Patients' autonomic activation during clinical interaction: A review of empirical studies

Exploring the role of emotions and conversation content in interpersonal synchrony: A case study of a couple therapy session

OBJECTIVE

This exploratory study investigated the association between interpersonal movement and physiological synchronies, emotional processing, and the conversational structure of a couple therapy session using a multimodal, mixed-method approach.

METHOD

The video recordings of a couple therapy session, in which the participants' electrodermal activity was recorded, were analyzed. The session was divided into topical episodes, a qualitative analysis was conducted on each topical episode's emotional aspects, conversational structure and content. In addition, movement and physiological synchrony were calculated in each topical episode. Regression models were used to discover the associations between qualitative variables and synchronies.

RESULTS

Physiological synchrony was associated with the emotional aspects of the session and to episodes in which the spouses' relationship was addressed, while movement synchrony was only related to emotional valence. No association between synchrony and conversational structure was found.

CONCLUSION

The findings suggest that physiological and movement synchrony play distinct roles in psychotherapy. The exploratory study sheds light on the association between momentary synchrony, emotions, and conversational structure in a couple therapy session.

Opening the Black Box of Family-Based Treatments: An Artificial Intelligence Framework to Examine Therapeutic Alliance and Therapist Empathy

The evidence-based treatment (EBT) movement has primarily focused on core intervention content or treatment fidelity and has largely ignored practitioner skills to manage interpersonal process issues that emerge during treatment, especially with difficult-to-treat adolescents (delinquent, substance-using, medical non-adherence) and those of color. A chief complaint of "real world" practitioners about manualized treatments is the lack of correspondence between following a manual and managing microsocial interpersonal processes (e.g. negative affect) that arise in treating "real world clients." Although family-based EBTs share core similarities (e.g. focus on family interactions, emphasis on practitioner engagement, family involvement), most of these treatments do not have an evidence base regarding common implementation and treatment process problems that practitioners experience in delivering particular models, especially in mid-treatment when demands on families to change their behavior is greatest in treatment - a lack that characterizes the field as a whole. Failure to effectively address common interpersonal processes with difficult-to-treat families likely undermines treatment fidelity and sustained use of EBTs, treatment outcome, and contributes to treatment dropout and treatment nonadherence. Recent advancements in wearables, sensing technologies, multivariate time-series analyses, and machine learning allow scientists to make significant advancements in the study of psychotherapy processes by looking "under the skin" of the provider-client interpersonal interactions that define therapeutic alliance, empathy, and empathic accuracy, along with the predictive validity of these therapy processes (therapeutic alliance, therapist empathy) to treatment outcome. Moreover, assessment of these processes can be extended to develop procedures for training providers to manage difficult interpersonal processes while maintaining a physiological profile that is consistent with astute skills in psychotherapeutic processes. This paper argues for opening the "black box" of therapy to advance the science of evidence-based psychotherapy by examining the clinical interior of evidence-based treatments to develop the next generation of audit- and feedback- (i.e., systemic review of professional performance) supervision systems.

Data mining techniques in psychotherapy: applications for studying therapeutic alliance

Therapeutic Alliance (TA) has been consistently reported as a robust predictor of therapy outcomes and is one of the most investigated therapy relational factors. Research on therapists' and clients' contributions to the alliance development and the alliance-outcome relationship had shown mixed results. The relation of the therapist's and client's biological markers with the alliance is an important and under-investigated topic. Taking advantage of data mining techniques, this exploratory study aimed to investigate the role of different therapist and client factors, including heart rate (HR) and electrodermal activity (EDA), in relation to TA. Twenty-two dyads with 6 therapists and 22 clients participated in the study. The Working Alliance Inventory (WAI) was used to evaluate the client's and therapist's perception of the alliance at the end of each session and through the therapy processes. The Cross-Industry Standard Process for Data Mining (CRISP-DM) was used to explore patterns that may contribute to TA. Machine Learning (ML) models have been employed to provide insights into the predictors and correlates of TA. Our results showed that Linear Regression (LR) was the best technique for predicting the therapist's TA, with client "Diagnostic" and therapy "Termination" being identified as significant predictors of the therapist's TA. In addition, for clients' TA, the Random Forest (RF) was shown to have the best performance. The therapist's TA and therapy "Outcome" were observed as the most influential predictors for the client's TA. In addition, while the Heart Rate (therapist) was negatively associated with the therapist's TA, EDA in the client was a physiological indicator related to the client's TA. Overall, these findings can assist in identifying key factors that therapists should focus on to enhance the quality of therapeutic alliance. Results are discussed in terms of their consistency with empirical literature, innovative and interdisciplinary research on the therapeutic alliance field, and, in particular, the use of the Data Mining approach in a psychotherapy context.

