Process Of Therapeutic Change Research Articles

Who is the Expert in Change? Exploring the Role of Therapists in Client Change Processes: A Systemic Therapy Case Study

ABSTRACT This case study focuses on the therapeutic change process, highlighting the crucial role of therapists in facilitating it. Rooted in constructivist epistemology, we employed an integrative systemic model. Our exploration centers on the presence or absence of system restructuring within the therapeutic process. We delve into the differing perceptions of change between the therapist and the client, particularly regarding the criteria for therapy discharge. A significant aspect of our analysis is the discussion on the authenticity of change. We examine the dual role of therapists as expert observers and participants in the therapy, navigating between “objective” and subjective perspectives in their interventions. This includes assessing various levels of change, first and second order. We highlight the client’s autonomy in defining the reality and authenticity of change, advocating for a balance between the therapist’s guidance and the client’s agency. Additionally, we emphasize the therapist’s need for self-reflection and adherence to ethical practices. Our study contributes to systemic therapy literature by demonstrating the effective application of an integrative approach. It reinforces the importance of collaboration in therapeutic change, offering insights into how therapists can navigate complex therapeutic dynamics.

Exercise combined with Acceptance and Commitment Therapy for chronic pain: One-year follow-up from a randomized controlled trial.

Acceptance and Commitment Therapy (ACT) is a type of Cognitive Behavioural Therapy, which has demonstrated positive outcomes in individuals with chronic pain. The purpose of this study was to compare the effect of an 8-week programme combining Exercise with Acceptance and Commitment Therapy (ExACT) with a standalone supervised exercise programme at 1-year follow-up. One hundred and seventy-five people with chronic pain were randomly assigned to ExACT or supervised exercise only. The primary outcome was pain interference measured with the Brief Pain Inventory-Interference Scale. Secondary and treatment process outcomes included pain severity, depression, anxiety, pain catastrophizing, pain self-efficacy, fear avoidance, pain acceptance, committed action, healthcare utilization, patient satisfaction, and global impression of change. Estimates of treatment effects at 1-year follow-up were based on intention-to-treat analyses, implemented using a linear mixed-effects model. Eighty-three participants (47.4%) returned the outcome measures at 1-year follow-up. No significant difference was observed between the groups for the primary outcome, pain interference. There was a statistically significant difference between the groups, in favour of ExACT for pain catastrophizing. Within group improvements that were observed within both groups at earlier timepoints were maintained at 1-year follow-up for many of the secondary and treatment process outcomes. ExACT group participants reported higher levels of satisfaction with treatment and global perceived change. The study results showed no significant difference between the two groups for the primary outcome pain interference at 1-year follow-up. Future research could investigate factors that may predict and optimize outcomes from these types of intervention for people living with chronic pain. Few previous randomized controlled trials investigating ACT for chronic pain have included long-term follow-up. This study found that Exercise combined with ACT was not superior to supervised exercise alone for reducing pain interference at 1-year follow-up. Further research is necessary to identify key processes of therapeutic change and to explore how interventions may be modified to enhance clinical outcomes for people with chronic pain.

Cognitive change before sudden gains in cognitive behavioural therapy for panic disorder.

Sudden gains occur in a range of disorders and treatments and are of clinical and theoretical significance if they can shed light on therapeutic change processes. This study investigated the relationship between sudden gains in panic symptoms and preceding cognitive change during cognitive behavioural therapy (CBT) for panic disorder. Participants with panic disorder completed in session measures of panic symptoms and catastrophic cognitions. Independent samples t-tests were used to compare the post-treatment score of those who met criteria for one or more sudden gain during treatment with those who did not, and to compare within-session cognitive change between pre-sudden gain sessions and the previous (control) session. Twenty-two (42%) of 53 participants experienced a sudden gain during treatment. Participants demonstrating a sudden gain showed more improvement in panic symptoms from pre- to post-treatment than those without a sudden gain. The within-session cognitive change score in the pre-gain session was significantly greater than in the control session. Sudden gains occurred in individual CBT for panic disorder and within-session cognitive change was associated with sudden gains. This is consistent with the cognitive model of panic disorder and highlights how sudden gains can help to identify key change processes.

