Psychotherapeutic Change Research Articles

Proposed necessary and sufficient conditions for optimal psychotherapeutic change

The original concepts of psychological hurt and therapeutic catharsis are proposed as possible necessary and sufficient conditions for optimal psychotherapeutic change. The basic meaning of psychological hurt is any nonorganic, residual interference with psychological functioning that resulted from an event the person experienced. The irreducible source of such interference is a registration in the brain of sensory input from hurtful events, which when sufficiently activated is manifested in affective, cognitive, behavioral, and physiological symptomatology. Accordingly, unresolved psychological hurt is considered as the most productive target for intervention. Therapeutic catharsis, a fundamental reconceptualization of how catharsis has been traditionally understood, is the process by which the nervous system heals itself of residual interference. Therapeutic catharsis is assumed, therefore, to have the most potential for resolving psychological hurt. Optimal therapeutic change occurs when unresolved psychological hurt is resolved through a therapeutic cathartic release.

Encouraging acceptance of ambivalence using the expressive writing paradigm

Ambivalence is regarded as a key target for psychotherapeutic change. This study aimed to examine the effectiveness of a brief expressive writing intervention for reducing distress about goal ambivalence. A sample of 40 undergraduate students were randomly allocated to an experimental 'expressive writing' condition or a control condition. Participants rated their ambivalence about the 10 most important goals they were currently pursuing and rated how distressing they found these feelings of ambivalence. Participants then completed three short expressive writing sessions on consecutive days. Participants in the experimental condition participants wrote about their deepest thoughts and feelings relating to their ambivalence, and participants in the control condition wrote about how they had spent their time that day or week. When controlling for baseline distress about ambivalence, there was a significant effect of writing condition on distress about ambivalence at follow-up; individuals who wrote about their ambivalence experienced a significant reduction in their level of distress about ambivalence. It was concluded that expressive writing might represent an analogue of therapeutic approaches to encourage acceptance of ambivalence.

Ressourcenorientierte Akutbehandlung unipolarer Depressionen: Eine randomisierte kontrollierte Psychotherapiestudie

Resource activation is considered to be a central mechanism in psychotherapeutic change. However, it is widely unknown whether a special focus on resource activation is associated with higher efficacy in cognitive behavioural therapy. 52 patients with unipolar depression took part in a randomized controlled study comparing cognitive behavioural therapy plus resource activation (RFCBT) with cognitive behavioural therapy (CBT) alone. Overall, treatment effects were comparable to published research. In both treatment groups patients equally improved on cognitive, emotional and interpersonal outcome measures. A combined treatment approach of cognitive behavioural therapy and resource activation was shown to be an effective treatment of unipolar depression. Yet, compared to a standard CBT-treatment an additional focus on resource was not associated with higher efficacy.

The Right Brain Implicit Self Lies at the Core of Psychoanalysis

In this contribution I expand my continuing work on the centrality of right brain structures and unconscious processes from the neuropsychoanalytic perspective of regulation theory, an overarching model of the development, psychopathogenesis, and treatment of the implicit self. In an introduction I highlight the essential role of not only implicit cognition but implicit affect, communication, and regulation in current relational psychoanalytic models. I then briefly discuss recent developmental and neurobiological studies of implicit processes in early development and psychopathogenesis. In the bulk of this work I explore the essential role of implicit affective processes in psychotherapeutic change processes. I focus particularly on the expression of right brain unconscious mechanisms in affect-laden enactments, and on the therapist's moment-to-moment navigation through these heightened affective moments by not left brain explicit secondary process cognition but right brain implicit primary process affectively driven clinical intuition. Direct access to these right brain implicit processes by both patient and therapist is central to effective treatment.

Clients', therapists', and observers' agreement on the amount, temporal location, and content of psychotherapeutic change and its relation to outcome

Clients', therapists', and observers' identification of change was studied in 27 therapeutic processes, and agreement on the amount, temporal location, and content of change was related to outcome. Results show that clients reported more changes in successful therapies. Client–therapist temporal match of change moments was low irrespective of outcome. Results from all three perspectives were consistent in that manifestation of new behaviors and emotions was the most representative content of change among all therapies. Meanwhile, client–therapist agreement on the frequency of grouped change indicators reported was associated with positive outcome, whereas client–observer agreement was related to negative outcome. Therapists and observers agreed in both successful and nonsuccessful therapies. The relationship between agreement and therapeutic outcome is discussed in relation to each dimension of analysis.

Logic, Hermeneutics, or Both?

