interpersonal and communication skills (ie, presence of skills such as listening, encouragement, confidence, being empathetic and friendly, and nonverbal communication), (2) physical therapist practical skills (ie, physical therapist expertise and level of training, although the ability to provide good education was considered as important only by patients), (3) individualized patient-centered care (ie, individualizing the treatment to the patient and taking patient's opinions into account), and (4) organizational and environmental factors (ie, time and flexibility with care and appointments). Only studies published in English were included. A mix of interpersonal, clinical, and organizational factors are perceived to influence patient-therapist interactions, although research is needed to identify which of these factors actually influence patient-therapist interactions. Physical therapists' awareness of these factors could enhance patient interactions and treatment outcomes. Mechanisms to best enhance these factors in clinical practice warrant further study.

Emotional Processing, Interaction Process, and Outcome in Clarification-Oriented Psychotherapy for Personality Disorders: A Process-Outcome Analysis

It is important to understand the change processes involved in psychotherapies for patients with personality disorders (PDs). One patient process that promises to be useful in relation to the outcome of psychotherapy is emotional processing. In the present process-outcome analysis, we examine this question by using a sequential model of emotional processing and by additionally taking into account a therapist's appropriate responsiveness to a patient's presentation in clarification-oriented psychotherapy (COP), a humanistic-experiential form of therapy. The present study involved 39 patients with a range of PDs undergoing COP. Session 25 was assessed as part of the working phase of each therapy by external raters in terms of emotional processing using the Classification of Affective-Meaning States (CAMS) and in terms of the overall quality of therapist-patient interaction using the Process-Content-Relationship Scale (BIBS). Treatment outcome was assessed pre- and post-therapy using the Global Severity Index (GSI) of the SCL-90-R and the BDI. Results indicate that the good outcome cases showed more self-compassion, more rejecting anger, and a higher quality of therapist-patient interaction compared to poorer outcome cases. For good outcome cases, emotional processing predicted 18% of symptom change at the end of treatment, which was not found for poor outcome cases. These results are discussed within the framework of an integrative understanding of emotional processing as an underlying mechanism of change in COP, and perhaps in other effective therapy approaches for PDs.

Changes in Reflective Functioning during Psychoanalytic Psychotherapies.

This study examines how reflective functioning (RF) can be assessed in analytic sessions and throughout psychoanalytic psychotherapy. The goals are to replicate in part a study by Josephs and colleagues (2004) by applying the RF Scale to analytic sessions and to study fluctuations of RF within each session. Additionally, RF based on sessions was compared with the RF ratings based on the Adult Attachment Interview (AAI) during the course of two psychoanalytic psychotherapies with a duration of 240 hours. RF changes based on 10 sessions per patient, assessed at baseline and after 80, 160, and 240 hours of therapy, and RF changes based on AAI ratings measured at baseline and after 240 hours of therapy, and in one case at follow-up, were related to changes of symptoms and attachment classifications over time. Results showed that in both cases RF fluctuated within sessions. The average RF rating per session increased over the course of treatment, while the AAI-based RF rating needed longer to increase. Rather good correspondence was found between session-based RF ratings and independent AAI-based RF ratings. In both cases, changes in RF over time were compared to changes in attachment classification based on the AAI and to symptomatic change. Better correspondence between symptomatic and attachment changes was found with the AAI-based RF rating. It was tentatively interpreted that session-based RF ratings may represent a state of RF that is strongly influenced by the therapist-patient interaction, whereas AAI-based RF can be considered to have more trait characteristics.

Exploring physiotherapists’ personality traits that may influence treatment outcome in patients with chronic diseases: a cohort study

BackgroundDuring treatment of patients with Chronic Diseases (CD) the therapist-patient interaction is often intense, and the strategies used during treatment require physiotherapists to assume a coaching role. Uncovering therapist factors that explain inter-therapist variation might provide tools to improve treatment outcome and to train future therapists. The purpose of this study was to explore the so-called ‘therapist-effect’, by looking at the influence of intrinsic therapist factors, specifically personality traits, on treatment outcome in patients with CD.MethodsA cohort study was performed using data from the NIVEL Primary Care Database (NPCD) in 2011–2012 and an additional questionnaire. Patients with CD (n = 393) treated by Dutch physiotherapists working in outpatient practices (n = 39) were included. Patient and treatment outcome variables were extracted from NPCD. The course of complaint was measured using the Numeric Rating Scale. Therapist variables were measured using a questionnaire consisting of demographics and the Big Five traits: Extraversion, Neuroticism, Agreeableness, Conscientiousness and Openness to experiences. Data were analysed using multilevel linear regression.ResultsOnly Neuroticism was found to be significant (Neuroticism F = 0.71, P = 0.01; therapist gender F = 0.72, P = 0.03; life events F = −0.54, P = 0.09; patient gender F = −0.43, P = 0.10; patient age F = 0.01, P = 0.27). Subgroup analyses of 180 patients with Osteoarthritis and 30 therapists showed similar results.ConclusionsThere are indications that patients with CD who are treated by therapists who tend to be calmer, more relaxed, secure and resilient have a greater reduction in severity of complaints compared to patients treated by therapists who show less of these traits. Being a male therapist and having experienced life events influence outcome positively. However, more extensive research is needed to validate the current findings.