The Power Threat Meaning Framework and Self-Discrepancy Theory: Complementary Perspectives

The efficacy of psychotherapy is now well-established, and research has provided strong evidence for several change factors, such as the therapeutic relationship, insight, corrective experiences, and reality testing (Goldfried, 2019). Increased understanding of the therapeutic change process has been a notable advance in psychotherapy, but an agreed view of the nature and causality of psychological problems has eluded the psychotherapeutic professions. The dominant medical paradigm within psychiatry and psychology asserts a predominantly neurobiological basis for psychological problems while humanist and relational paradigms prefer a broader and meaning-oriented basis for understanding such problems. This paper provides a review of one alternative conceptual framework, the Power Threat Meaning Framework (PTMF) developed by the British Psychological Society. While the PTMF offers a comprehensive alternative method for conceptualising mental health, it does not provide a specific practice roadmap. The framework’s authors encourage therapists to apply the PTMF in conjunction with their own theoretical preferences. In this paper, I have two aims: the first, to outline and examine the principles inherent within the PTMF, and the second, to provide an example of how the PTMF might be operationalised using an existing theoretical model, self-discrepancy theory (SDT). While the principles of the PTMF can be integrated with a host of theories of psychotherapy, SDT is utilised here as an heuristic to demonstrate the utility of the PTMF.

Perfectionism as Possible Predictor for Treatment Success in Mindfulness-Based Cognitive Therapy and Metacognitive Training as Third-Wave Treatments for Obsessive-Compulsive Disorder

BackgroundIdentifying predictors of treatment outcome can guide treatment selection and optimize use of resources. In patients affected by obsessive-compulsive disorder (OCD), perfectionism has emerged as one possible predictor, with some data suggesting that cognitive-behavioral therapy outcomes are poorer for more perfectionistic patients. Findings so far are inconsistent, however, and research has yet to be extended to newer treatment approaches.MethodsWe administered measures of concern over mistakes, clinical perfectionism, as well as OCD and depression symptom severity to a sample of OCD patients in out-patient group treatments (N = 61), namely, metacognitive training (MCT-OCD) or mindfulness-based cognitive therapy (MBCT) for OCD. Hierarchical data over time was submitted to multi-level analysis.ResultsNeither concern over mistakes nor clinical perfectionism at baseline predicted OCD symptoms across time points. However, concern over mistakes at baseline did significantly predict comorbid depressive symptoms. Furthermore, exploratory analysis revealed change in clinical perfectionism during treatment as a predictor of OCD symptoms at follow-up.ConclusionThese results suggest that initial concern over mistakes may not prevent patients with OCD from benefitting from third-wave treatments. Change in clinical perfectionism may present a putative process of therapeutic change. Limitations and avenues for future research are discussed.

The Contribution of Psychological Inflexibility and Metacognitive Processes to Emotional Distress.

Process-based cognitive behavior therapy (PB-CBT) may be informed by identifying shared mechanisms of disorder linked to shared processes of therapeutic change. Repetitive negative thinking (RNT) is a molar pathogenic process common to both generalized anxiety disorder and depression. Acceptance and commitment therapy (ACT) and metacognitive therapy (MCT) offer separate models of the relationship between RNT and emotional distress. In a pair of related studies, the relative degree to which processes specific to the two models accounted for variability in levels of generalized anxiety and depression in college student samples was evaluated. Across both studies, processes of cognitive fusion and obstructed valued living within the ACT model and beliefs about the negative consequences of RNT within the MCT model were most predictive of variability in levels of emotional distress. Limitations of this project as well as implications for further research and practice of PB-CBT for disorders of emotional distress are discussed.

Minding my brain: Fourteen neuroscience-based principles to enhance psychotherapy responsiveness.

