Introduction: current developments in psychotherapy process research /Introducción: desarrollos actuales en la investigación del proceso psicoterapéutico

Lessons from ten years of psychotherapy process research

Objective: The aim of this review is to systematize and interpret results produced over one decade of Psychotherapy Process Research (2009-2019) in eight journals. Method: It is a Mixed Studies Review of quantitative as well as qualitative primary studies. The analysis of the results of these studies included a descriptive quantitative part and a qualitative part that followed the logic of Qualitative Meta Analysis, categorizing the main results of both types of studies in a bottom-up procedure that generates specific content categories that are synthesized in further steps of a higher level of abstraction, leading to an "interpretive synthesis" presented in a narrative way. Results: The review shows that psychotherapy process research uses a variety of qualitative and quantitative methods, often creating new procedures. Furthermore, the review indicates that the most commonly assessed macroprocess variables are ongoing change, therapeutic relationship (predominantly therapeutic alliance), and therapeutic intervention; while the most extensively studied microprocess variables are change events, difficult episodes (mainly ruptures), and therapeutic intervention. Macrolevel results reveal that the main contents of ongoing change are the building of new meanings and progressive psychological integration; underscore the association of the therapeutic alliance with ongoing change and outcome; and show the complexity of associating intervention with outcome, because different phases of therapy (and problems) need different assessments. Microlevel results indicate that change events impact on ongoing change and outcome; that for ruptures the key fact is their repair; and that therapist communication has an immediate influence on patient communication. Conclusion: Our knowledge regarding relevant aspects of psychotherapy is very fragmented; robust and replicated results are still scarce. Only a few variables have been found to consistently predict outcome across most therapies. Only in the field of alliance research it has been possible to perform meta-analyses that clearly demonstrate the impact of this factor on final outcomes. Despite these limitations, psychotherapy process research is a powerful tool for uncovering change mechanisms and is at present widely implemented. Our conclusion is that, in order to generate useful future knowledge, change mechanisms need to be linked to ongoing change; this, in turn, requires models of change, hopefully of a transtheoretical nature.

Doing-together with words: the sequential unfolding of a moment of meeting in a psychoanalytic therapy session

Changes in psychoanalytic therapy have been traditionally attributed to self-knowledge (insight) in the client, provided by the therapist's interpretations. In recent years there has been growing realization that such changes can also be the consequence of the development of new forms of relatedness through client-therapist interaction, particularly through special intersubjective moments called moments of meeting. Drawing on the methods and findings of Conversation Analysis about the sequential organization of psychotherapeutic interaction, this single-case study examines the unfolding of a moment of meeting in the final session of a brief psychoanalytic therapy in Peru (in Spanish) with a female client victim of domestic violence. Our analysis shows that the moment of meeting, which resolves a challenge to the intersubjective relationship posed by a now moment, comes about interactionally through a sequentially accomplished shared practice of co-animation. In this sequence the client, who had previously assumed a passive role, exercises her own agency to assume an active role, which the therapist ratifies through his response. In this way, a momentary but significant transformation in the here-and-now relationship between client and therapist occurs. Thus, our analysis contributes to the understanding of how a transformation of relation-the transitory emergence of a new form of relatedness-can take place in and through sequentially organized talk and action in psychotherapy. Our study also sheds light on the role of language in moments of meeting, as the moment of meeting in our segment does not occur in parallel with the exchange of linguistic utterances between client and therapist, but through the exchange of such linguistic utterances and through the sequence of actions carried out by that exchange. In this way, the sequential doing-together with words leads to a moment of meeting, bringing about change, at least momentarily, in the implicit ways-of-being-with-others of the client.

Case formulation as a bridge between theory, clinical practice, and research: A commentary

This commentary section is based on a comparative analysis of the five articles and case examples presented in this special issue. The place of Case Formulation in the field of psychotherapy is conceptualized as a necessary bridge between diagnostic systems and clinical practice. The common aspects of the five approaches included in the issue, as well as of the cases to which they were applied, are discussed to explore their possible cross-theoretical nature, especially in psychotherapy with more severe cases. All the clients presented in this section have experienced traumas, which manifest themselves as difficulties in their interpersonal relationships. We discuss the value of Case Formulation in the context of clinical practice and research as well as the challenges of fostering the cross-theoretical approach of this tool.

