Process Of Change In Psychotherapy Research Articles

How Can We Study Change Processes in Psychotherapy While Addressing Its Interactive Nature

Does the empathy or personality of psychotherapists influence the way they do therapy? Is the therapeutic relationship the key to success? Questions such as these are commonly shared in Change Process Research (CPR) and outcome studies. However, these statements, posed in descriptive cross-sectional terms, often imply the use of strategies grounded in causal-linear explanatory models. The present study offers an alternative tool to measure elements of psychotherapy in dynamic, interactive, and interdependent terms. With nine observational categories defined under analytical-behavioral lens, the Acoveo System is an instrument designed to detect the potential functions of verbal exchanges that take place in the psychotherapeutic context from any theoretical orientation. A guide to its application is provided, and its usefulness is elaborated on two of the pivotal common factors in change process research: empathy and therapeutic alliance.

Mental flexibility and epistemic trust through implicit social learning – A meta-model of change processes in psychotherapy with personality disorders

This position paper follows the call for transtheoretical meta-models of general clinical change by concentrating on severe mental illness such as Personality Disorders (PDs). We have identified a core process of change related to mental flexibility through implicit learning and propose recommendations for stance and technique that are informed by research on Mentalization-Based-Treatment (MBT) and the learning components as represented in the Mediational Intervention for Sensitizing Caregivers (MISC). While the idea of corrective emotional experience as a general change mechanism involves discriminating between an old and new relationship to update relationship knowledge, the capacity to understand and process corrective emotional experiences may be limited and even iatrogenic in patients with PDs. By integrating MBT and MISC, a meta-model of change is created that allows training in and observation of the granular-level, behaviorally anchored, actions taken by the therapist to open up social learning. Here, social learning is conceptualized as epistemic trust, increasing the client’s reflective functioning during sessions to ultimately enhance cognitive flexibility outside the therapy room. This opens the possibility to implement and observe micro changes in what should be termed now implicit cognitive and emotional corrective experiences. Thus, we propose to shift towards implicit learning within professional relationships; that is, internalizing a new way of thinking about any life-event that requires adaption thereby creating adaptive capacities via mental flexibility as the general change mechanism of Personality Disorder (PD) treatment.

Using machine learning algorithms to predict the effects of change processes in psychotherapy: Toward process-level treatment personalization.

This study aimed to develop and test algorithms to determine the individual relevance of two psychotherapeutic change processes (i.e., mastery and clarification) for outcome prediction. We measured process and outcome variables in a naturalistic outpatient sample treated with an integrative treatment for a variety of diagnoses (n = 608) during the first 10 sessions. We estimated individual within-patient effects of each therapist-evaluated process of change on patient-evaluated subsequent outcomes on a session-by-session basis. Using patients' baseline characteristics, we trained machine learning algorithms on a randomly selected subsample (n = 407) to predict the effects of patients' process variables on outcome. We subsequently tested the predictive capacity of the best algorithm for each process on a holdout subsample (n = 201). We found significant within-patient effects of therapist perceived mastery and clarification on subsequent outcome. In the holdout subsample, the best-performing algorithms resulted in significant but small-to-medium correlations between the predicted and observed relevance of therapist perceived mastery (r = .18) and clarification (r = .16). Using the algorithms to create criteria for individual recommendations, in the holdout sample, we identified patients for whom mastery (14%) or clarification (18%) were indicated. In the mastery-indicated group, a greater focus on mastery was moderately associated with better outcome (r = .33, d = .70), while in the clarification-indicated group, the focus was not related to outcome (r = -.05, d = .10). Results support the feasibility of performing individual predictions regarding mastery process relevance that can be useful for therapist feedback and treatment recommendations. However, results will need to be replicated with prospective experimental designs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Shifting between Self-States and Narrative Change—Implicit and Explicit Change Processes in Psychotherapy

