Towards a taxonomy of common factors in psychotherapy-results of an expert survey

Nature heals: An informational entropy account of self-organization and change in field psychotherapy

This paper reviews biophysical models of psychotherapeutic change based on synergetics and the free energy principle. These models suggest that introducing sensory surprise into the patient-therapist system can lead to self-organization and the formation of new attractor states, disrupting entrenched patterns of thoughts, emotions, and behaviours. We propose that the therapist can facilitate this process by cultivating epistemic trust and modulating embodied attention to allow surprising affective states to enter shared awareness. Transient increases in free energy enable the update of generative models, expanding the range of experiences available within the patient-therapist phenomenal field. We hypothesize that patterns of disorganization at behavioural and physiological levels, indexed by increased entropy, complexity, and lower determinism, are key markers and predictors of psychotherapeutic gains. Future research should investigate how the therapist's openness to novelty shapes therapeutic outcomes.

Reward processes in extinction learning and applications to exposure therapy

Anxiety disorders are common and highly distressing mental health conditions. Exposure therapy is a gold-standard treatment for anxiety disorders. Mechanisms of Pavlovian fear learning, and particularly fear extinction, are central to exposure therapy. A growing body of evidence suggests an important role of reward processes during Pavlovian fear extinction. Nonetheless, predominant models of exposure therapy do not currently incorporate reward processes. Herein, we present a theoretical model of reward processes in relation to Pavlovian mechanisms of exposure therapy, including a focus on dopaminergic prediction error signaling, coinciding positive emotional experiences (i.e., relief), and unexpected positive outcomes. We then highlight avenues for further research and discuss potential strategies to leverage reward processes to maximize exposure therapy response, such as pre-exposure interventions to increase reward sensitivity or post-exposure rehearsal (e.g., savoring, imaginal recounting strategies) to enhance retrieval and retention of learned associations.

Therapeutic alliance in individual adult psychotherapy: a systematic review of conceptualizations and measures for face-to-face- and online-psychotherapy

Background

The therapeutic alliance (TA) is a robust and pantheoretical predictor of treatment outcome in Face-to-Face- (F2F-) and Online-psychotherapy (Online-PT). Many authors have proposed several conceptualizations of TA, which are oftentimes operationalized. The resulting diversity of conceptualizations and measures is presented in this review.

Methods

We performed a three-parted literature search for self-report-instruments of TA in individual, voluntary F2F-PT with adults (1. utilization of past reviews, 2. systematic literature search yielding 5,205 articles, 3. reference lists). Analogously, we conducted a systematic literature search for instruments of TA in the Online-setting (yielding 200 articles). Additionally, we analyzed the content of the instruments qualitatively.

Results

A current overview of 48 instruments for measuring TA (46 for F2F-PT, 2 for Online-PT) including their conceptual backgrounds, characteristics and main content aspects is presented. Most instruments (n = 24) operationalize one or more theoretical conceptualizations of TA. Other instruments are adaptation/syntheses of existing measures (n = 14), based on literature searches (n = 3) or on an empirical survey (n = 3) and two instruments provide no conceptual background information. The content of the instruments mainly focused on the following aspects: 1. Self-disclosure and authenticity; 2. Agreement; 3. Active participation, motivation and compliance; 4. Trust and secure attachment; and 5. Considering needs/abilities/wishes of the patient. Additionally, a narrative review of various approaches to conceptualize TA is presented and linked to respective corresponding instruments.

Discussion

The broad variety of conceptualizations and measures of TA makes coherent research on TA difficult. There are conceptual challenges such as the role of attachment style in TA that remain to be clarified. The current conceptualizations and measures do not incorporate the practical experience and expertise of psychotherapists and patients sufficiently. A metatheoretical conceptualization and measure of TA based on an empirical survey of psychotherapists and patients could address these issues.

Associations between therapists' verbal techniques and patient-rated therapeutic alliance, insight, and problem solving

OBJECTIVE

To investigate associations between common factors (alliance, insight, problem solving) and therapists' techniques. We expected a positive association between (1) supportive techniques and the alliance, (2) interpretative techniques and insight, and (3) a stronger association between interpretative techniques and insight for patients with more severe baseline symptoms. Other associations were analyzed in an exploratory way.

METHOD

Sixty sessions from 15 adult female patients diagnosed with personality disorder were analyzed using the Psychodynamic Interventions List (verbal techniques, observer-rated transcripts), and the Session Questionnaire for General and Differential Individual Psychotherapy (common factors, patient-rated after each session). Multilevel modeling was applied.

RESULTS

A greater use of supportive techniques was related to a higher therapeutic alliance (b = .28, 95% CI: .01-.55, p = .042). Neither the positive association between interpretative techniques and insight nor the moderating effect of baseline symptom severity could be confirmed. Exploratory analyses revealed associations between problem-solving and different verbal techniques.

CONCLUSION

Therapists' use of supportive techniques seems to influence the therapeutic alliance positively in patients with personality disorders. The effect of interpretative techniques might depend on other factors like patient characteristics. In general, there seem to be differential and specific associations between different therapists' verbal techniques and common factors.

"It takes time to see the whole picture": patients' views on improvement in cognitive behavioral therapy and psychodynamic therapy after three years

Introduction

There is a lack of qualitative research that retrospectively explores how patients with major depressive disorder view their improvement in psychotherapy.

Methods

Fifteen patients who received short-term cognitive behavioral therapy and psychodynamic therapy were individually interviewed approximately three years after completing therapy.

Results

Some patients had altered their views on therapy, especially those who initially were uncertain of how helpful therapy had been. They said they did not realize the extent and importance of their improvement in therapy before some time had passed, which can be explained by the surprising cumulative effects of seemingly small changes.

Discussion

This should make retrospective qualitative research an important part of future psychotherapy research.

Towards a taxonomy of mechanisms of change? Findings from an expert survey on the association between common factors and specific techniques in psychotherapy

OBJECTIVE

In the present study, we used structural equation modeling (SEM) to investigate the complex relationship between common factors, i.e., mechanisms of change, and specific factors, i.e., therapeutic techniques.

METHOD

N = 256 psychotherapy experts were asked to rate the appropriateness of 14 techniques commonly used in psychotherapy to facilitate five different common factors - resource activation, motivational clarification, self-management & emotion regulation, social competence, and therapeutic relationship. Using SEM, we defined techniques as indicators and common factors as latent variables. Data were split randomly into two subsets. Indicators were selected if three a priori defined criteria were met based on training data (n = 128). Subsequently, the goodness of model fit was assessed in the test data (n = 128).

RESULTS

The proposed model revealed adequate fit. All factor loadings were theoretically sound and significant in magnitude. Findings suggest that psychotherapy experts discriminate between common factors by their various associations with therapeutic techniques.