Intersections between psychotherapy and neurosciences are at its dawn. The quest to understand the neural underpinnings of psychological processes has led several generations of scientists to explore neural correlates between mind, brain and behaviour. Neuroscience methods and research have given psychology new perspectives and insights about the structure and function of complex neural pathways that underlie human functioning (cognition, emotion, motivation, somatic reactions and interpersonal behaviour). By translating neuroscientific findings into psychotherapeutic principles of change, it is possible to promote responsiveness towards brain dysfunction that underlies patients' psychological malfunctioning. In psychotherapy, responsiveness is a core aspect of the therapeutic change process, especially to adapt psychological interventions to patients' motivational stages and preferences, coping styles, neurobehavioural modes and emotional needs. Within a transtheoretical and translational approach, contemporary neuroscientific findings are revised, discussed and used to attempt to build on 14 theoretical brain-based principles that may be applied to psychotherapy. Translating these empirical findings into practical principles, clinical strategies and tasks is expected to enhance psychotherapy responsiveness grounded on a science-based knowledge of brain functioning.

The therapeutic relationship and change processes in child psychotherapy: a qualitative, longitudinal study of the views of children, parents and therapists.

Through the perspectives of children, parents and therapists, this study explored the therapeutic relationship as a change facilitator in different moments of psychotherapy. The children, parents, and therapists (N=15) who formed part of five therapeutic treatments were studied using a qualitative, longitudinal design. Thirty semi-structured interviews were done; half at the beginning and half after four months of psychotherapy. Children’s drawings were incorporated, and data were analysed through grounded theory methods and qualitative analysis guidelines for drawings. Participants identified several aspects of the therapeutic relationship as change facilitators. From the first encounters, the therapists’ close and adaptable attitude promoted an improved motivation for psychotherapy and enhanced engagement among children and parents. Later in the process, a positive, child-centred and affective therapeutic relationship fostered the child’s trust with the therapist as well as a positive relational experience, promoting associated changes in children and the development of socio-affective tools. Parents and therapists saw their own relationship as a change facilitator, as well as a broader understanding in parents of their children and an improved relationship with them. Parent’s and child’s changes helped each other. Specific and common aspects between participants’ perspectives provided a richer understanding of the studied phenomena. This study supports the view that a positive therapeutic relationship facilitates early changes in the motivation of children and parents, and provides them with a healing, relational experience as it develops. A positive parent-therapist relationship is also key for changes to further progress.

A grounded theory study exploring change processes following cognitive behavioural therapy for distressing voices

ABSTRACT Background Cognitive Behavioural Therapy for voice hearing (CBTv) has been shown to be effective at reducing distress. However, it is unclear why voice hearers might deteriorate or continue to benefit post-intervention. This study aimed to explore therapeutic change processes following CBTv. Methods A critical realist, grounded theory methodology was utilised. Individual interviews were conducted with 12 participants who had experienced distressing voice hearing and had completed a CBTv intervention in the last 3–12 months. Participants were recruited from a specialist hearing voices service. Results Three categories were found to be facilitative of positive change within CBTv: “New Ways of Managing”, “Overcoming Challenges” and “Gaining New Perspectives”. Five categories denoted the maintenance or furthering of positive change following intervention: “Having a Sense of Control”, “Standing on My Own Two Feet”, “Voices Are Just Part of My Life”, “Investing in Sustaining Relationships”, and “Rediscovering and Developing Identity”. Challenging circumstances faced by participants are also incorporated into a model for maintaining change following CBTv. Discussion The model adds to current literature on change processes occurring within and after CBTv. The results support the need for those working with voice hearers post-therapy to focus on rebuilding social relationships, meaning making and identity.

Somatic Interventions and Depth of Experiencing in Emotionally Focused Couple Therapy

ABSTRACT Emotionally Focused Couple Therapy (EFT), an attachment-based couple therapy, views emotion as being central to the process of therapeutic change. As affect arousal of emotion is a somatic reaction, the purpose of this study was to focus on therapists’ interventions classified as noting and commenting on clients’ somatic cue of emotional experience, such as their facial expression or posture, in relation to depth of emotional experiencing demonstrated by clients in EFT couple therapy sessions. The sample included 13 therapists, each treating one couple during a single EFT training demonstration session. We coded therapists’ interventions (i.e., commenting on one partner’s somatic cue of emotion). Immediately prior to and following such therapist interventions, we rated the partner’s depth of emotional experiencing. The results of multilevel modeling demonstrated a significant linear increase in terms of depth of partner’s experiencing throughout the session. Furthermore, partners demonstrated a significant immediate increase in the depth of experiencing following somatically focused interventions. These findings suggest that interventions focusing on somatic experience of emotion may facilitate deeper experiencing for clients in EFT sessions.