"INTEGRO INTEGRated Psychotherapeutic InterventiOn" on the Management of Chronic Pain in Patients with Fibromyalgia: The Role of the Therapeutic Relationship

Fibromyalgia (FM) is a chronic disease characterized by a heterogeneous set of physical and psychological conditions. The chronic experience of disability felt by patients and the impact on quality of life (QoL) of the disease may worsen the cognitive reappraisal ability and contribute to maintaining an altered pain modulation mechanism. This paper presents the study protocol of an INTEGRated psychotherapeutic interventiOn on the management of chronic pain in patients with fibromyalgia (INTEGRO). The aim of the study is to investigate the efficacy of an integrated psychotherapeutic intervention focused on pain management on QoL and pain perception, in a pilot sample of 45 FM patients with idiopathic chronic pain. The contribution of perceived therapeutic relationship (alliance) and physiological attunement, in both the patient and therapist, will be considered as possible mediators of intervention efficacy. Attachment dimensions, traumatic experiences, difficulties in emotion regulation, mindfulness attitude and psychophysiological profile will also be considered as covariates. The objectives are to evaluate longitudinally if patients will experience an increase in QoL perception (primary endpoint), pain-managing self-efficacy and emotion-regulation abilities as well as a reduction in pain intensity (secondary endpoints), considering the mediating role of perceived therapeutic alliance and physiological attunement in both the patient and therapist.

Palliation of heart failure: value-based supportive care

OBJECTIVES

Heart failure (HF) is a prevalent condition associated with poor quality-of-life and high symptom burden. As patients reach ceilings of survival-extending interventions, their priorities may be more readily addressed through the support of palliative care services; however, the best model of care remains unestablished.We aimed to create and evaluate a cospeciality cross-boundary service model for patients with HF that better provides for their palliative care needs in the latter stages of life, while delivering a more cost-effective patient journey.

METHODS

In 2016, the Heart Failure Supportive Care Service (HFSCS) was established to provide patient-centred holistic support to patients with advanced HF. Patient experience questionnaires were developed and distributed in mid-2018 and end-of-2020. Indexed hospital admission data (in-patient bed days pre-referral/post-referral) were used allowing statistical comparisons by paired t-tests.

RESULTS

From 2016-2020, 236 patients were referred to the HFSCS. Overall, 75/118 questionnaires were returned. Patients felt that the HFSCS delivered compassionate care (84%) that improved symptoms and quality of life (80% and 65%). Introduction of the HFSCS resulted in a reduction in HF-related admissions: actual days 18.3 to 4 days (p<0.001), indexed days 0.05 to 0.032 days (p=0.03). Cost mapping revealed an estimated average saving of at least £10 218.36 per referral and a total estimated cost saving of approximately £2.4 million over 5 years.

CONCLUSION

This service demonstrates that a cospeciality cross-boundary method of care delivery successfully provides the benefits of palliative care to patients with HF in a value-based manner, while meeting the priorities of care that matter to patients most.

Challenges and added value of measuring embodied variables in psychotherapy

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

Spanish Medical Interpreters' Management of Challenges in End of Life Discussions

OBJECTIVE

Professional medical interpreters facilitate patient understanding of illness, prognosis, and treatment options. Facilitating end of life discussions can be challenging. Our objective was to better understand the challenges professional medical interpreters face and how they affect the accuracy of provider-patient communication during discussions of end of life.

METHODS

We conducted semi-structured interviews with professional Spanish medical interpreters. We asked about their experiences interpreting end of life discussions, including questions about values, professional and emotional challenges interpreting these conversations, and how those challenges might impact accuracy. We used a grounded theory, constant comparative method to analyze the data. Participants completed a short demographic questionnaire.