CONCLUSION

Suggestions are made, how therapeutic techniques are to be used to facilitate desirable change in the patient. Our model is a step towards a taxonomy of mechanisms of change that may help to improve research-informed decision-making.

Definition and Criteria for the Assessment of Expertise in Psychotherapy: Development of the Psychotherapy Expertise Questionnaire (PEQ)

Therapist expertise is a complex, multifaceted, and continually evolving concept. Defining this construct and its constituent components can yield a substantial contribution to the field of psychotherapy, consequently enhancing the comprehension of the fundamental factors that underlie its effectiveness. Within this framework, the present research aimed at developing and assessing the psychometric properties of the Psychotherapy Expertise Questionnaire (PEQ), a self-report measure to assess therapist expertise. A sample of 260 psychotherapists of various theoretical orientations were involved in this research. They completed a survey that included the PEQ as well as other self-reported measures aimed at evaluating personality traits, self-efficacy, self-esteem, and insight orientation. The analysis provided evidence of a good fit for both a correlational model with eight factors and a higher-order model, where the eight subdimensions were grouped into subjective (performance; cognitive functioning; personal and relational qualities of the therapist; therapist self-assessment) and objective (experience; reputation with clients and colleagues; training and professional updating; deontological ethics and setting rules) factors. The eight dimensions, two higher-order factors, and total score all showed excellent levels of internal consistency. Furthermore, significant associations were found between PEQ scores and insight orientation, general self-efficacy, self-esteem, personality traits, and time exercising clinical practice. To conclude, the Psychotherapy Expertise Questionnaire (PEQ) is a valuable, theoretically guided, and psychometrically robust self-report measure designed to assess therapist expertise and its constitutive dimensions. This measure can have practical applications in guiding tailored training and customised supervision.

Growth curves of common factors in psychotherapy: Multilevel growth modelling and outcome analysis

OBJECTIVE

A large body of literature discusses change mechanisms underlying psychotherapy with an emphasis on common factors. The present study examined how different comprehensive common factors change over the course of therapy and whether this change was associated with clinical outcome at discharge.

METHOD

Three hundred forty-eight adults (mean age = 32.1, SD = 10.6; 64% female) attended a standardized 14-week day-clinic psychotherapy program. They provided longitudinal data on common factors based on weekly assessments. Additionally, pre- and post-assessment questionnaires on clinical outcome were completed. Using multilevel modelling, we predicted common factors by time (week in therapy). Multiple linear regression models tested the association between changes in common factors and clinical outcome.

RESULTS

The common factor 'Therapeutic Alliance' was best fitted by linear growth models, whereas models for the common factors 'Coping', 'Cognitive Integration' and 'Affective Processing' indicated logarithmic changes over time. 'Coping', that is change in patients' ability to cope with their individual problems, was most closely linked with outcome.

CONCLUSIONS

The present study provides evidence for the changeability of common factors over the course of therapy as well as their specific contributions to psychotherapeutic progress.

Problem mastery and motivational clarification as mechanisms of change in cognitive-behavioral therapy for depression: Secondary analysis of a randomized controlled trial

OBJECTIVE

In process-outcome research, there is a growing body of literature investigating the therapeutic mechanisms underlying the promotion of positive change. This study investigated the between- and within-patient effects of problem mastery and motivational clarification on outcome in patients receiving two variations of cognitive therapies for depression.

METHODS

This study drew on data of a randomized controlled trial conducted at an outpatient clinic and included 140 patients randomly assigned to 22 sessions of either cognitive-behavioral therapy or exposure-based cognitive therapy. To address the nested structure of the data and analyze mechanism effects, we used multilevel dynamic structural equations models.

RESULTS

We found significant within-patient effects of both problem mastery and motivational clarification on subsequent outcome.

CONCLUSION

The results suggest that changes in problem mastery and motivational clarification precede symptom improvement during cognitive therapy for depressed patients and thus there may be benefit in fostering these putative mechanisms during psychotherapy.

Dyadic nonverbal synchrony during pre and post music therapy interventions and its relationship to self-reported therapy readiness

Nonverbal interpersonal synchronization has been established as an important factor in therapeutic relationships, and the differentiation of who leads the interaction appears to provide further important information. We investigated nonverbal synchrony - quantified as the coordination of body movement between patient and therapist. This was observed in music therapy dyads, while engaged in verbal interaction before and after a music intervention in the session. We further examined associations with patients' self-reported therapy readiness at the beginning of the session. Eleven neurological in-patients participated in this study. Our results showed an increase in both nonverbal synchrony and patient leading after the music intervention. A significant negative correlation was found between self-reported therapy readiness and nonverbal synchrony after the music intervention. These findings point to the empathic ability of the music therapist to sense patients' therapy readiness. Higher patient leading in nonverbal synchrony after the music intervention may thus indicate that the music intervention may have allowed dyadic entrainment to take place, potentially increasing self-regulation and thus empowering patients.

Wie wirkt das Miteinanderreden in Psychotherapien aus Sicht von Personen ohne Therapieerfahrung?

Hintergrund und Ziel

Das Miteinanderreden nimmt in Psychotherapien einen zentralen Raum ein – auch aus Sicht von Personen ohne Therapieerfahrungen. Es ist davon auszugehen, dass Personen ohne Therapieerfahrungen Ideen darüber entwickeln, auf welche Weise das therapeutische Miteinanderreden hilft. Diese Vorstellungen und Vorerwartungen können die therapeutische Interaktion in Psychotherapien beeinflussen. Um ein besseres Verständnis der Erwartungen an Prozesse in der Psychotherapie zu erhalten, soll untersucht werden, welches Bild sich Personen ohne Therapieerfahrungen vom Miteinanderreden in der Psychotherapie machen.

Material und Methode

Es handelt sich um eine „Mixed-methods“-Studie (qualitative Kategorienbildung mit anschließender quantitativer Häufigkeitsanalyse). An der querschnittlichen Onlineerhebung nahmen 225 Erwachsene ohne Therapie- oder Beratungserfahrung (Alter: Mittelwert [M] = 27,53 Jahre, Standardabweichung [SD] ± 9,93 Jahre, Range 19 bis 91 Jahre, Geschlecht: 207 weiblich, 18 männlich) teil. Neben soziodemografischen Daten wurden Antworten auf die offene Frage: „Wie und auf welche Art und Weise hilft das Miteinanderreden in der Psychotherapie?“ erhoben und inhaltsanalytisch ausgewertet.