This study examined the relationship between implicit and explicit levels of change in psychotherapy—the ability to shift between self-states, measured by the Two Person APES (TPA), a relational extension of the Assimilation of Problematic Experiences Scale (APES), and the emergence of exceptions to the problematic self-narrative, measured by the Innovative Moments Coding System (IMCS). The contribution of each of these dimensions of change to session outcome was also examined. Eighty sessions of eight psychodynamic treatments (10 sessions each) were sampled and coded according to the TPA and the IMCS. Session outcome was measured by the Outcome Rating Scale (ORS). A repeated measures correlation approach was used, revealing a positive association between IMs and client TPA. Also, IMs showed stronger correlations with session outcome compared to TPA. These results indicate that a growing ability to shift between self-states in the implicit level is related to the client’s ability to construct new meanings in the explicit level, and that these explicit changes have stronger correlations with functioning improvement at the session level than implicit processes concerning the renewal of dialogue between self-states.

Respiratory Sinus Arrhythmia as a Therapy Measurement Strategy: The Example of Functional Analytic Psychotherapy

Introduction: Respiratory sinus arrhythmia (RSA) may be a psychophysiological measure that can gauge change processes in psychotherapy. RSA is a cardiovascular marker of nervous system functioning and has been proposed as an index of social engagement. Given the emphasis on social relationships in Functional Analytic Psychotherapy (FAP), RSA may be useful for understanding the process of change in FAP. The current study details the logic of using RSA as a measurement tool and provides data to establish proof of concept. Methods: RSA data were collected from three participants in a multiple baseline experiment which involved a control condition of reading two-person plays and a FAP condition. Sessions were coded using the FAP Rating Scale. RSA was calculated for each session and each client-therapist interaction. Results: RSA higher during FAP sessions (P1Mean = 6.60, P2Mean = 6.41, P3Mean = 6.32) than the control condition (P1Mean = 6.29, P2Mean = 5.79, P3Mean = 5.96). Conclusions: Data are consistent with outcomes that might be anticipated during therapy and suggest RSA could improve as a function of treatment. RSA was able to be isolated for therapeutic moves when coded at the turn-by-turn level. Thus, data suggest RSA’s utility for measuring therapy processes and outcomes.

Supplemental Material for Using Machine Learning Algorithms to Predict the Effects of Change Processes in Psychotherapy: Toward Process-Level Treatment Personalization

Supplemental Material for Using Machine Learning Algorithms to Predict the Effects of Change Processes in Psychotherapy: Toward Process-Level Treatment Personalization

Challenges and added value of measuring embodied variables in psychotherapy.

Research on embodied aspects of clinical encounters is growing, but discussion on the premises of including embodied variables in empirical research is scarce. Studies have repeatedly demonstrated that embodied aspects of psychotherapy interaction are vital in developing a therapeutic alliance, and these should be considered to better understand the change process in psychotherapy. However, the field is still debating which methods should be used and which features of the embodied aspects are relevant in the clinical context. The field lacks methodological consistency as well as a theoretical model. In the Relational Mind research project, we have studied the embodied aspects of interaction in the context of couple therapy for almost a decade and have gained experience with the positive and negative aspects of studying embodied variables in quantitative and qualitative studies. We have set out to develop the methodology (or procedures) for studying embodied variables in a multiperson setting, concentrating on interpersonal synchrony of sympathetic nervous system responses and movements, and we have strived to create methods for integrating information from different embodied modalities. In this narrative review, we share our experiences of the challenges and added value of studying embodied aspects in psychotherapy. The research field urgently needs an ongoing discussion of what researchers should take into consideration when studying the embodied aspects of interaction. We urge researchers to collaborate between research groups to jointly decide on the basic parameters of studies on the different embodied modalities of the research so that the individual researcher can become more aware of the impact the methodological choices have on their studies, results, and interpretations. We also see the use of embodied variables as having added value in the clinical work of psychotherapists, since it not only deepens our understanding about what is helpful in psychotherapy but will enable fine-tuning therapy processes to better suit clients who are verbally less fluent.