Stiles’ (2009) thesis that logical operations can be employed in case studies making them contributory to theory-building is examined in the light of methodical hermeneutics. The assimilation model of psychotherapeutic change developed by Stiles and colleagues is used to demonstrate the utility of this alternative framework. The question is raised of whether the case-study research conducted by Stiles et al. illustrates theory-building as Stiles claims or instead illustrates his concept of enriching research. In terms of logical operations, it is pointed out that in order for Stiles’ uptake of C.S. Peirce’s theory of inference to work, it is necessary to take into account how that theory has been has been modified to fit with qualitative research. Throughout, the epistemological positions of Stiles’ experiential correspondence theory of truth versus methodical hermeneutics are considered.

Perceptions of Clients and Counseling Professionals Regarding Spirituality in Counseling

Although current research indicates that psychotherapeutic change both affects and is affected by spiritual concerns, relatively little is known about the degree to which spirituality is used as an intervention in counseling and how it is perceived by clients and mental health professionals. The purpose of this study was to examine the perceptions of clients and professionals regarding the use of spirituality in counseling. The results suggest that more professionals may be using spirituality in counseling than has previously been reported.

Relational Trauma and the Developing Right Brain

Psychoanalysis, the science of unconscious processes, has recently undergone a significant transformation. Self psychology, derived from the work of Heinz Kohut, represents perhaps the most important revision of Freud's theory as it has shifted its basic core concepts from an intrapsychic to a relational unconscious and from a cognitive ego to an emotion-processing self. As a result of a common interest in the essential, rapid, bodily based, affective processes that lie beneath conscious awareness, a productive dialogue is now occurring between psychoanalysis and neuroscience. Here I apply this interdisciplinary perspective to a deeper understanding of the nonconscious brain/mind/body mechanisms that lie at the core of self psychology. I offer a neuropsychoanalytic conception of the development and structuralization of the self, focusing on the experience-dependent maturation of the emotion-processing right brain in infancy. I then articulate an interdisciplinary model of attachment trauma and pathological dissociation, an early forming defense against overwhelming affect that is a cardinal feature of self-psychopathologies. I end with some thoughts on the mechanism of the psychotherapeutic change process and suggest that self psychology is, in essence, a psychology of the unique functions of the right brain and that a rapprochement between psychoanalysis and neuroscience is now at hand.

Patterns of change in psychotherapy: An investigation of sudden gains in cognitive therapy using the assimilation model

The aim of this study was to provide a detailed descriptive account of the large improvement seen over a single-session interval in psychotherapy, known as “sudden gain,” by applying a process model of psychotherapeutic change. Passages from sessions before and after the sudden gain of five clients receiving cognitive therapy for depression were rated for assimilation level. Results indicated that insight and understanding of the problematic experience was reached in the session before the sudden gain. Case analyses confirmed this but suggested that this insight was only partial and did not develop into full insight until the therapy session after the gain.

Person-Centered Family Therapy: Old wine in new bottles / Personzentrierte Familientherapie: Alter Wein in neuen Schläuchen / Terapia Familiar Centrada en la Persona: Viejo vino en botellas nuevas / La Thérapie Familiale Centrée sur la Personne: Du vin vieux dans des bouteilles neuves / Terapia de Família Centrada na Pessoa: Vinho velho em garrafas novas /

In the half century since its inception Carl Ransom Rogers' seminal exposition of the necessary and sufficient conditions for psychotherapeutic change has confirmed both its reliability and validity despite efforts to condense or augment the conditions. Furthermore, their application beyond the individual therapy hour has enhanced their veracity and proven their effectiveness as determinants for effective change within and between persons. This paper addresses the application of the conditions to the practice of couple and family therapy.

Speaking with the Client's Voices: How a person-centered therapist used reflections to facilitate assimilation / Mit den Stimmen des Klienten reden: Wie ein Personzentrierter Therapeut das Spiegeln nutzte, um Assimilation zu fördern / Hablando con las Voces del Cliente: Cómo un terapeuta centrado en la persona usó reflejos para facilitar la asimilación / Parler avec les Voix du Client: L'utilisation

We describe how reflections facilitated change in person-centered therapy with a 29-year-old man we called Bill. The assimilation model conceives people as having multiple internal voices, and it conceives psychotherapeutic change as building meaning bridges (explicit understandings) between voices. In a previous paper (Mosher, Goldsmith, Stiles, & Greenberg, 2008), we described the mutual assimilation among three of Bill's voices. In this paper we explore how the therapist's reflections facilitated assimilation between two of these voices, a Self-Doubting Critic that directed criticism inwardly and a timid and depressed Guy Who Let Bill Down that internalized this criticism. Through reflections, the therapist expressed the positions of these voices, allowing them to hear and respond to each other, to explore and clarify their experiences, and to build useful meaning bridges.

Emotion and cognition in psychotherapy: The transforming power of affect.