Ergebnisse

Die Teilnehmer:innen erwarteten Wirksamkeit des Miteinanderredens in der Psychotherapie in Bezug auf die 4 Hauptkategorien 1) Therapeutische Beziehung erleben, 2) Erleichterung verschaffen, 3) Erkenntnis gewinnen sowie 4) Veränderungen ermöglichen. Jeder dieser Oberkategorien wurden eine bis 8 Subkategorien zugeordnet. Besonders häufig wurden die Subkategorien „von der Seele reden/Ballast loswerden“ und „Perspektivwechsel“ genannt.

Diskussion

Die vorliegenden Ergebnisse deuten auf hin, dass Personen ohne Psychotherapieerfahrung differenzierte und jeweils individuell unterschiedliche Annahmen darüber haben, wie das Miteinanderreden in der Psychotherapie heilen kann. Ein Austausch darüber, mit welchen diesbezüglichen Erwartungen Patient:innen in eine Psychotherapie kommen, kann hilfreich sein.

[Empirical Conceptualization of Common Factors in Psychotherapy: Factor Structure of the WEB]

OBJECTIVE

Our goal was to explore the association pattern of 26 common factors and thereby contribute conceptually to the debate on change mechanisms in psychotherapy with an empirically derived conception of superordinate common factors (global common factors). In addition, we tested reliability and validity aspects of a new instrument to assess common factors.

METHOD

The activation of common factors during in- and outpatient psychotherapy was assessed in 502 patients using a weekly process measure ('Wochenerfahrungsbogen', WEB). The factor structure of the WEB was determined by exploratory factor analysis and verified by confirmatory factor analyses.

RESULTS

The four factors Coping, Therapeutic Alliance, Cognitive Integration, and Affective Processing accounted for 59.8 % of the total variance. Subsequent confirmatory factor analyses, using in- and outpatient samples, confirmed this structure.

CONCLUSIONS

The study provided an empirically based integrative categorisation of common factors. Results on reliability (internal consistency) and construct validity indicate that the WEB is an appropriate measurement instrument to investigate global common factors.

Clients' and therapists' experiences of five general change mechanisms during an Internet-based cognitive behavioral intervention for family caregivers

OBJECTIVES

Despite its efficacy, little is known about what makes Internet-based cognitive behavioral therapy (iCBT) effective. We, therefore, analyze participants' and therapists' experiences of Grawe's five general change mechanisms (alliance, resource activation, clarification, problem actuation, mastery) during an iCBT intervention for family dementia caregivers, and how their experiences were related to treatment outcomes.

METHOD

Participants (N = 30) exchanged eight weekly messages with a therapist via an Internet platform. We used the Bern Post Session Report to assess participants' and therapists' experiences of the general change mechanisms after each session.

RESULTS

Treatment outcomes were associated with therapists' overall experiences of alliance, clarification, and mastery. Participants experienced more problem actuation than therapists. Only participants' and therapists' experiences of clarification over time differed.

CONCLUSIONS

Grawe's general change mechanisms are also relevant for iCBT. We recommend considering Grawe's framework when designing Internet-based therapeutic interventions and when training therapists to deliver such interventions.

It's the therapist and the treatment: The structure of common therapeutic relationship factors

Objective: Prior research has established that common therapeutic relationship factors are potent predictors of change in psychotherapy, but such factors are typically studied one at a time and their underlying structure when studied simultaneously is not clear. We assembled empirically validated relationship factors (e.g., therapist empathy; patient expectations; agreement about goals) into a single instrument and subjected it to factor analysis. Method: The instrument was applied to patients (N = 332) undergoing intensive psychotherapy of different types for depressive disorders, anxiety disorders, eating disorders, and childhood trauma in an inpatient specialized mental health setting. In order to examine the psychometric properties of the scale, we used half the sample (N=164) to conduct exploratory factor analysis (EFA) and parallel analysis before we tested the solution using exploratory structural equation modeling (ESEM) on the second half of the sample (N=168). Measurement invariance analysis was conducted to examine the stability of the factor structure. Results: The analysis yielded two factors, which were termed 1. "Confidence in the therapist" and 2. "Confidence in the treatment." Discussion: When assessed simultaneously, patients differentiate between their evaluation of the therapist and of the treatment. The results indicate that there is substantial overlap among previously established relationship factors.Trial registration: ClinicalTrials.gov identifier: NCT03503981.

[Functions of language in psychotherapy: A qualitative study of psychotherapists' subjective theories of the "talking cure"]

Functions of language in psychotherapy: A qualitative study of psychotherapists' subjective theories of the "talking cure" Objectives: Psychotherapy is traditionally considered as a "talking cure". The specific functions of verbal activity, however, are disputed. The present study aims at identifying central therapeutic functions of verbal activity. Methods: In qualitative interviews n = 23 psychotherapists with psychodynamic (n = 12) or behavioral (n = 11) background were interviewed regarding their theories of the "talking cure." Based on Consensual Qualitative Research (CQR) a category system of therapeutic functions of verbal activity was constructed. Results: The participants described a wide range of relational, experiential, and behavioral functions of verbal activity in psychotherapy. Psychodynamic therapists emphasized relational and experiential functions of verbal activity, while behavioral therapists emphasized behavioral functions. Conclusions: The findings imply that verbal activity fulfills diverse functions in therapeutic contexts. This suggests a basic verbal materiality of many therapeutic techniques and common factors that needs to be specified in subsequent research.

Common Factors in Biofeedback Administered by Psychotherapists

Common factors are nonspecific therapeutic elements common across different varieties of psychotherapy. In a recent study, 68 expert psychotherapy researchers with a variety of allegiances collectively rated biofeedback as being negatively associated with many common factors (Tschacher et al. in Clin Psychol Psychother 21(1):82-96, 2014), including the therapeutic alliance. However, it seems implausible that biofeedback could benefit so many people while being incompatible with the therapeutic alliance and other common factors. The present study investigated the experiences of biofeedback clients who participated in a brief heart rate variability biofeedback protocol in order to explore the potential roles of common factors in biofeedback. The results of this study offer preliminary evidence that many common factors-including therapeutic alliance, self-efficacy expectation, mastery experiences, provision of explanatory scheme, mindfulness, and even cognitive restructuring-may play a role in biofeedback outcomes. Future research on this topic should include mediation and moderation models investigating the role of specific common factors on outcome and process studies to help determine what clinician behaviors are most helpful. Deeper investigation of common factors in biofeedback may benefit future biofeedback research and practice and address the concerns of colleagues outside of the biofeedback community who believe that biofeedback is at odds with common factors.

