Impact of confrontations by therapists on impairment and utilization of the therapeutic alliance

Unraveling the optimal balance of problem-related affective experiences and need satisfaction in cognitive-behavioral therapy: A response surface analysis

Objective: Although therapists are encouraged to balance emotionally involving work on the patient's problems with need satisfaction in therapy sessions, effects of this balance have rarely been studied empirically. Hence, we examined congruence effects between problem-related affective and need-satisfying experiences in cognitive-behavioral therapy (CBT). Method: 165 distressed family caregivers rated problem-related affective experiences, need-satisfying experiences comprising self-esteem, positive interpersonal, and control experiences, as well as coping experiences after 12 CBT sessions. We examined within-person congruence effects of problem-related affective and need-satisfying experiences on subsequent coping in multilevel response surface analysis. Further, we included between-person problem-related affective and need-satisfying experiences and pretreatment depression and anxiety as moderators of within-person effects. Results: A slight predominance of self-esteem over problem-related affective experiences as well as exact correspondence between problem-related affective and both interpersonal and control experiences was most predictive of coping. Between-person moderators supported a cross-level balance heuristic of problem-related affective and self-esteem experiences. Finally, a stronger emphasis on self-esteem and interpersonal over problem-related affective experiences proved more beneficial for patients with high anxiety and low depression. Conclusions: The findings highlight the importance of balancing problem-related affective and need-satisfying experiences in CBT and provide insights into how balancing may be tailored to specific patients.

Mediating mechanism of posttraumatic growth as buffers of burnout and PTSD among nurses during the COVID-19 pandemic

Objective

The study aims to investigate factors that prevent burnout (BO) and symptoms of posttraumatic stress disorder (PTSD) while facilitating posttraumatic growth (PTG) among nurses combating the coronavirus disease 2019 (COVID-19) pandemic, with the purpose of validating the mediating effects of PTG.

Methods

A total of 247 nurses who provided patient care during the COVID-19 pandemic were enrolled, and a questionnaire was used to measure BO, PTSD, and PTG, data on deliberate rumination, emotional expression, adaptive cognitive emotion regulation (CER), maladaptive CER, and social support. The mediation path models for the effects of the predictors on BO and PS through the mediation of PTG were analyzed using the R Lavaan package.

Results

The results showed that deliberate rumination, emotional expression, and adaptive CER significantly increased PTG, while PTG significantly reduced BO and PTSD symptoms (PSs). However, maladaptive CER did not have a significant effect on PTG and only had significant direct effects on BO and PS. Bootstrapping confirmed that PTG significantly mediated the effects of all predictors. It partially mediated the effects of deliberate rumination and adaptive CER and completely mediated the effects of emotional expression.

Conclusion

Based on the results, it has been supported that deliberate rumination, emotional expression, and adaptive CER should be addressed as important variables in psychological interventions addressing nurses' adversities during the pandemic. These variables can prevent BO and PS by facilitating PTG.

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.

Therapists' responsiveness in the process of ruptures and resolution: Are patients and therapists on the same page?

OBJECTIVE

This study examined the association between the rupture-repair process and patients' and therapists' perceptions of the therapist's responsiveness.

METHOD

We used the Rupture Resolution Rating System to rate early sessions (3-5) in 35 short-term psychodynamic psychotherapy cases. The patients and therapists rated their perceptions of the therapist's responsiveness after each session using the Patient's Experience of Attunement and Responsiveness (PEAR) Scale.

RESULTS

Therapists' contribution to ruptures was negatively associated with both patients' and therapists' PEAR ratings. Confrontation ruptures were negatively associated with patients' PEAR ratings, whereas there was no significant association with withdrawal ruptures. Resolution was positively associated with both patients' and therapists' PEAR ratings. In addition, resolution moderated the negative association between ruptures and patients' PEAR ratings.

CONCLUSION

The findings emphasize the link between therapists' responsiveness and the rupture-repair process. They also highlight the significance of providing therapists with the necessary training to recognize these dynamics and engage in discussions about them with their patients when appropriate.