Therapist Attachment and the Working Alliance: The Moderating Effect of Emotional Regulation

Objective: To explore whether the therapist's emotional regulation strategies moderate the relationship between therapist attachment and the working alliance from the therapist's perspective. Method: A non-experimental, descriptive correlational design was used. Sixty-three psychotherapists (6 men, 57 women) participated in this study, ranging in age from 27 to 69 years, with a mean age of 39.3 years. The therapists completed the Attachment evaluation questionnaire for adults, the Spanish Adaptation of the Working Alliance Inventory, and the Difficulties in Emotion Regulation Scale. Associations between attachment and emotional regulation traits and working alliance were examined using multilevel modeling, controlling for therapist demographics, and clinical experience. Results: Moderation analyses revealed significant interaction effects between therapist attachment and emotional regulation strategies. Conclusion: Attachment styles would not significantly affect the therapist's ability to establish an adequate therapeutic alliance bond. The results show that the attachment style of the therapists interacted with their emotional regulation abilities.

Walking the middle ground between hermeneutics and science: A research proposal on psychoanalytic process

In 100 years of clinical research and 40 years of empirical research, the concept of psychoanalytic process continues to elude a consensual definition, probably because the problem and methodology must be approached in a different way. This article outlines the empirical implications of the epistemological model exposed in a previous article, by proposing a scientific, innovative, and clinically sensitive research programme for the study of psychoanalytic process. This proposal is an attempt at developing psychotherapy research that is founded on psychoanalytic hypotheses derived from a two-person psychology. The research programme focuses on the interactional nature of the analytical work, and on the relationship between the implicit (unconscious) and the explicit (conscious) levels of the analytic endeavour. The authors propose that this research programme be articulated around three methodological approaches: (1) the use of systematic case studies; (2) the adoption of the events paradigm for accessing the salient phenomena of the psychoanalytic process; and (3) a micro-analytic approach to the specific phenomena occurring within relevant sequences of interaction. These ideas are illustrated with a description of the micro-analysis of a clinical case. This article is intended to contribute to a constructive dialogue between psychoanalytic practice and psychotherapy research.

Interaction structures in the psychodynamic psychotherapy of a patient with chronic diseases and somatic symptoms

OBJECTIVE

This study aimed to identify and analyze the interaction structures (ISs) (patterns of reciprocal interaction between the patient-therapist dyad) that characterize the process of a successful long-term psychodynamic psychotherapy (28 months) of a patient with chronic diseases (lupus and fibromyalgia) and somatic symptoms.

METHODS

The 113 sessions were videotaped and analyzed alternately (n = 60) by independent judges using the Psychotherapy Process Q-Set. Inter-rater reliability ranged from 0.60 to 0.90, with a mean of r = 0.71 (Pearson's correlation). Through a principal component exploratory factor analysis, four ISs were identified.

RESULT

The patterns of interaction between patient and therapist showed clinical validity (i.e., they were easily interpretable in the context of the case under study). The ISs were non-linear and more or less prominent across different treatment sessions and stages. Some ISs were similar to those in other studies, and others were probably unique to the present process. In addition, some ISs were independent, whereas others were interrelated over time.

CONCLUSION

Process studies, such as the present one, seek to address questions about the characteristics of the interaction between patient and therapist as well as to identify particular patterns of interaction that are most prominent with a specific patient at a specific condition or time. Therefore, these studies can provide some support in establishing knowledge for clinical practice, assisting in the training of therapists, as well as in the elaboration of general guidelines for the technical management of patients with specific characteristics.

Eficácia adaptativa e indicadores genéricos de mudança em psicoterapia: um estudo exploratório

Resumo Esta pesquisa exploratória objetivou avaliar a relação entre evolução dos indicadores genéricos de mudança e qualidade da eficácia adaptativa de uma paciente adulta atendida em psicoterapia breve psicodinâmica. Os vídeos e transcrições das 11 sessões deste processo foram analisados com os Indicadores Genéricos de Mudança e com a Escala Diagnóstica Adaptativa Operacionalizada Redefinida. Os resultados demonstraram evolução dos indicadores de mudança e progresso nas respostas adaptativas. Se por um lado respostas mais adequadas sugeriram mudanças na vida da paciente, por outro, essas melhoras puderam ser captadas pelos Indicadores Genéricos de Mudança. As duas medidas usadas em conjunto podem auxiliar o terapeuta na avaliação de progresso do paciente e na compreensão dos fatores que ocasionam ou que limitam a mudança. Sugere-se a realização de pesquisas que compreendam maior número de casos, contem com processos considerados mal sucedidos e envolvam abandono por parte do paciente.