Delivering tele-chairwork: A qualitative survey of expert therapists

Objective: Recent years have seen a significant and rapid increase in the provision of tele-therapies. Chairwork methods such as empty-chair dialogues and role-play represent a "common" category of therapeutic interventions which are utilized in many psychotherapeutic approaches. However, guidelines for facilitating chairwork in tele-therapy are currently lacking. The aim of this study was to survey expert providers regarding how chairwork is best provided in internet-delivered psychotherapy.Method: Forty one experts were recruited from a range of therapeutic backgrounds including cognitive behaviour therapy, compassion focused therapy, emotion focused therapy, psychodrama, schema therapy, and voice dialogue. Participants completed a brief questionnaire survey exploring the delivery of tele-chairwork. Responses were analysed using thematic analysis.Results: Five themes were identified: (i) divided opinion; (ii) convergence between therapy and home; (iii) disconnection and depth; (iv) practical impediments and benefits; and (v) revising and re-visioning chairwork. Overall, results indicate that chairwork can be successfully incorporated into tele-therapy, but requires adaption and special considerations.Discussion: Despite challenges, tele-chairwork appears to be a feasible method of psychotherapeutic intervention. Preliminary guidelines for initiating, facilitating, and concluding tele-chairwork are presented, alongside future directions for research.

Mediators and mechanisms of change in internet- and mobile-based interventions for depression: A systematic review

The efficacy of Internet- and mobile-based interventions (IMIs) for depression in adults is well established. Yet, comprehensive knowledge on the mediators responsible for therapeutic change in these interventions is pending. Therefore, we conducted the first systematic review on mediators in IMIs for depression, investigating mechanisms of change in interventions with different theoretical backgrounds and delivery modes (PROSPERO CRD42019130301). Two independent reviewers screened references from five databases (i.e., Cochrane Library, Embase, MEDLINE/PubMed, PsycINFO and ICTRP), selected studies for inclusion and extracted data from eligible studies. We included 26 RCTs on mediators in IMIs for depression (6820 participants), rated their risk of bias and adherence to methodological quality criteria for psychotherapy process research. Primary studies examined 64 mediators, with cognitive variables (e.g., perceived control, rumination or interpretation bias) being the largest group of both examined (m = 28) and significant mediators (m = 22); followed by a range of other mediators, including mindfulness, acceptance and behavioral activation. Our findings might contribute to the empirically-informed advancement of interventions and mental health care practices, enabling optimized treatment outcomes for patients with depression. Furthermore, we discuss implications for future research and provide methodological recommendations for forthcoming mediation studies with more pertinent designs, allowing for inferences with higher causal specificity.

Differential and shared effects of psychological skills training and mindfulness training on performance-relevant psychological factors in sport: a randomized controlled trial

BACKGROUND

Mental training intends to support athletes in mastering challenges in sport. The aim of our study was to investigate the differential and shared effects of psychological skills training and mindfulness training on psychological variables relevant to athletic performance (e.g., handling emotions or attention control). We assumed that each approach has its own strengths (e.g., mindfulness has a differential effect on the acceptance of emotions), but for some goals (e.g., attention control), both training forms are expected to be equally successful (i.e., shared effects).

METHODS

A total of 95 athletes (Mage = 24.43, SDage = 5.15; 49% female) were randomly assigned into three groups: psychological skills training intervention (PST), mindfulness training intervention (MT), and wait-list control group (WL). Participants completed a questionnaire battery before and after the training (pretest and posttest). We assessed mindfulness, use of mental strategies, handling of emotions, attention in training and competition, as well as the dealing with failure. The two intervention programs each consisted of four 90-min group workshops conducted over a period of 4 weeks.

RESULTS

Both interventions passed the manipulation check, that is, PST led to more mental strategies being used (probabilities > 95%), and MT led to an increase in two of three aspects of mindfulness (probabilities > 98%) when compared to WL. Compared to WL, both interventions equally improved in the ability to not let emotions interfere with performance (probabilities > 99%) and in controlling attention in training and competition (probabilities > 89%). To a lesser extend, both interventions showed shared improvements in dealing with failure indicated by more action orientation (probabilities > 82%). We found a differential effect of MT on decreased experiential avoidance: MT decreased compared to WL and PST (probabilities > 92%), whereas PST did not differ from WL.

CONCLUSION

We conclude that both forms of mental training lead to improvements in performance-relevant psychological factors, especially concerning the handling of emotions and attention control. The results of our study suggest that different paths may lead to the desired outcomes, and accordingly, both forms of mental training seem justified.

TRIAL REGISTRATION NUMBER

ISRCTN11147748 , date of registration: July 11, 2016.

Building an Expanded Therapeutic Alliance: A Task Analysis with Families Trapped in Parental-Adolescent Conflict

Parental-adolescent conflict is part of the normal developmental cycle of families, but when it occurs in a dysfunctional way, it is associated with the appearance of various harmful conditions for the family system and for the adolescent in particular. Family therapy is one of the main options for psychotherapeutic intervention in these cases and has ample evidence of its effectiveness. The success of this intervention is conditioned to the construction of an adequate therapeutic alliance with the family, but the process of this task has not been clarified yet. The present study is a task analysis, the purpose of which was to create a heuristic model of how an expanded alliance may be built in these kinds of cases. The model was revised and improved from the intensive analysis of six cases. The resulting model can be a useful guide for family therapists in that it describes the specific client and therapist behaviors involved in balancing the alliance, as well as the potential obstacles and suggested ways to resolve them.

Wie kann Reden heilen? Zur Sprache in der Psychotherapie

Psychotherapie gilt traditionell als „talking cure“, als Heilverfahren also, das wesentlich über Sprache operiert. Unklar ist allerdings, was diese Zuschreibung konkret bedeutet, insofern die therapeutische Wirkung von Sprache unterschiedlich expliziert wurde. Vor diesem Hintergrund rekonstruiert diese Studie zentrale Ansätze, die die „talking cure“ in Termini von 1. Katharsis, 2. Symbolisierung, 3. Metaphern, 4. verbalen Interventionen und 5. Narrativen beschreiben, und diskutiert diese im Hinblick auf Befunde der Psychotherapieforschung. Im Resultat ergibt sich ein komplexes Bild disparater theoretischer Zugriffe, die in der Grundannahme konvergieren, das therapeutische Potenzial von Sprache in ihrer Möglichkeit zur Explikation beziehungsweise zur Modifikation pathologisch-maladaptiver Erlebens- und Erfahrungskonstellationen zu sehen. Die empirische Befundlage bezüglich dieser Ansätze ist heterogen: Die meisten Typen verbaler Aktivität zeigen unklare Assoziationen mit dem Behandlungserfolg. Konsistenter sind Zusammenhänge mit Prozessvariablen, wobei spezifische Prozesse von unterschiedlichen verbalen Aktivitäten evoziert werden können (zum Beispiel Verstehen durch Übertragungsdeutungen, Selbstoffenbarungen, Metaphern oder Narrative). Weiterhin wurde gezeigt, dass verbale Aktivität auch negative Effekte haben kann. Insgesamt legen diese Befunde eine integrative Sicht auf die Sprache im Sinne eines Sets sprachinduzierter veränderungsrelevanter Prozesse nahe, deren heilsame Wirkung im Kontext eines umfassenden Beziehungsgeschehens zu betrachten ist und dabei komplexen Randbedingungen unterliegt, die zu präzisieren und systematisieren ein wichtiges Desiderat der Psychotherapieforschung darstellt.