A longitudinal view of an approach to responsiveness: Principles followed and lessons learned

AbstractResponsiveness is currently a hot topic in the psychotherapy literature with a large variation in what the term means to colleagues of various orientations. This adds to its popularity but limits the scope of whatever is written or said about responsiveness. The fact that the meaning of responsiveness has developed over time within the approaches adds also to the variation, while an understanding of development has the potential of deepening the understanding of each approach. As a fair description and comparison of even just the most important approaches is by far out of reach for a page-limited article, the development of one approach, which may be termed the "Bernese" approach is described here, along with lessons learnt and general comments. The approach includes Plan Analysis case formulations, the concept of complementary or Motive-Oriented Relationship, a description of a combined qualitative and quantitative assessment, and many methodological and conceptual considerations. Personal development is woven in. Overall, it seems fair to say that this approach, at its core developed long before responsiveness became popular, has turned out to still be useful, with a gain in depth as far as concepts and assessment are concerned.

Between- and within-person effects of affective experiences on coping in CBT: Direct effects and interplay with therapeutic alliance and resource activation

OBJECTIVE

The role of affective experiences (AE) in cognitive-behavioral therapy (CBT) has rarely been investigated. We examined between- and within-person effects of AE on coping in CBT for family caregivers and interactions with therapeutic alliance and resource activation.

METHODS

67 family caregivers rated AE, therapeutic alliance, resource activation, and coping after each of 12 sessions of telephone-based CBT. We examined direct session-to-session effects of AE on coping in structural equation modeling and interactions of AE with therapeutic alliance and resource activation in multilevel models.

RESULTS

AE did not directly predict coping. Instead, within-person effects of AE interacted with simultaneous within-person emotional bond. Given strong emotional bond, AE positively predicted coping, whereas given weak emotional bond, AE negatively predicted coping. Further, cross-level interactions of between-person AE and within-person agreement on collaboration and resource activation indicated that these positively predicted coping only in dyads with high between-person AE.

CONCLUSION

AE may enhance coping when complemented with strong emotional bond. Further, within-person effects of agreement on collaboration and resource activation seem to rely on a certain degree of between-person AE. Results are discussed in relation to current findings on emotional processing in CBT.

Alliance ruptures in cognitive-behavioral therapy: A cognitive conceptualization

The therapeutic relationship is crucial to the ethical and effective practice of any psychotherapy. In Cognitive Behavior Therapy (CBT) as formulated by Aaron T. Beck, the generic elements of the relationship including expressed empathy, expressions of positive regard, agreement on goals, and agreement on tasks within a therapeutic bond were considered a necessary condition for change. Alliance ruptures can therefore have a detrimental effect on therapy if left unrepaired. This article contributes to the In-Session issue on rupture repairs by outlining the role of the alliance as a component of the therapeutic relationship in CBT and illustrates how ruptures can be identified and effectively resolved through detailed case examples. Given the central importance of using collaborative empiricism and Socratic dialogue for the therapeutic relationship in CBT, we demonstrate the distinctive role of these elements in repairing ruptures.

Rupture Resolution Rating System (3RS): Development and validation

OBJECTIVE

Our aim was to examine the reliability and validity of the Rupture Resolution Rating System (3RS), an observer-based measure of alliance ruptures and resolution processes.

METHOD

We used the 3RS to rate early sessions from 42 cases of cognitive behavior therapy. We compared the 3RS to a simplified version of the Structural Analysis of Social Behavior (SASB), as well as patient and therapist self-reports of ruptures and the alliance.

RESULTS

Coders achieved high rates of interrater reliability on the frequency of confrontation and withdrawal ruptures and resolution strategies (ICCs = .85 to .98), as well as ratings of the therapist's contribution to ruptures and the extent to which ruptures were resolved (ICC = .92). Predictive validity analyses found that confrontation markers (d = .74), successful resolution (d = .67), and ratings of the therapist's contribution to ruptures (d = .61) predicted dropout from therapy. Analyses of convergent validity with the SASB failed to meet predictions; however, we observed theoretically coherent relations between 3RS and SASB variables. Confrontation rupture markers were significantly associated with patient self-report of rupture (d = 1.54) and therapist self-reported alliance (r = -.50, p = .002).

CONCLUSIONS

This study provides evidence that the 3RS is a reliable and useful tool for examining psychotherapy process and predicting dropout. Clinical or methodological significance of this article: This study provides evidence of the reliability and validity of the 3RS, an observer-based measure of alliance ruptures and resolution processes. The 3RS can be used to identify problems in the therapeutic relationship that are associated with premature dropout from therapy.