Patient affect experiencing following therapist interventions in short-term dynamic psychotherapy

Moments of change: Clients' immediate experiences when sharing emotions in psychotherapy

OBJECTIVE

In-session processing of emotions is important in facilitating psychotherapeutic change. This study explores how clients in active treatment experience inner changes when sharing emotions in psychotherapy sessions. The aim was to retrieve in-depth knowledge about clients' moment-by-moment experiences of change in a naturalistic psychotherapy context.

METHOD

Two psychotherapy sessions (session 3 or 4 and session 7 or 8) were videotaped and immediately followed by semi-structured interviews with clients (n = 11) in the format of Interpersonal Process Recall (IPR). Interviews were analysed using thematic analysis.

RESULTS

Four themes resulted from analysis: (1) reaching a new clarity about inner struggles; (2) a shift in how I approach and experience my feelings; (3) grieving losses and gaining a more positive understanding of myself; (4) feeling relief and liberation when allowing difficult emotions.

CONCLUSION

The resulting themes took into account the importance of the felt quality of change experiences within sessions, which appears to be important in making micro-processes of change salient. Across themes, we found accounts of shifts in awareness and self-compassion, which we discuss as micro-outcomes that clients can ideally be guided to dwell with.

Research evidence on psychotherapist skills and methods: Foreword and afterword

This article serves as both the foreword and the afterword to the special section of Psychotherapy Research devoted to research reviews of psychotherapist skills and methods: it introduces the interorganizational Task Force that guided the reviews and then features its conclusions. We begin by operationally defining therapist skills and methods and then contrasting them with other components of psychotherapy. Next, we consider the typical assessment of skills and methods and how they are linked with outcomes (immediate in-session, intermediate, and distal) in the research literature. We summarize the strength of the research evidence on the skills and methods reviewed in the 8 articles in this special section and in the companion special issue in Psychotherapy. We end with diversity considerations, research limitations, and the formal conclusions of the interorganizational Task Force on Psychotherapy Skills and Methods that Work.

Enhancing emotion regulation

BACKGROUND

Emotion regulation (ER) refers to the process of modulating an affective experience or response. Objectives: This is a systematic review of the research on therapist methods to facilitate patient ER, including affect-focused, experiential methods that aim to enhance immediate patient emotion regulation, and structured psychoeducation, skills training in ER.

METHOD

A total of 10 studies of immediate and intermediate outcomes of emotion regulation methods were examined. A total of 38 studies were included in the meta-analysis of distal treatment effects on emotion regulation.

RESULTS

In eight studies with 84 clients and 33 therapists, we found evidence of positive intermediate outcomes for affect-focused therapist methods and interpretations. A meta-analysis of 26 studies showed that the average effect size of ER methods from pre- to post-treatment was large (g = 0.82).

CONCLUSIONS

Both affect-focused and structured skill training are associated with distal improvements in emotion regulation. When working with ER in psychotherapy, therapists must consider how patients' cultural backgrounds inform display rules, as well as what might be considered adaptive or maladaptive. The article concludes with training implications and therapeutic practices based on the research evidence.

Unpacking the active ingredients of internet-based psychodynamic therapy for adolescents

Internet-based psychodynamic psychotherapy (iPDT) for adolescents has been found to be effective for treating depression, but not much is known about its active ingredients.

OBJECTIVE

To explore the techniques used in chat sessions in an iPDT program for depressed adolescents, and to investigate whether they predicted improvement in depression symptoms.

METHOD

The study uses data collected from a pilot study. The iPDT consisted of 8 modules delivered over 10 weeks that included text, video, exercises, and a weekly text-based chat session with a therapeutic support worker (TSW). The participants were 23 adolescents meeting criteria for depression. The TSWs were 9 psychology master's students. A depression inventory QIDS-A17-SR was filled weekly by the participants, and a self-rated techniques inventory (MULTI-30) was filled by the TSWs after each chat session.

RESULTS

Common factor techniques were the most widely used techniques in the chat sessions. Both common factors and psychodynamic techniques predicted improvement in depression, with psychodynamic techniques predicting improvement at the following week. CBT techniques were also used but did not predict improvement in depression.

CONCLUSION

iPDT seem to work in line with theory, where the mechanisms thought to be important for change in treatment were predictive of outcome.