Acceptance and Commitment Therapy for women living with Vulvodynia: A single-case experimental design study of a treatment delivered online

IntroductionVulvodynia is a condition characterised by persistent vulval pain and includes particular impacts on sexual and emotional functioning. Acceptance and Commitment Therapy (ACT) has been successfully applied in persistent pain but has not been tested in this population. This single-case experimental design (SCED) study aimed to evaluate whether an online ACT programme improves clinical outcomes in women with Vulvodynia. We also evaluated whether the intervention led to changes in hypothesised processes of therapeutic change. MethodsThis study applied a nonconcurrent multiple baseline SCED method to assess ACT in women with Vulvodynia. During baseline and treatment phases, participants completed daily self-report outcomes of pain severity and interference, sexual functioning and satisfaction, depression, and hypothesised process-variables: pain-acceptance, present-moment-awareness, committed-action, perceived injustice, and body-exposure anxiety during sexual activities. Full-length assessments of these variables were also completed before and after treatment. The intervention comprised a six-week online ACT programme, combined with a Vulvodynia-specific manual. Visual and statistical analyses were conducted. ResultsSeven participants, mostly with mixed Vulvodynia, provided baseline and treatment phase data, and completed the intervention and diaries. Based on the visual inspection, and Tau and Tau-U values as effect sizes from the daily data, all participants showed moderate size improvements in two or more outcomes. However, participants had highly individual treatment effects. Limited improvement was found in depression. Pain-acceptance, committed-action, and perceived injustice also demonstrated change for some participants. DiscussionThe results suggest online ACT may improve pain and sexual outcomes for some women with Vulvodynia. Pain-acceptance, committed-action, and perceived injustice are highlighted as potential processes of change for some participants. In general, responses to treatment appear highly individual. Further application of the SCED approach to ACT for Vulvodynia is recommended.

A qualitative comparison of mindfulness meditation, cognitive therapy, and mindfulness-based cognitive therapy for chronic low back pain.

This study reports a qualitative analysis of patient experiences following cognitive therapy (CT), mindfulness meditation (MM), or mindfulness-based cognitive therapy (MBCT) for chronic low back pain (CLBP). It aimed to investigate the procedural elements reported by participants as important across these approaches, as well as the role of treatment-related change processes and common factors. Research Method/Design: A qualitative analysis of posttreatment semistructured interviews was conducted with participants who enrolled in a randomized controlled trial comparing MM, CT, and MBCT (N = 57 adults with CLBP). A thematic analysis of transcribed interviews was undertaken by two independent coders; emerging themes, subthemes, and direct quotes were collated, and thematic maps were created. Procedural elements that were both unique (e.g., "cognitive restructuring" in CT) and shared among the three treatments (e.g., "knowledge gained" on pain-related topics) were reported as important. Each treatment was associated with a small number of unique therapeutic processes that were consistent with theoretical tenets underlying the interventions (e.g., "staying in the present moment" in MM). A large number of shared processes and common factors also emerged as important across all three treatments. These first-person accounts provide insight into those participant-identified therapeutic procedures and change processes that were most valued by individuals completing cognitive and mindfulness-based interventions for CLBP. Early identification of treatment barriers and strategies to overcome these barriers is necessary. Further, therapeutic rapport and training participants in coping skills they themselves can use were critical, as was engendering changes in cognitive, emotional, and behavioral mechanisms. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Insight and Outcome in Long-Term Psychotherapies of Depression