Abstract Theory and research on emotion in both psychology and psychotherapy are reviewed to demonstrate the importance of emotion in human functioning and psychotherapeutic change. A proposal is made for the importance of integrating empirically supported emotion-focused change processes into psychotherapeutic work. Five principles of change in the emotion domain-emotion awareness; expression; regulation; reflection on emotion; and the more novel principle of emotion transformation, by which emotion is changed by emotion-are offered as processes of change that are rapidly gathering empirical support. The result of emotion coming of age will be the expansion of theories of dysfunction and of treatment to include emotion-focused coping and emotional processes of change. Keywords: emotion, emotion-focused therapy, awareness, regulation transformation This article reviews both the evolving understanding of the role of emotion in human functioning and the evidence for the important role of emotion in psychotherapy, and a set of empirically grounded principles of emotional change is proposed. Given that emotion now is seen as information, as signalling the significance of the situation to a person's well being, and given that affect regulation is seen as a key human motivation, it has become clear that emotion needs to be focused on, accepted and worked with directly in therapy to promote emotional change. (Foa, Riggs, Massie, & Yarczower, 1995; Fosha, 2000; Greenberg, 2002; Goldman, Greenberg, & Angus, in press; Linehan et al., 2002; Samoilov & Goldfried, 2000). The idea that accessing and exploring painful emotions, within the context of a secure therapeutic relationship, leads to therapeutic change has been widely held by several schools of psychotherapy (Bowlby, 1980; Kohut, 1977; Rogers, 1951; Peris, 1969) but has been difficult to prove. However over the past decade, newer therapeutic approaches that treat affect as a primary target of intervention, within the context of an empathie relationship, have been developed, tested, and shown to be effective in the treatment of affective disorders, personality disorders, and trauma (Goldman et al., in press; Svartberg, Stiles, & Seltzer, 2004). Emotions as an Adaptive Resource Until recently, the prevalent commonsense view of emotion, endorsed by many, was that emotions were disruptive to functioning, were due to misinterpretation and were to be controlled, tempered, bypassed, or avoided (Beck, 1976). Control of emotion, however, is not always wise or adaptive, and overregulation of emotion, or its avoidance, does not ensure health or happiness. A large volume of research has now been collected on the debilitating physiological effects of not expressing deeply felt emotions (Traue & Pennebaker, 1993). It appears that inhibiting the expression of emotion can lead to impaired immune system function and poorer health on a variety of indices. In addition, there is increasing evidence on the importance of emotion knowledge and emotional intelligence in enhancing social competence and healthy development (Mayer & Salovey, 1997). Emotions are a fundamentally adaptive resource because they involve a meaning system that informs people of the significance of events to their well-being, and they organise people for rapid adaptive action (Frijda, 1986; Izard, 1991; Oatley & Jenkins, 1992; Tomkins, 1963). From birth onward, emotion also is a primary signalling system that communicates intentions and regulates interaction (Sroufe, 1996). Emotion thus regulates self and other and gives life much of its meaning. With the advent of a view of emotion as an adaptive resource, the understanding of its relationship with cognition and its role in human functioning and psychotherapy has changed. This new look has begun to set a new agenda for psychological research-to determine the conditions under which emotions play a determining role in human experience and how this occurs. …

Client Uncertainty and the Process of Change in Psychotherapy: The Impact of Individual Differences in Self-concept Clarity and Intolerance of Uncertainty

We describe a number of ways in which two major components of client uncertainty, namely, self-concept clarity and intolerance of uncertainty may either facilitate or impede change in psychotherapy. Clients with low self-concept clarity find it much more difficult to clearly identify and understand their problematic thoughts, emotions, and behaviors; thus slowing down their progress through the various stages identified in Prochaska’s model of psychotherapeutic change. To illustrate, they may engage in much more contemplation prior to action, as they struggle to increase their awareness and insight. Clients with high intolerance of uncertainty experience substantial discomfort when faced with uncertainty, causing them to be highly motivated to avoid or minimize any aspects of psychotherapy that focus on change. This may cause them to avoid confronting their problems during the action stage of therapy. We further suggest that it would be beneficial to assess these two components of client uncertainty very early on in the therapeutic process, in order to facilitate a given client’s progress. Finally, we indicate a need for much more research that explores the role of these two individual difference constructs during therapy. This might include, for example, studies that directly examine how self-concept clarity and intolerance of uncertainty may relate to progress through each stage of change, or the selective use of avoidance strategies.