The Effect of Career Counselor Behavior on Reemployment

When looking at career interventions, one-on-one career counseling is one of the most effective and firmly established types of intervention. Furthermore, career counseling process quality has been validated as a predictor of job seekers’ reemployment. To elucidate the underlying components of a high-quality counseling process, the effects of counselor behavior in mandatory counseling sessions at three Swiss job centers are investigated. Based on a transfer of psychotherapeutic effectiveness research into the domain of career counseling, three behavior categories are proposed as components of a high-quality counseling process: providing structured guidance during the counseling process, providing personalized support, and activating job seekers’ resources. Scientific observers rated these counselor behavior categories in 32 counseling sessions. The ratings of “providing structured guidance” predicted job seekers’ reemployment speed at a correlation of .58. The measured effect equals yearly savings of 831 million Swiss Francs CHF (US$839) in Swiss unemployment benefits. The correlations with the other two behavior category ratings were in the same direction but nonsignificant.

Common Factors: What Are They and What Do They Mean for Humanistic Psychology?

Although common factors have been widely discussed in the clinical literature, the two questions addressed in this article remain relevant: (a) What are the common factors? (b) What do they mean for humanistic psychology? The first question is important because there is no “definitive list” of common factors, and lists presented in the literature often differ dramatically. In response to this question, the article suggests that an evidence-based list of nine common factors by Wampold provides a useful and credible list. The second question is also important, particularly to humanistic psychologists. Among other answers, the article shows that research findings on common factors provide scientific support for humanistic psychology’s emphasis on the importance of the human and relational factors in psychotherapy.

Early developments in general change mechanisms predict reliable improvement in addition to early symptom trajectories in cognitive behavioral therapy

General change mechanisms (GCMs) have been shown to predict treatment outcome in cognitive behavioral therapy (CBT). Early changes in GCMs (early-change-GCMs) and in symptom severity were also linked to treatment outcome, but evidence is still limited. We investigated whether early-change-GCMs from patients' and therapists' perspectives in addition to early changes in symptom severity predict treatment outcome. Data from a university-based outpatient clinic was analyzed (N = 911 completers). Most treatments were provided by therapists in CBT training. Outcomes were symptom severity and life satisfaction. Continuous post-treatment scores and categories of reliable improvement (improved vs. not improved) were investigated. Some patient-rated early-change-GCMs and early changes in symptom severity proved to be predictors for continuous outcomes (p < .05) in symptom severity and life satisfaction. In addition, some patient-rated early-change-GCMs predicted reliable improvement in life satisfaction. By contrast, therapist-rated early-change-GCMs and early symptom severity change predicted reliable improvement in symptom severity. Early-change-GCMs explained between two and four percent additional variance in outcomes. Thus, it is important to consider early changes in GCMs in addition to early changes in symptom severity in routine monitoring.

A design for process-outcome psychotherapy research in adolescents with Borderline Personality Pathology

Underage patients with Borderline Personality Pathology (BPP) are in need of specialised psychotherapeutic treatment. A handful of these treatments, including Adolescent Identity Treatment (AIT) and Dialectical Behavior Therapy for Adolescents (DBT-A), have been adapted for adolescent patients. Psychotherapy research has shown that the outcome of different psychotherapeutic approaches can be very similar despite conceptual and practical differences between the theoretical models. Therefore, to understand what really works in psychotherapy, it is necessary to investigate the psychotherapeutic process and its effects on the patient. This paper presents a study design for process-outcome research, integrating (1) a classical outcome design, comparing AIT and DBT-A in a non-inferiority trial assessing changes in psychosocial functioning at 12 months after baseline as primary outcome; and (2) a process research design, addressing multiple BPP and psychotherapy relevant factors. These factors include well-studied generic variables such as the psychotherapeutic alliance, more recent approaches such as video-based identification of significant therapeutic events, as well as more experimental approaches such as psychophysiological markers measured during the therapeutic sessions. The use of repeated measures and the methodological pluralism which includes event and micro-process analyses has been recommended for psychotherapy research aiming at a better understanding of the interplay of factors at work to narrow the gap between research and practice in this field.

The change process in adult anorexia nervosa inpatient treatment: a path model

PURPOSE

Knowledge on the change process in the treatment of anorexia nervosa (AN) is an important starting point for the improvement of treatment, yet very little evidence exists. In an exploratory analysis, we aimed to investigate the interdependencies between higher-rank change process factors, BMI and AN-specific cognitions and behaviours over the course of inpatient treatment.

METHODS

We included 176 female adult AN inpatients from three specialized centres. The temporal interdependencies between the change factors and the outcome variables over the course of treatment (t0: beginning, t1: mid-treatment, t2: end) were investigated using a path model.

RESULTS

The sample had a mean age of 27.1 years (SD = 8.9 years) and a mean BMI at admission of 15.0 kg/m² (SD = 1.6 kg/m²). A greater basic need satisfaction and a greater emotional involvement and commitment to treatment at t0 positively influenced the BMI at t1. Furthermore, greater basic need satisfaction at t0 led to less AN-specific cognitions and behaviours at t2.

CONCLUSIONS

The results are discussed with respect to the self-determination theory and the consistency theory. Further research on the change process in AN treatment is recommended.

Embodied Cognition and the Direct Induction of Affect as a Compliment to Cognitive Behavioural Therapy

We make the case for the possible integration of affect experience induced via embodiment techniques with CBT for the treatment of emotional disorders in clinical settings. Theoretically we propose a possible integration of cognitive behavioural theory, neuroscience, embodied cognition and important processes of client change outcomes such as the therapeutic alliance to enhance client outcomes. We draw from evidence of bidirectional effects between embodiment modes of bottom-up (sensory-motor simulations giving rise to important basis of knowledge) and top-down (abstract mental representations of knowledge) processes such as CBT in psychotherapy. The paper first describes the dominance and success of CBT for the treatment of a wide range of clinical disorders. Some limitations of CBT, particularly for depression are also outlined. There is a growing body of evidence for the added value of experiential affect-focused interventions combined with CBT. Evidence for the embodied model of cognition and emotion is reviewed. Advantages of embodiment is highlighted as a complimentary process model to deepen the intensity and valence of affective experience. It is suggested that an integrated embodiment approach with CBT enhances outcomes across a wide range of emotional disorders. A description of our embodiment method integrated with CBT for inducing affective experience, emotional regulation, acceptance of unwanted emotions and emotional mastery is given. Finally, the paper highlights the importance of the therapeutic alliance as a critical component of the change process. The paper ends with a case study highlighting some clinical strategies that may aid the therapist to integrate embodiment techniques in CBT that can further explore in future research on affective experience in CBT for a wider range of clinical disorders.