RESULTS

Seventeen Spanish language interpreters participated. Participants described intensive attention to communication accuracy during end of life discussions, even when discussions caused emotional or professional distress. Professional strains such as rapid discussion tempo contributed to unintentional alterations in discussion content. Perceived non-empathic behaviors of providers contributed to rare, intentional alterations in discussion flow and content.

CONCLUSION

We found that despite challenges, Spanish language interpreters focus intensively on accurate interpretation in discussions of end of life.

PRACTICE IMPLICATIONS

Provider training on how to best work with interpreters in these important conversations could support accurate and empathetic interpretation.

Incorporating physiology into the study of psychotherapy process

Increasing evidence indicates that psychological factors important to therapy effectiveness are associated with physiological activity. Knowledge of the physiological correlates of therapy process variables has the potential to provide unique insights into how and why therapy works, but little is currently known about the physiological underpinnings of specific therapy processes that facilitate client growth and change. The goal of this article is to introduce therapy process researchers to the use of physiological methods for studying therapy process variables. We do this by (a) presenting a conceptual framework for the study of therapy process variables, (b) providing an introductory overview of physiological systems with particular promise for the study of therapy process variables, (c) introducing the primary methods and methodological decisions involved in physiological research, and (d) demonstrating these principles and methods in a case of therapeutic presence during couple therapy. We close with a discussion of the promise and challenges in the study of physiological correlates of therapy process variables and consideration of future challenges and open questions in this line of research. Online supplemental materials include additional resources for therapy process researchers interested in getting started with physiological research. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Healthcare communication distress scale: Pilot factor analysis and validity

OBJECTIVE

To develop psychometrically an evidence-based, patient-centred measure of patient-practitioner communication. We explored the underlying constructs of a self-report questionnaire measuring adult patients' enduring perceptions of their emotional experiences when communicating with primary healthcare practitioners.

METHODS

A cross-sectional on-line survey included 16 items from a piloted questionnaire, as well as existing measures of generalised anxiety, psychological distress, and body vigilance. Exploratory factor analysis and hierarchical multiple regression were used to explore underlying constructs in an Australian sample (N = 220).

RESULTS

A 6-item communication distress factor and a 3-item environmental arousal factor were supported, indicating good face validity and internal consistency. Bivariate correlations support convergent and discriminant validity for both factors. Hierarchical analysis exploring predictors of communication distress included sex, age, and chronic condition status; and scores on body vigilance, anxiety, distress, and environmental arousal in healthcare. Environmental arousal was the most important significant predictor of communication distress.

CONCLUSION

The patient communication questionnaire can be developed into a brief scale to measure patient distress associated with engaging with, and communicating in, healthcare settings.

PRACTICE IMPLICATIONS

A brief self-report measure to identify patients' communication distress and environmental arousal could assist in clinical practice and provide useful data in healthcare communication research.

Affective communication during bad news consultation. Effect on analogue patients' heart rate variability and recall

OBJECTIVE

The aim of the study was to investigate the effect of physicians' supportive communication on analogue patients' (APs) heart rate variability (HRV) and recall, while watching a video of palliative treatment being explained to a female patient.

METHODS

Sixty healthy women, acting as APs, were randomly assigned to watch one of two versions (standard vs. affective) of a scripted video-vignette of a bad news consultation to a female patient. The physician's communication differed only in the delivery of four supportive comments. Empathy, support and engagement perception were assessed by three questions. APs' HR was recorded during video-observation and recall was assessed immediately after. HRV was determined through measures defined in time and frequency domains.

RESULTS

Data of 54 APs (27 + 27) were included. The group with supportive communication perceived the physician as more empathic and supportive. Intra- and Inter-group comparisons suggested a greater sense of stress in the standard communication group. Recall did not differ in the two groups.

CONCLUSION AND PRACTICE IMPLICATIONS

Findings show that the use of supportive expressions contribute to the perception of the physician as more empathic, potentially buffer patients' arousal after a bad news announcement, but does not confirm a positive impact on general recall.