Modern Attachment Theory: The Central Role of Affect Regulation in Development and Treatment

Over the past decade attachment theory has undergone an intense expansion of both its original scientific foundations as well as its applications to clinical work. Bowlby’s original description occurred during a period of behaviorism and an emphasis on the strange situation and secure base behaviors, which then gave way to a dominance of cognition and an emphasis on attachment narratives and reflective capacities. We will argue that in line with Bowlby’s fundamental goal of the integration of psychological and biological models of human development, the current interest in affective bodily-based processes, interactive regulation, early experience-dependent brain maturation, stress, and nonconscious relational transactions has shifted attachment theory to a regulation theory. This emphasis on the right brain systems that underlie attachment and developmental change has in turn forged deeper connections with clinical models of psychotherapeutic change, all of which are consonant with psychoanalytic understandings. Modern attachment theory can thus be incorporated into the core of social work theory, research, and practice.

A qualitative investigation of eminent therapists' values within psychotherapy: Developing integrative principles for moment-to-moment psychotherapy practice.

Ample empirical research on values has demonstrated that clients’ values tend to become increasingly like those of their therapist during therapy. There is little research, however, on how therapists negotiate value conflicts and the role of values in therapy. In order to better understand this process, 14 expert psychotherapists from four major psychotherapy orientations were interviewed about their use of values in the psychotherapeutic change process. A grounded theory analysis was conducted leading to an integrative understanding of how expert therapists from different orientations conceptualize the relationship of values and change in therapy and how they work with values in sessions. Based on this analysis, four transtheoretical principles were generated that can be applied to training and practice and used to inform research on psychotherapy process and integration.

A guide to conducting a task analysis of psychotherapeutic change

The epistemological and methodological underpinnings of task analysis are discussed and the steps and concrete procedures for its implementation are described and exemplified in a task analysis of the resolution of unfinished business. Task analysis, a method for studying the process of change, consists of two main phases: a discovery-oriented phase based on rational–empirical model building and a validation phase based on hypothesis testing. The goals of the approach are to (a) build an observationally based model of how therapeutic change occurs for a particular type of affective–cognitive problem, (b) validate the model of change, and (c) relate the process of change to outcome. Benefits and strengths of the approach are presented and factors that have impeded the use of this approach in the study of change processes are discussed.

Measuring Transference Phenomena With fMri

Measuring Transference Phenomena With fMri

A Phenomenological Investigation of the Experience of Ambivalence

Ambivalence, broadly defined as feeling more than one emotion at a time, is thought to be a central aspect of human experience and to play an important role in a range of psychological processes. Ambivalence is experienced in close relationships, identity development, social and political attitudes, decision-making behavior, anxiety states, as well as in psychotherapeutic change. Eight undergraduate students participated in phenomenological interviews that were transcribed and served as the basis for the investigation. The primary purpose of this paper is to shed light on the meaning of the experience of ambivalence by explicating the organizational relationships of its constituent meanings. The paper will also clarify the relation of ambivalence to important psychological processes and developmental transitions during young adulthood.

Defining the neurocircuitry of borderline personality disorder: Functional neuroimaging approaches

Functional neuroimaging recently has been used to localize brain dysfunction in borderline personality disorder (BPD). Initial studies have examined baseline activity or emotional reactivity, and our group has investigated what we consider to be a crucial interaction between negative emotion and behavioral (dys)control. This research is beginning to identify abnormal frontolimbic circuitry likely underlying core clinical features of this condition. We review the evidence for dysfunction in specific frontolimbic regions, leading to a mechanistic model of symptom formation in BPD. In addition, we offer an integration of these neuroimaging findings with developmental perspectives on the emergence of borderline psychopathology, focusing on the ways in which early psychosocial experience may interact with developing brain systems. We also consider possible mechanisms of psychotherapeutic change at the neural systems level in BPD. Finally, we propose that future neuroimaging studies of BPD should integrate multiple levels of observation (structural, functional, neurochemical, genetic, and clinical) in a model-driven fashion to further understand the dynamic relationship between biological and psychological factors in the development and treatment of this difficult condition.

The “Something More” Than Interpretation Revisited: Sloppiness and Co-Creativity in the Psychoanalytic Encounter

Features of dynamical systems thinking can illuminate insufficiently recognized levels of psychoanalytic process. A central aspect of dynamical models is that changes in complex systems are unpredictable and arise out of the interaction of elements. Examination of the moment-by-moment micro-foreground, or local level, of psychoanalytic sessions led to the conclusion that indeterminacy and surprise are inherent properties of intersubjective systems. This indeterminacy, or sloppiness, comprises several interrelated features of the dialogue: "fuzzy" intentionalizing, unpredictability, improvisation, variation, and redundancy. Audiotaped transcripts of two analytic sessions illustrate how these sloppy features generate unpredictable and potentially creative elements that contribute to psychotherapeutic change.