Using the Achievement of Therapeutic Objectives Scale to Operationalize "Unlocking" of the Unconscious

OBJECTIVE

Intensive short-term dynamic therapy (ISTDP) is an evidence-based psychotherapy supported by a growing literature base. "Unlocking" of the unconscious is a central process in ISTDP. This study sought to operationalize the concept of unlocking by adopting a detailed process analysis of the early phase of therapy for four patients by using a structured measure, the Achievement of Therapeutic Objectives Scale (ATOS).

METHODS

The ATOS is a measure of psychotherapy processes. A profile of the scale's cutoff scores was developed to identify episodes of unlocking in videos of 28 ISTDP therapy sessions. Expert raters assessed for episodes of unlocking for up to the first 10 recorded psychotherapy sessions of four participants in a naturalistic private practice setting. Sessions were then rated with the ATOS profile, and these ratings were compared with expert ratings to assess the sensitivity of the ATOS in identifying episodes of unlocking.

RESULTS

Using the profile of subscale cutoff scores, the ATOS successfully identified seven of 11 episodes of unlocking. A visual analysis of descriptive data indicated that average ATOS subscale scores consistently identified episodes of unlocking and the presence of complex feelings of rage and guilt about the rage. Expert ratings of unlocking and the ATOS ratings were found to have high interrater reliability.

CONCLUSIONS

This pilot study suggests that the ATOS may be adapted to provide a profile that can identify episodes of unlocking of the unconscious. The proposed measure is worthy of further study, representing an initial step toward operationalizing a central process associated with positive outcomes in ISTDP.

Die Affektphobietherapie

Hintergrund

Ein zentraler Faktor psychischer Gesundheit ist die Fähigkeit, Affekte wahrnehmen und adaptiv regulieren zu können. Die Verbesserung dieser Fähigkeit ist ein Ziel der psychodynamischen Psychotherapie. Psychodynamische Behandlungsmodelle, die sich aus der gut validierten Tradition der „short-term dynamic psychotherapy“ (STDP) ableiten und die heute unter dem Dach der International Experiential Dynamic Therapy Association (https://iedta.net/) versammelt sind, legen auf besondere Weise den Behandlungsfokus auf das emotionale Erleben. Ein derartiges psychodynamisches transdiagnostisches Behandlungsmodell ist die Affektphobietherapie (APT).

Ziel der Arbeit (Fragestellung)

Ziel der Übersicht ist es, den Leser mit dem Behandlungsrational und der Evidenz der APT vertraut zu machen.

Material und Methoden

Es werden die theoretischen Grundlagen der APT, typische Interventionen und Prozessinstrumente beschrieben. Die Evidenz des APT-Modells wird als narrative Übersicht der Studienlage dargestellt.

Ergebnisse und Schlussfolgerung

Die APT ist ein evidenzbasiertes psychodynamisches Behandlungsmodell. Das Rational ist schulenübergreifend. Ein Selbsthilfeprogramm auf der Basis der APT wird von Patienten gut aufgenommen. Manualisierung, Fertigkeitenorientierung und Prozessinstrumente machen es zu einem vielversprechenden Modell für die Aus- und Fortbildung.

An explanatory sequential investigation of the working alliance as a change process in videoconferencing psychotherapy

OBJECTIVES AND DESIGN

Debate exists as to patient experience, and the importance, of the working alliance (WA) in videoconferencing psychotherapy (VCP). This study used a two-phase explanatory sequential design to investigate the WA as a change process in VCP.

METHODS

Phase I: sessional VCP outcome and WA data were analysed using multilevel modelling (n = 46). Phase II: participants (n = 12) from Phase I were recruited to semi-structured interviews, analysed using thematic framework analysis.

RESULTS AND CONCLUSIONS

Results demonstrate: (1) a significant correlation between WA and outcome (F(1, 15.19) = 25.01, p < 0.001), (2) previous session WA significantly predicted outcome in the next session (F(1, 355.61) = 4.47, p < 0.05), and (3) previous session outcome significantly predicted next session WA (F(1, 55.3) = 15.19, p < 0.001), with three core themes explaining patient experience (engaging with the medium, connection with the therapist, and working via the medium). Results are discussed and future research recommended.