Patients' and therapists' experiences of general change mechanisms during bug-in-the-eye and delayed video-based supervised cognitive-behavioral therapy. A randomized controlled trial

OBJECTIVE

This secondary analysis of a randomized controlled trial investigated whether bug-in-the-eye (BITE) supervision (live computer-based supervision during a psychotherapy session) affects the manner in which patients and therapists experience general change mechanisms (GCMs) during cognitive-behavioral therapy (CBT).

METHOD

A total of 23 therapists were randomized either to the BITE condition or the control condition (delayed video-based [DVB] supervision). After each session, both patients (BITE: n = 19; DVB: n = 23) and therapists (BITE: n = 11; DVB: n = 12) completed the Helping Alliance Questionnaire (HAQ) and the Bernese Post Session Report (BPSR). The HAQ total score and the 3 secondary factors of the BPSR (interpersonal experiences, intrapersonal experiences, problem actuation) functioned as GCMs. Multilevel models were performed.

RESULTS

For patients, GCMs did not develop differently between BITE and DVB during CBT. Therapists rated the alliance as well as interpersonal and intrapersonal experiences not significantly different between BITE and DVB during CBT, but they perceived problem actuation to increase significantly more in BITE than in DVB (p < .05).

CONCLUSION

BITE supervision might be helpful in encouraging CBT therapists to apply interventions, which focus on the activation of relevant problems and related emotions.

Talking Cure Models: A Framework of Analysis

Psychotherapy is commonly described as a "talking cure," a treatment method that operates through linguistic action and interaction. The operative specifics of therapeutic language use, however, are insufficiently understood, mainly due to a multitude of disparate approaches that advance different notions of what "talking" means and what "cure" implies in the respective context. Accordingly, a clarification of the basic theoretical structure of "talking cure models," i.e., models that describe therapeutic processes with a focus on language use, is a desideratum of language-oriented psychotherapy research. Against this background the present paper suggests a theoretical framework of analysis which distinguishes four basic components of "talking cure models": (1) a foundational theory (which suggests how linguistic activity can affect and transform human experience), (2) an experiential problem state (which defines the problem or pathology of the patient), (3) a curative linguistic activity (which defines linguistic activities that are supposed to effectuate a curative transformation of the experiential problem state), and (4) a change mechanism (which defines the processes and effects involved in such transformations). The purpose of the framework is to establish a terminological foundation that allows for systematically reconstructing basic properties and operative mechanisms of "talking cure models." To demonstrate the applicability and utility of the framework, five distinct "talking cure models" which spell out the details of curative "talking" processes in terms of (1) catharsis, (2) symbolization, (3) narrative, (4) metaphor, and (5) neurocognitive inhibition are introduced and discussed in terms of the framework components. In summary, we hope that our framework will prove useful for the objective of clarifying the theoretical underpinnings of language-oriented psychotherapy research and help to establish a more comprehensive understanding of how curative language use contributes to the process of therapeutic change.

Was hilft, was wirkt?

Zusammenfassung. Was bewirkt Tanz- und Bewegungstherapie? Auf welche gesundheitsrelevanten Aspekte wirkt sie? Und vor allem: Wie wirkt sie? Was genau hilft? Auf der Grundlage eines Überblicks über Effektivitätsstudien der Tanz- und Bewegungstherapie (DMT), der deutlich macht, für welche Patientengruppen Tanztherapie bereits evidenzbasiert als wirksam getestet wurde, wendet sich der Artikel der Wirkweise der Tanztherapie zu, die noch weitgehend unerforscht ist. Zu dieser Wirkweise gehören generelle Wirkfaktoren, die für alle Psychotherapien gelten, Mechanismen, die für alle Künstlerischen Therapien gelten (von denen die Tanztherapie ein Teil ist), Mechanismen, die für alle Körperpsychotherapien gelten (von denen die Tanztherapie ebenfalls ein Teil ist); und spezifische Wirkfaktoren, die nur für die Tanztherapie gelten. Auf der Grundlage eines Überblicks differentieller Indikationen, und unter Einbezug existierender Theorien und der wenigen vorliegenden empirischen Ergebnisse werden Wirkfaktoren und Wirkweisen der Tanz- und Bewegungstherapie diskutiert und in ein Theoriemodell der Verkörperten Ästhetik eingebettet, das für alle Künstlerischen Therapien entwickelt wurde, und auch für die Körperpsychotherapien einen sinnvollen Rahmen bietet. Das Modell legt die Zirkularität von „Merken“ (Impression, Bewegt sein, Kinästhetik) und „Wirken“ (Expression, Bewegen, Kinetik) zugrunde, betont die aktive Seite des „Kunst-Schaffens“, und erlaubt die Ableitung und Überprüfung von Hypothesen zu angenommenen Wirkfaktoren. Schließlich werden die spezifischen Wirkfaktoren der Tanztherapie herausgearbeitet und diskutiert.

Quality of Life in Persons with Schizophrenia

Not available

Moderating Effects of Alexithymia on Associations between the Therapeutic Alliance and the Outcome of Brief Psychodynamic-Interpersonal Psychotherapy for Multisomatoform Disorder

This secondary analysis of a trial on brief psychodynamic-interpersonal therapy (PIT) for patients with multisomatoform disorder investigated whether alexithymia moderates the associations between the therapeutic alliance and the outcome of PIT and whether moderating effects of alexithymia remain significant when controlling for depression. Eighty-three patients with multisomatoform disorder receiving PIT were statistically analyzed. Moderation analyses were performed with the SPSS macro PROCESS. The primary outcome (Y), self-reported physical quality of life at 9-month after the end of PIT, was measured with the physical component summary (PCS) of the SF-36 Health Survey. The potential moderator (M) alexithymia was operationalized with the Toronto Alexithymia Scale (TAS-20) at pre-treatment and the predictor (X) the therapeutic alliance was rated by both patients and therapists via the Helping Alliance Questionnaire (HAQ) at the end of PIT. Moreover, the PCS at pre-treatment functioned as covariate in all moderation models. When the patients' alliance ratings were analyzed, alexithymia did not moderate associations between the alliance and the outcome. When the therapists' alliance ratings were evaluated, alexithymia moderated the relationship between the alliance and the outcome (p < 0.05): a stronger alliance in the therapists' perspective was beneficial for the outcome only for patients scoring above 61 on the TAS-20. This moderating effect of alexithymia was, however, not statistically significant anymore when adding the pre-treatment depression scores (PHQ-9) as a covariate to the moderation model. The results underline the importance of a good therapists' view of the alliance when treating alexithymic patients and highlight the complex interaction between alexithymia and depression. Future studies are needed to extend the scope of research regarding which psychotherapeutic mechanisms of change are beneficial for which patients.