"Where have you been in this world?" a qualitative study of clients' curiosity about their psychotherapists.

Curiosity is widely seen as a basic human drive, important to the development of relationships as well as to the process of change in psychotherapy. Less attention, however, has been directed toward examining curiosity in the client-therapist relationship. In particular, we lack a comprehensive understanding of what occurs for clients when they become curious about their therapists. As a result, we aimed to explore clients' experiences of curiosity about their therapists. Using a consensual qualitative research approach, we analyzed data from ten current and former adult psychotherapy clients. Results were organized in six domains that captured different facets of participants' experiences of curiosity about their therapists: the content of the curiosity, motivation(s) for the curiosity, triggers of the curiosity, expressions of curiosity, influences on the curiosity, and consequences of the curiosity. More specifically, results revealed participants experienced curiosity that (a) concerned the therapist's professional and personal life, (b) was motivated by concerns over the therapist's ability to understand or relate, and (c) was triggered by therapist behavior (e.g., disclosures). For some participants, having a positive therapeutic relationship led to greater curiosity; by the same token, participants' desire for professional boundaries at times quelled this curiosity. Moreover, although some participants described positive relational outcomes, others disclosed feelings of shame or discomfort resulting from their curiosity. Several cultural factors were also found to influence participants' curiosity. Implications for research and practice are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Rupture repair as change process and therapist challenge (Reparación de rupturas como proceso de cambio y desafío para el terapeuta)

ABSTRACT Our practice-based research programme has devoted itself to the study of how psychotherapy works for over 30 years. It has focused on how to negotiate the therapeutic alliance: more specifically, on rupture resolution as a critical change process in psychotherapy. Rupture refers to moments in which the patient and therapist experience a disagreement in the tasks and goals of treatment, a deterioration in their emotional bond or a breakdown in the intersubjective negotiation of their needs. Resolution (or repair) refers to the dyadic process that patient and therapist engage in to restore the alliance and to effect a new or corrective emotional experience. Our research has not only sought to provide further definition to this process but has striven to define and evaluate training for psychotherapists to be better able to identify ruptures and resolve them. We will provide some review of the evidence-based change process literature and the cognitive, emotion and social sciences that have informed our programme, concluding with a brief introduction to our research on clinical practice.

Change processes in psychotherapy for patients presenting with histrionic personality disorder.

Histrionic personality disorder (HPD) with a lifetime prevalence rate of 1.8% is an under-researched psychiatric diagnosis. The present study therefore aimed to investigate both the processes and outcomes of psychotherapy for HPD in a non-controlled study. A total of 159 patients diagnosed with HPD were recruited and received clarification-oriented psychotherapy. Sessions 15, 20, and 25 were video-recorded and analysed using the Process-Content-Relationship Scale. Therapy outcome was assessed with symptom measures at intake and discharge. Hierarchical linear modelling was applied to estimate the changes in the psychotherapeutic outcome and associations with patient and therapist process developments. Improvements in relationship processes of patients and therapists were systematically related to outcome while only partial relationships were found on the levels of process and content. The present study represents the first systematic insight into core changes in patients with HPD undergoing psychotherapy.

How to become a responsive therapist: A study of experiences of developing therapists

ABSTRACT Objective : A growing body of empirical evidence suggests that psychotherapy is more effective when therapists tailor interventions to fit their specific clients’ needs, a concept referred to as therapist responsiveness in the psychotherapy literature. However, the question of how therapists learn to become responsive rarely has been examined. Method : The central question of this study, put to eleven graduate student therapist trainees, was, “How did you learn to be responsive to clients as a novice therapist, and in what ways have you become responsive?” A critical-constructivist grounded theory method was employed to generate themes from trainees’ replies. Results : The analysis showed that trainees learned to improve their responsiveness to clients by: (1) becoming more aware of cues that signaled the need to adapt interventions (as related to psychotherapy change processes, client-therapist relational dynamics, clients’ identities and cultural contexts, and the maximizing of clients’ agency); (2) developing attunement to their own emotions and engaging in self-care; and (3) adopting mindsets that facilitated their trying new relational or therapy approaches while also maintaining professionalism. Conclusion Based upon these findings, preliminary suggestions for responsiveness training are presented to guide programs that wish to train responsive psychotherapists .