In-session emotional expression predicts symptomatic and panic-specific reflective functioning improvements in panic-focused psychodynamic psychotherapy

In panic-focused psychodynamic psychotherapy (PFPP), exploration and interpretation of avoided and conflicted emotions and fantasies surrounding anxiety are thought to promote panic-specific reflective functioning (PSRF), which drives panic disorder improvements. Patient emotional expression within a session may be a marker of engaged processing and experiencing of affectively charged material. Degree of in-session expressed emotion, indicating both verbal and nonverbal emotions, was examined across three early therapy sessions for prediction of subsequent outcomes. We further investigated whether personality disorder traits, theorized to relate to constricted (obsessive-compulsive) or heightened (borderline) emotions, moderated this relationship. Emotional expression in Sessions 2, 5, and 10 of a 24-session PFPP protocol was assessed by blinded observers in 44 patients randomized to PFPP in a two-site randomized controlled trial of psychotherapies for panic disorder. Robust regressions were conducted to examine the relationship between average emotional expression across the measured sessions and symptom and PSRF changes subsequent to the sampled sessions, as well as moderation by personality disorder criteria, controlling for early outcomes. Higher levels of emotional expression across the early sessions predicted greater subsequent symptom and PSRF improvement. Elevations in expression of grief/sadness drove the symptomatic finding. Patients meeting more borderline criteria experienced a smaller and potentially negative relationship between emotional expression and symptom improvement. Emotional expression in PFPP may be an indicator of positive therapy process for patients without comorbid borderline personality traits, predicting prospective improvements in both a key mediator (PSRF) and symptoms. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

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.

Davanloo's Intensive Short-Term Dynamic Psychotherapy in a tertiary psychotherapy service: overall effectiveness and association between unlocking the unconscious and outcome

Background. Intensive Short-Term Dynamic Psychotherapy (ISTDP), as developed by Habib Davanloo, is an intensive emotion-focused psychodynamic therapy with an explicit focus on handling resistance in treatment. A core assumption in ISTDP is that psychotherapeutic effects are dependent on in-session emotional processing in the form of rise in complex transference feelings that occurs when treatment resistance is challenged. Recent research indicates that an unlocking of the unconscious, a powerful emotional breakthrough achieved at a high rise in complex transference feelings, can potentially enhance ISTDP's effectiveness. While ISTDP has a growing evidence base, most of the research conducted has used small samples and has tested therapy delivered by expert therapists. The aims of this study were to evaluate the overall effectiveness of ISTDP when delivered in a tertiary psychotherapy service, and to investigate if having an unlocking of the unconscious during therapy predicted enhanced treatment effectiveness. Methods. A total of 412 patients were included in the analyses. The average length of treatment was 10.2 sessions (SD 13.3). Multilevel growth curve modeling was used to evaluate treatment effectiveness and the association between unlocking the unconscious and outcome. A number of control predictors including type of treatment resistance were selected and included in the analyses. Outcome measures were the Brief Symptom Inventory (BSI) and the Inventory of Interpersonal Problems (IIP). About half of the patients in the study were treated by therapists in training and the other half by more experienced therapists. Results. Growth curve analyses using the full intention-to-treat sample revealed significant within-group effects of ISTDP on both the BSI and the IIP. Effect sizes were large (>0.80). Unlocking the unconscious during therapy was associated with significantly larger treatment outcome. The relationship was further moderated by type of treatment resistance. Conclusion. This study adds to the empirical base of Davanloo's ISTDP with confirmed treatment effectiveness in a large-scale patient sample when ISTDP was delivered by therapists with a range of experience. Furthermore, emotional mobilization in the form of unlocking the unconscious was confirmed as a process factor enhancing the effectiveness of ISTDP.

Brief dynamic psychotherapy in a case of obsessive compulsive disorder

A 57 years old married, retired official of Indian Railway service presented with two months complaints of recurrent fears of circulation of a duplicate CD of one of his presentations in an international conference, recurrent thoughts that the years of winning medals during his tenure in Indian Railways service were misrepresented in the records as early years. He recognized these fears as irrational, intrusive causing irritability and extreme anxiety, as he felt an urge to go and check the records, and feared it would cause humiliation. A diagnosis of obsessive compulsive disorder predominantly obsessions were made. Patient refused medication and a keen interest to receive insight. Patient had strong ego functions, stable heterosexual partnership, was open to interpretations and therapeutic contract of ten sessions of David Malan's school of brief dynamic therapy was initiated. Unconscious therapeutic alliance dominated over resistance. Displacement, isolation of affect and undoing were the neurotic defenses interpreted by the therapist. Therapeutic focus was relief of obsessions occurred by 9(th) session and therapy was successfully terminated.