Objectives: In different therapeutic approaches, insight is acknowledged as an important part of patient's therapeutic change process. We examined whether the level of insight (1) differs between psychoanalytic (PA), psychodynamic (PD) and cognitive-behavioral therapy (CBT), and (2) predicts long-term symptomatic outcome. Methods: A completer sample of 67 depressed patients from the Munich Psychotherapy Study was analyzed. Symptoms were assessed with Beck Depression Inventory (BDI) and Symptom Checklist-Revised (SCL-90-R) at pre-treatment and three-year follow-up. Insight was assessed from 242 sessions of mid-therapy phase with the Experiencing Scale. Results: The general level of insight was higher in PA as compared to CBT, and associated with lower depressive symptoms (BDI) across all three therapeutic modalities at three-year follow-up. Insight was unrelated to general distress (SCL-90-R). Exploratory analyses suggested that patients treated with PA showed higher levels of insight especially in high quality sessions (assessed by therapist). Patients for whom the extent of insight was positively linked to session quality, suffered from more depressive symptoms at three-year follow-up than patients gaining insight when session quality was low. Conclusion: Insight differs between PA and CBT and may be a common change mechanism in long-term psychotherapies.

Trajectories of change in the therapeutic alliance during Cognitive Analytic Therapy for depression.

Managing the alliance is considered to be a core competency and central therapeutic change process during cognitive analytic therapy (CAT). This study examined latent trajectories of change in the alliance and their relationship to depression treatment outcomes. Secondary analysis of a randomized controlled trial. A sample of N=79 depressed participants completed standardized alliance (WAI-SF) and depression symptom measures (PHQ-9) every session during an 8-session CAT intervention. Growth mixture modelling was applied to model alliance trajectories and to classify cases into different latent classes. Associations between alliance class and post-treatment PHQ-9 scores were examined using hierarchical linear regression, controlling for confounders. There were two classes of alliance trajectories. The majority class (91%) displayed stable alliance trajectories, whilst a minority class (9%) had initially poor alliance ratings that significantly improved during treatment. Baseline severity and early change in depression symptoms significantly predicted treatment outcomes, but early alliance and longitudinal alliance change did not. Alliance trajectories did not significantly predict depression treatment outcomes after controlling for initial symptom severity and early change. An important limitation concerns the small sample size, so future replication in larger samples is necessary.

Tracking Changes in the Disruption/Repair Sequences: Important Aspects of Clinical Work

ABSTRACT In keeping with the movement toward refining clinical theories and working with experience-near phenomena in the analytic situation, in this paper we are asking how we recognize change and how we know what particular interactional sequences between analyst and analysand have transmutative power. Following disruption-repair sequences in the therapeutic relationship sheds light on the process of change. Disruption-repair sequences not only re-establish the connection between therapist and patient, they also promote new levels of understanding for both parties in the dyad. Because such sequences are frequent in the course of treatment, they are particularly useful in creating and recognizing modifications in the patient’s defenses and related symptoms. In this paper, we track verbatim interchanges between analyst and analysand during two specific episodes of disruption-repair as a vehicle for understanding and illustrating the process of therapeutic change. This close tracking allows us to notice shifts in self-states within the analysand between trailing edge archaic selfobject mergers and forward edge strivings and transference as well as shifts in the therapeutic relationship.

Facial-affective communication and verbal relational offers during ruptures and resolution strategies: A single case study

Research on the therapeutic relationship has underscored its central role for the therapeutic change process, indicating the relevance of determining the specific elements and mechanisms involved in its configuration (Knobloch-Fedders, Elkin, & Kiesler, 2014). Research on ruptures of the therapeutic relationship has yielded particular contributions to better understanding the interpersonal negotiation process involved in the patient-therapist interaction. Although previous studies have contributed to the objective characterization and the exhaustive description of ruptures, more research is needed to further specify markers that allow a better understanding about how patterns of affective regulation between patient and therapist are involved and contribute to the emergence of these events and the attempts at reparation. The aim of this study is to characterize patient’s and therapist’s facial-affective behavior associated to verbal relational offers (RO) during rupture (R) and resolution strategy (RS) events in a brief psychodynamic therapy. Facial-affective behavior was determined using the Facial Action Coding System (FACS), ROs were derived from the content analysis of session transcripts, and R and RS were determined using the 3RS. Nested analyses were carried to establish associations between variables. Results indicate characteristic patient-therapist facial-verbal regulatory patterns for both rupture and resolution strategy events. These findings underscore the value of combining multiple approaches to allow an access to observable indicators of dyadic affect regulatory processes that can contribute to better understand and be attentive to the oscillations of the therapeutic relationship.