Sparks of psychotherapeutic change: How therapists understand moments of meetings’ contribution to change in psychotherapy

Moments of Meeting (MoM) in psychotherapy are understood as shared moments between patients and therapists that allow a mutual implicit understanding about their relationship and create a new state of intersubjectivity that reconfigures the patient’s procedural knowledge of “being with others.” Despite ample theoretical and clinical descriptions of this phenomenon, little is known, from an empirical standpoint, about these kinds of moments in therapy. Objective : This study describes therapists’ experience of moments of meeting with their patients in psychotherapy, and how these moments relate to the patient’s change process. Method 13 in-depth interviews conducted with therapists from different theoretical backgrounds were analyzed using Grounded Theory. Results Four categories were established: (1) Characteristics of moments of meeting, (2) Triggers of moments of meeting (3) Enabling conditions, and (4) Main effects of moments of meeting. A conceptual model was developed around an axial phenomenon that provides understanding on how moments of meeting contribute to the change process in psychotherapy, through the construction of shared relational knowing. Discussion : The value of moments of meeting for the therapeutic process is discussed and reflected upon, as well as their effect on changes regarding implicit relational knowing.

How do we help people regain control over their lives? An introduction to method of levels therapy

There are many different approaches to psychotherapy. Research indicates comparable effectiveness of various therapies, despite having different theoretical assumptions and using different therapeutic methods. In recent years, many researchers have attempted to understand such results by investigating specific and common factors in psychotherapy. It has been suggested that further developments in the field should aim to investigate factors underlying mental health problems and the principles informing the process of change in psychotherapy. In the current article, we will present perceptual control theory as a scientifically grounded approach that integrates theory and practice. Transdiagnostic principles explain the sources of emotional distress and the process of psychological change in psychotherapy. The main aim of the article is to introduce method of levels therapy, which has been created as a direct application of perceptual control theory principles. Description of the process of therapy is accompanied by clinical examples.

Disentangling Trait-Like Between-Individual vs. State-Like Within-Individual Effects in Studying the Mechanisms of Change in CBT.

Hofmann et al. argued that “[w]hile the clinical field has produced a dizzying number of treatment models and treatment protocols for virtually every psychiatric and psychological problem imaginable, increases in understanding of the processes of change in psychotherapy has been slow to arrive.” We propose that one of the reasons for the slow progress is that prior psychotherapy research conflates trait-like and state-like components of mechanisms of change. Trait-like components can serve as prescriptive or prognostic variables, whereas state-like components reflect within-client processes of change, and may highlight active ingredients of successful treatment. Distinguishing between the two is essential for clarifying the underlying processes of change in psychotherapy, and ultimately identifying empirically-derived individualized treatment targets. We review studies that implement methodological and statistical approaches for disentangling the two. These studies clarified particular mechanisms of change that may operate in a given treatment, highlighted differences in the processes of change between different treatments, and explored the within-individual interplay between different mechanisms of change during treatment. Examples include studies investigating the therapeutic role of behavioral, cognitive, and interpersonal skills, as well as emotional processing. We conclude with suggestions for future research, including attention to diversity, improved measurement to facilitate a reliable and valid estimation of trait-like and state-like components, the use of appropriate statistical approaches to adequately disentangle the two components, integration of theory-driven and data-driven methods of analysis, and the need to experimentally manipulate the state-like changes in a given mechanism of change to strengthen causal inferences.