Synchrony in Psychotherapy: A Review and an Integrative Framework for the Therapeutic Alliance

During psychotherapy, patient and therapist tend to spontaneously synchronize their vocal pitch, bodily movements, and even their physiological processes. In the present article, we consider how this pervasive phenomenon may shed new light on the therapeutic relationship- or alliance- and its role within psychotherapy. We first review clinical research on the alliance and the multidisciplinary area of interpersonal synchrony. We then integrate both literatures in the Interpersonal Synchrony (In-Sync) model of psychotherapy. According to the model, the alliance is grounded in the coupling of patient and therapist's brains. Because brains do not interact directly, movement synchrony may help to establish inter-brain coupling. Inter-brain coupling may provide patient and therapist with access to another's internal states, which facilitates common understanding and emotional sharing. Over time, these interpersonal exchanges may improve patients' emotion-regulatory capacities and related therapeutic outcomes. We discuss the empirical assessment of interpersonal synchrony and review preliminary research on synchrony in psychotherapy. Finally, we summarize our main conclusions and consider the broader implications of viewing psychotherapy as the product of two interacting brains.

Transactional Experiences of Existential Anxiety as a Barrier to Effective Humanistic Intervention

There are some who criticize mainstream mental health approaches and point out that individuals in distress appear to be getting worse, as opposed to better, while in treatment. Ex-patients often advocate for a person-centered, humanistic approach to working with emotional distress, while clinicians tend to offer a disease-based, deficit-focused model. This article is an exploration of the dynamics between patients and professionals that may be contributing to conflicting perspectives on what constitutes helpful intervention. Specifically, concepts of terror management theory are used to explore how the existential anxieties experienced both by individuals with serious emotional difficulties as well as their treating clinicians, which are consciously or unconsciously avoided in treatment, can reciprocally trigger distressing anxiety in the other. Suggestions are offered as to what could help mitigate this existential stalemate in the psychotherapeutic context.

Klassen allgemeiner Wirkfaktoren der Psychotherapie und ihr Zusammenhang mit Therapietechniken

Zusammenfassung. Theoretischer Hintergrund: Bis heute wird die Frage, welche Faktoren für die Wirkung von Psychotherapie verantwortlich sind, kontrovers diskutiert. Im Zentrum dieser Diskussion stehen zwei vermeintlich gegensätzliche Wirkmodelle – das Modell spezifisch wirksamer Therapietechniken und das allgemeine Wirkfaktorenmodell. Allgemeine Wirkfaktoren und Therapietechniken sind konzeptuell jedoch auf unterschiedlichen Ebenen des Psychotherapieprozesses angesiedelt. An Stelle der Entweder-oder-Debatte sollte deshalb die Analyse ihres Zusammenwirkens in den Vordergrund rücken. Fragestellung: Mit Hilfe von Expertenratings wurde untersucht, ob sich verschiedene allgemeine Wirkfaktoren durch typische Zusammenhänge mit bestimmten Therapietechniken zu übergeordneten Klassen zusammenfassen lassen. Methode: 68 deutschsprachige Psychotherapieexperten schätzten in einer internetbasierten Umfrage ein, mit welchen spezifischen Therapietechniken verschiedene allgemeine Wirkfaktoren zusammenhängen. Mittels Faktorenanalyse wurde dann geprüft, welche Klassen von allgemeinen Wirkfaktoren sich durch bestimmte Muster von Technikzusammenhängen abbilden. Durch eine hierarchische Regressionsanalyse wurden zudem die Stärke und Richtung der Zusammenhänge zwischen einzelnen Wirkfaktorenklassen und den verschiedenen Techniken untersucht. Ergebnisse: Die Faktorenanalyse zeigt, dass den Zusammenhängen zwischen allgemeinen Wirkfaktoren und Techniken eine vierdimensionale Struktur unterliegt. Die vier Klassen von allgemeinen Wirkfaktoren hängen jeweils mit einer bestimmten Gruppe von Therapietechniken zusammen. Schlussfolgerungen: Die Vielzahl allgemeiner Wirkfaktoren lässt sich mittels ihrer Operationalisierung durch Therapietechniken zusammenfassen.

Measuring Verbal Psychotherapeutic Techniques-A Systematic Review of Intervention Characteristics and Measures

Language is one of the most important “tools” of psychotherapists. The working mechanisms of verbal therapeutic techniques, however, are still marginally understood. In part, this is due to the lack of a generally acknowledged typology as well as a gold standard for the assessment of verbal techniques, which limits the possibility of conducting studies focusing this topic. The present study reviews measures used in clinical research which assess directly observable dimensions of verbal interventions in a reliable manner. All measures were evaluated with respect to their theoretical foundation, research goals, assessment modes, and various psychometric properties. A systematic search in databases (PubMed, PsycInfo, PsycArticles, PSYNDEX, Web of Science, Embase) followed by an additional “snowballing” search covering the years 1940–2013 yielded n = 179 publications eligible for review. Within these publications, 34 measures were identified showing great heterogeneity regarding the aspects under study. Only two measures reached the highest psychometric standards and can be recommended for clinical use without any reservation. Central problems include deficiencies in the systematization of techniques as well as their partly ambiguous and inconsistent definitions. To promote this field of research, it will be important to achieve a consensus concerning the terminology, conceptions and measures of verbal interventions.

A Meta-Analytic Review of Stand-Alone Interventions to Improve Body Image

OBJECTIVE

Numerous stand-alone interventions to improve body image have been developed. The present review used meta-analysis to estimate the effectiveness of such interventions, and to identify the specific change techniques that lead to improvement in body image.

METHODS

The inclusion criteria were that (a) the intervention was stand-alone (i.e., solely focused on improving body image), (b) a control group was used, (c) participants were randomly assigned to conditions, and (d) at least one pretest and one posttest measure of body image was taken. Effect sizes were meta-analysed and moderator analyses were conducted. A taxonomy of 48 change techniques used in interventions targeted at body image was developed; all interventions were coded using this taxonomy.