Mindfulness-based cognitive therapy experiences in youth with inflammatory bowel disease and depression: findings from a mixed methods qualitative study

ObjectivesMindfulness-based cognitive therapy (MBCT) is effective in treating psychosocial comorbidities in inflammatory bowel disease (IBD); however, there have been no qualitative studies of MBCT experiences among youth with IBD. We...

The embodied listener: a dyadic case study of how therapist and patient reflect on the significance of therapist’s personal presence for the therapeutic change process

Objective: There is a need to understand more of the dyadic processes in therapy and how the therapist’s ways of being are experienced and reflected upon by both patient and therapist. The aim of this dyadic case study was to investigate how the therapist’s personal presence was perceived by the patient and the therapist as contributing to change. Method: From a larger project on collaborative actions between patient and therapist, a dyadic case involving in-depth interviews of the therapist and patient was selected to examine the research question. Interpretative phenomenological analysis of four interviews with the therapist and one interview with the patient was conducted. Results: The analyses indicated that the therapist’s way of being, as perceived by both therapist and patient, was expressed at a superordinate level through the concept of embodied listening, which was of particular help for the patient, and influenced by the therapist’s theoretical orientation, as well as being rooted in his own personal history. Three sub-themes emerged from the analysis, each illustrating how embodied listening contributed to the therapeutic relationship and process. Our findings flesh out how the underlying phenomena of emotional attunement, presence, and genuineness are observable in therapeutic encounters.

Rehabilitation intervention in an ice hockey context: What changes under the helmet

Most studies of sport-based interventions in rehabilitation settings with youth with disruptive behaviors look at their effects. To our knowledge, there are few studies of the processes by which these interventions allow participants to benefit from them. This article looks at the process of therapeutic change based on the subjective theories concept and is inspired by the significant events approach. The participants are five young people receiving services under the Youth Protection Act or the Youth Criminal Justice Act for adolescents who took part in a rehabilitative intervention in an ice hockey context. All of these young people have experienced early relational traumas. A semi-structured interview on the highlights of their participation was conducted at the end of the activity. A qualitative content analysis aimed at identifying psychological changes and an interpretative phenomenological analysis intended to explore their experience in the intervention revealed psychological changes and linked them to significant events. The results support the idea that psychological change is a singular process. In order to capture the clinical significance, the results were linked to Winnicott's theoretical elaboration of the parent-child relationship in the context of early relational trauma.

Oxytocin as a biomarker of the formation of therapeutic alliance in psychotherapy and counseling psychology.

The therapeutic alliance is one of the most consistent predictors of therapeutic change, including symptom reduction and improvement in wellbeing and quality of life, across a variety of mental health interventions. Yet, little is known about its biological mechanisms. Oxytocin (OT) has been suggested as a biological mechanism by which bonds are formed and strengthened across species. This article is intended to demonstrate the potential of OT as a biomarker of therapeutic change in psychotherapy and counseling psychology, especially of the therapeutic alliance. We delineate three main potential paths of investigation based on the most recent research on OT in parent-child and romantic partner dyads. For each path, we provide a detailed explanation for whom, when, and how OT should be measured. Each path is illustrated using data collected in a randomized controlled trial of psychotherapy for major depressive disorder. These illustrations demonstrate the great potential of OT as a biomarker of (a) trait-like characteristics of the patients and the therapists, (b) the processes of therapeutic change, and (c) the dyadic synchrony between patients and their therapists. The potential clinical contribution of OT as a biomarker for each of these three paths is further demonstrated using a case study. Practical suggestions and directions for future research are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).