The Change Process in Psychotherapy: Listening for Other Voices as a Tool for Research Analysis

Academic research is valuable in transactional analysis because it provides evidence to support long-used theories that may not have been substantiated in the wider academic world. The author expla...

Using event-related potentials to explore processes of change in counseling psychology.

The purpose of this article is to serve as a guide for counseling psychologists to learn about a neuroscience methodology that can be used to study psychotherapy change processes. Event-related potential (ERP) is a specific type of electroencephalography that can be time-locked to a stimulus and thus allows researchers to examine neural responses to specific therapeutic techniques. A conceptual overview of the method and its applicability to counseling psychologists is provided. Additionally, this article contains basic guidelines for designing an ERP study, the tools necessary for setting up an ERP lab, and an overview of data-processing strategies. Common pitfalls encountered both broadly in neuroscience research and specifically in ERP research are discussed. An integrated review of relevant literature is presented here, along with suggestions for future counseling psychology research, with a focus on establishing biomarkers of successful interventions. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Processes of Change in Psychotherapy for Narcissistic Personality Disorder.

The present study aims at determining the role for outcome of potential processes of change in psychotherapy for narcissistic personality disorder (NPD). They were examined on three levels: the content, the process, and the relationship. A total of 161 patients suffering with NPD were recruited in a naturalistic setting as part of the present study. They underwent a long- term clarification-oriented psychotherapy. Sessions 15, 20, and 25 were video- or audio-recorded and analyzed with an observer-rated instrument that measures the quality of the interaction processes from the patient's and therapist's perspectives. Different self-report measures were used to assess therapy outcomes. In-session improvement was observed in both patient and therapist processes across sessions. Patient improvement in the three levels of processes was systematically related with outcome. Only partial relationships were found between therapist improvement and outcome. The present study represents the first systematic insight into core changes in patients with NPD undergoing psychotherapy.

Change processes underlying “good outcome”: A qualitative study on recovered and improved patients’ experiences in psychotherapy for major depression

Aim: Exploring change processes underlying “good outcome” in psychotherapy for major depression. We examined the perspectives of patients who “recovered” and “improved” (Jacobson & Truax) following time-limited CBT and PDT. Method: In the context of an RCT on the treatment of major depression, patients were selected based on their pre–post outcome scores on the BDI-II: we selected 28 patients who recovered and 19 who improved in terms of depressive symptoms. A grounded theory analysis was conducted on post-therapy client change interviews, resulting in an integrative conceptual model. Results: According to recovered and improved patients, change follows from an interaction between therapy, therapist, patient, and extra-therapeutic context. Both helping and hindering influences were mentioned within all four influencing factors. Differences between recovered and improved patients point at the role of patients’ agency and patients’ internal and external obstacles. However, patients marked as “improved” described heterogeneous experiences. CBT- and PDT-specific experiences were also observed, although our findings suggest the possible role of therapist-related influences. Conclusion: From patients’ perspectives, various change processes underlie “good outcome” that do not necessarily imply an “all good process”. This supports a holistic, multidimensional conceptualization of change processes in psychotherapy and calls for more fine-grained mixed-methods process-outcome research.

Updating RFT (More Field than Frame) and its Implications for Process-based Therapy

The current article presents a response to the recent call for a focus on psychological processes of change in psychotherapy. In addressing the need for a more process-based focus, the need for clarity in defining psychological processes per se becomes apparent, before it is possible to develop process-based therapy. In grappling with this challenge, the current article is divided into two parts. In Part I, we present a modern view of behavioral processes as they apply specifically to verbally sophisticated humans. The view we offer is based on one of the main approaches to human language and cognition within behavioral science, relational frame theory (RFT), which has been updated in recent years. In Part 2, the view of behavioral processes, as seen through the lens of an updated RFT, is used to begin to develop a process-based approach to the assessment and treatment of human psychological suffering. The article ends with two case summaries and a series of brief take-home messages that aim to capture the core elements of the RFT-driven process-based therapy we are currently developing.

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.