The quest for connection in interpersonal and therapeutic relationships

Psychotherapy process research: Identifying productive in-session processes to enhance treatment outcomes and therapist responsiveness

This paper provides an overview of my research programme for the past 37 years. The focus of my work has been on identifying productive in-session processes to enhance treatment outcomes and therapist responsiveness. Two foci will be reviewed, first, my research on client and therapist interpersonal process and second, productive processing in psychotherapy in three different therapeutic approaches including EFT, CBT and CCT. Given that many competing theoretical perspectives are effective, I was curious about change processes that are common and unique to each. In my work, I employed a variety of research methodologies drawing on frameworks with alternative epistemological and ontological assumptions to capture specific in-session change processes in an attempt to reveal the richness and complexity of the phenomena being studied and illuminate the process of change.

Therapeutic distance in client-therapist narratives: client attachment, therapist attachment, and dyadic effects

Based on the attachment framework, therapeutic distance conceptualization focuses on closeness-distance dynamics in the therapeutic relationship. We aimed to evaluate the psychometric properties of the Therapeutic-Distance-Scale, Observer-version (TDS-O) and apply a dyadic approach to examine associations between attachment characteristics and therapeutic distance experiences of clients, therapists, and mutual effects. Sixty-six clients and their 29 therapists completed the ECR and relational narratives collected in RAP interviews at early, mid, and late psychodynamic-therapy were rated on TDS-O scales: too close, too distant, autonomy, and engagement. The TDS-O showed good IRR, internal reliability and content validity. Client anxiety was not associated with therapeutic distance but associated with autonomy. Client avoidance associated with clients' experiencing therapist as too close, and lower engagement only at early therapy, but was not associated with therapists' experience. Therapist anxiety was not related to closeness-distance at early therapy but related to gaps between client and therapist experiences at mid and late therapy. Therapist avoidance related to clients experiencing therapists as too close and granting less autonomy at early and mid-therapy, and to therapist experience of distance at late therapy. The findings underscore the importance of therapists' regulating therapeutic distance through attunement to client's interpersonal needs and therapy phase.

Early treatment response in psychotherapy for depression and personality disorder: links with core conflictual relationship themes

Objective: Depressed personality disorder patients showing an early rapid response (or sudden gain) in psychotherapy have better outcomes. Early responders are five times more likely to recover, despite equivalent ratings of working alliance. We explored core conflictual relationship themes (CCRTs) of early responders compared to others to further elucidate process-outcome links. Method: Patients (N = 20) with diagnosed major depression and personality disorder received 16 weeks of psychodynamic therapy. Early response was defined as a 50% reduction in Beck Depression Inventory symptoms during the first six sessions. Transcripts of therapy session three for early responders (n = 10) and others (n = 10) were analyzed using the CCRT Leipzig/Ulm method, identifying 728 components scored by two independent judges. Results: Relationship narratives showed CCRT-wish satisfaction was lower for those not having an early response, for both CCRT "Response of Other" and "Response of Self" components. These patients told narratives of others as more unreliable, aggressive, and less supportive, with less feelings of being loved and a lower experience of being self-determined. Conclusions: Specific negative relationship patterns may inhibit the ability to benefit from both therapy and extra-therapy relationships, contributing to a slower treatment response.

Mapping patterns of change in emotion-focused psychotherapy: Implications for theory, research, practice, and training

An important objective in humanistic-experiential psychotherapies and particularly emotion-focused psychotherapy (EFT) is to map patterns of change. Effective mapping of the processes and pathways of change requires that in-session processes be linked to in-session resolutions, immediate post-session changes, intermediate outcome, final therapy outcome, and longer-term change. This is a challenging and long-term endeavour. Fine-grained descriptions of in-session processes that lead to resolution of specific interpersonal and intrapersonal issues linked with longer-term outcomes are the foundation of EFT, the process-experiential approach. In this paper, evidence in support of EFT as a treatment approach will be reviewed along with research on two mechanisms of change, viewed as central to EFT, clients' emotional processing and the therapeutic relationship conditions. The implications for psychotherapy research are discussed. Given the methodological constraints, there is a need for more innovative methodologies and strategies to investigate specific psychotherapy processes within and across different approaches to map patterns and mechanisms of change to enhance theory, research, practice, and training.

Applying relationship anecdotes paradigm interviews to study client-therapist relationship narratives: Core conflictual relationship theme analyses

OBJECTIVE

We describe client-therapist relational narratives collected in relationship anecdotes paradigm (RAP) interviews during psychotherapy and the application of the core conflictual relationship theme (CCRT) method. Changes in clients' and therapists' CCRT in relation to each other are examined and associations between their CCRTs and self-reported ruptures and repairs are explored.

METHOD

Sixty-seven clients and 27 therapists underwent RAP interviews and completed self-report rupture and repair items at early, middle, and late psychodynamic psychotherapy. Client-therapist relationship narratives were rated on the CCRT and the relational interplay within dyads was explored qualitatively.

RESULTS

CCRT changes from early to late therapy showed that with time clients perceived the therapist (RO) and the self (RS) more positively, and the therapist perceived the self (RS) less negatively. Some associations were found between tension in the session and clients' and therapists' negative RO and RS. Therapists' reports of alliance repairs were associated with positive RO and RS.

CONCLUSIONS

Relational narratives that clients and therapists tell in RAP interviews about meaningful interactions between them, enhance our understanding of clients' and therapists' inner experiences during interpersonal dances in the therapeutic relationship. Limitations and directions for future research are discussed, and implications for training are suggested.