RESULTS

The literature search identified 62 tests of interventions (N = 3,846). Interventions produced a small-to-medium improvement in body image (d+ = 0.38), a small-to-medium reduction in beauty ideal internalisation (d+ = -0.37), and a large reduction in social comparison tendencies (d+ = -0.72). However, the effect size for body image was inflated by bias both within and across studies, and was reliable but of small magnitude once corrections for bias were applied. Effect sizes for the other outcomes were no longer reliable once corrections for bias were applied. Several features of the sample, intervention, and methodology moderated intervention effects. Twelve change techniques were associated with improvements in body image, and three techniques were contra-indicated.

CONCLUSIONS

The findings show that interventions engender only small improvements in body image, and underline the need for large-scale, high-quality trials in this area. The review identifies effective techniques that could be deployed in future interventions.

Analysing and reporting UK CAMHS outcomes: an application of funnel plots

BACKGROUND

Patient-reported outcomes measures are increasingly being used in child and adolescent mental health services (CAMHS). League tables are a common way of comparing organizations across health and education but have limitations that are not well known in CAMHS.

METHOD

Parent-rated Strengths and Difficulties Questionnaire (SDQ) outcomes data from 15,771 episodes of care across 51 UK CAMHS were analysed using funnel plots, an alternative to league tables.

RESULTS

While most services were indistinguishable from the national average there was evidence of heterogeneous outcomes and seven services had outcomes below 99.9% limits for SDQ added-value scores.

CONCLUSIONS

Funnel plots are powerful tools for navigating national data and can help prompt investigations using clinical theory and local service context. Examples are provided of factors to consider in these investigations. We argue that analyses of the local context are central to the valid application of funnel plots.

Alliance: a common factor of psychotherapy modeled by structural theory

There is broad consensus that the therapeutic alliance constitutes a core common factor for all modalities of psychotherapy. Meta-analyses corroborated that alliance, as it emerges from therapeutic process, is a significant predictor of therapy outcome. Psychotherapy process is traditionally described and explored using two categorically different approaches, the experiential (first-person) perspective and the behavioral (third-person) perspective. We propose to add to this duality a third, structural approach. Dynamical systems theory and synergetics on the one hand and enactivist theory on the other together can provide this structural approach, which contributes in specific ways to a clarification of the alliance factor. Systems theory offers concepts and tools for the modeling of the individual self and, building on this, of alliance processes. In the enactive perspective, the self is conceived as a socially enacted autonomous system that strives to maintain identity by observing a two-fold goal: to exist as an individual self in its own right (distinction) while also being open to others (participation). Using this conceptualization, we formalized the therapeutic alliance as a phase space whose potential minima (attractors) can be shifted by the therapist to approximate therapy goals. This mathematical formalization is derived from probability theory and synergetics. We draw the conclusion that structural theory provides powerful tools for the modeling of how therapeutic change is staged by the formation, utilization, and dissolution of the therapeutic alliance. In addition, we point out novel testable hypotheses and future applications.

Placebo eff ects in psychiatry: mediators and moderators

A strong placebo response in psychiatric disorders has been noted for the past 50 years and various attempts have been made to identify predictors of it, by use of meta-analyses of randomised controlled trials and laboratory studies. We reviewed 31 meta-analyses and systematic reviews of more than 500 randomised placebo-controlled trials across psychiatry (depression, schizophrenia, mania, attention-deficit hyperactivity disorder, autism, psychosis, binge-eating disorder, and addiction) for factors identified to be associated with increased placebo response. Of 20 factors discussed, only three were often linked to high placebo responses: low baseline severity of symptoms, more recent trials, and unbalanced randomisation (more patients randomly assigned to drug than placebo). Randomised controlled trials in non-drug therapy have not added further predictors, and laboratory studies with psychological, brain, and genetic approaches have not been successful in identifying predictors of placebo responses. This comprehensive Review suggests that predictors of the placebo response are still to be discovered, the response probably has more than one mediator, and that different and distinct moderators are probably what cause the placebo response within psychiatry and beyond.

The mind-body relationship in psychotherapy: grounded cognition as an explanatory framework

As a discipline, psychology is defined by its location in the ambiguous space between mind and body, but theories underpinning the application of psychology in psychotherapy are largely silent on this fundamental metaphysical issue. This is a remarkable state of affairs, given that psychotherapy is typically a real-time meeting between two embodied agents, with the goal of facilitating behavior change in one party. The overarching aim of this paper is to problematize the mind–body relationship in psychotherapy in the service of encouraging advances in theory and practice. The paper briefly explores various psychotherapeutic approaches to help explicate relationships between mind and body from these perspectives. Themes arising from this analysis include a tendency toward dualism (separation of mind and body from the conceptualization of human functioning), exclusivism (elimination of either mind or body from the conceptualization of human functioning), or mind–body monism (conceptualization of mind and body as a single, holistic system). We conclude that the literature, as a whole, does not demonstrate consensus, regarding the relationship between mind and body in psychotherapy. We then introduce a contemporary, holistic, psychological conceptualization of the relationship between mind and body, and argue for its potential utility as an organizing framework for psychotherapeutic theory and practice. The holistic approach we explore, “grounded cognition,” arises from a long philosophical tradition, is influential in current cognitive science, and presents a coherent empirically testable framework integrating subjective and objective perspectives. Finally, we demonstrate how this “grounded cognition” perspective might lead to advances in the theory and practice of psychotherapy.

Neural correlates of psychotherapy in anxiety and depression: a meta-analysis

Several studies have used neuroimaging methods to identify neural change in brain networks associated to emotion regulation after psychotherapy of depression and anxiety. In the present work we adopted a meta-analytic technique specific to neuroimaging data to evaluate the consistence of empirical findings and assess models of therapy that have been proposed in the literature. Meta-analyses were conducted with the Activation Likelihood Estimation technique, which evaluates the overlap between foci of activation across studies. The analysis included 16 studies found in Pubmed (200 foci of activation and 193 patients). Separate meta-analyses were conducted on studies of 1) depression, post-traumatic stress disorder and panic disorder investigated with rest state metabolism (6 studies, 70 patients); 2) depression, post-traumatic stress disorder and panic disorder investigated with task-related activation studies (5 studies, 65 patients); 3) the previous studies considered jointly; and 4) phobias investigated with studies on exposure-related activation (5 studies, 57 patients). Studies on anxiety and depression gave partially consistent results for changes in the dorsomedial prefrontal cortex and in the posterior cingulated gyrus/precuneus. Several areas of change in the temporal lobes were also observed. Studies on the therapy of phobia were consistent with a reduction of activity in medial temporal areas. The cluster of change in the prefrontal cortex may refer to increased recruitment of control processes, as hypothesized by influential models of emotion regulation changes due to psychotherapy. However, not all areas associated with controlled emotion regulation were detected in the meta-analysis, while involvement of midline structures suggested changes in self-related information processing. Changes in phobia were consistent with reduced reactivity to phobic stimuli.