Coregulation of therapist and client emotion during psychotherapy

Alliance processes in eating disorders with childhood maltreatment sequelae: Preliminary implications

BACKGROUND

Effective eating disorder (ED) treatments are drastically needed for patients with experiences of sustained and prolonged emotional, physical and sexual childhood maltreatment (CM) that often results in post-traumatic sequelae such as severe, complex posttraumatic stress disorder (cPTSD). EDs with comorbid cPTSD (cPTSD-ED) have protracted treatment courses and poorer prognoses.

AIM

To summarise the knowledge base on cPTSD-ED with specific emphasis on disturbances in self-organisation (DSO) in relation to therapeutic alliance (TA) processes.

METHOD

Expert opinions based on current relevant literature are critically examined.

RESULTS

Preliminary insights on change and alliance processes suggest that neglecting to address emotional-relational processes in the conceptualisation and treatment of cPTSD-ED impedes treatment progress.

CONCLUSION

We hypothesise that the DSO construct inherent in cPTSD-ED calls for a focus on TA processes in addition to traditional ED treatment elements such as nutritional rehabilitation and behaviour change, and regardless of ED treatment provided. More process research on a larger scale is urgently called for.

Developing Therapeutically Attuned Relationships with Autistic Children and Their Caregivers

The purpose of this paper is to propose the Intentional and Attuned Therapeutic Relationship Model as a means to emphasize an intentional and attuned therapeutic relationship among the therapist, autistic child, and their caregiver. Neurodiversity-affirming practice is strengths-based, collaborative, and inclusive of the needs and goals of the autistic child and their caregiver. As this necessitates reevaluating occupational therapy models of care delivered to autistic children, this paper provides a brief review of sensory processing and emotional regulation; discusses the Intentional Relationship Model and the phenomenon of attunement, respectively; and proposes the Intentional and Attuned Therapeutic Relationship Model, which combines elements of the Intentional Relationship Model and attunement to develop the therapeutic relationship in alignment with the neurodiversity-affirming paradigm.

Therapists' emotional responses and their relation to patients' experience of attunement and responsiveness

OBJECTIVE

Therapists' emotional responses play a significant role in the therapeutic relationship and in the therapy process. The current study examined the associations between therapists' emotional responses before and after therapy sessions, and patients' experience of them as attuned and responsive.

METHOD

Forty patient-therapist dyads participated in 16 weekly sessions of Supportive Expressive Psychotherapy. Therapists' emotions were assessed on the Feeling Word Checklist-58. We examined one positive feeling (Parental) and one negative feeling (Inadequate) Following each session, patients and therapists rated responsiveness on the Patient's Experience of Attunement and Responsiveness.

RESULTS

Feeling Parental before sessions was associated with patients' post-session ratings of therapist empathy, but not with session helpfulness or sensed achievement. Therapists' feelings of inadequacy before sessions were negatively associated with patients' ratings of helpfulness and achievement, but not with empathy. Therapists' Parental feelings after the session were positively associated with patients' ratings and their own ratings on all 3 PEAR subscales. Feeling Inadequate after the session was negatively associated with patients' ratings of helpfulness, achievement and empathy. Therapists' ratings were only negatively associated only with helpfulness.

CONCLUSION

The study demonstrates that therapists' emotional reactions play a role in their patients' experience of their responsiveness.

Clients' and therapists' parasympathetic interpersonal and intrapersonal regulation dynamics during psychotherapy for depression

OBJECTIVE

The literature on affective regulation in psychotherapy has traditionally relied on explicit client self-report measures. However, both clients' and therapists' affect fluctuate moment-to-moment during a session, highlighting the need for more implicit and continuous indices to better understand these dynamics. This study examined parasympathetic interpersonal and intrapersonal regulation dynamics between therapists and clients with Major Depressive Disorder during Supportive-Expressive Therapy.

METHOD

Data were collected from 52 dyads across five preselected sessions, using the Respiratory Sinus Arrhythmia (RSA) index. We employed a longitudinal Actor-Partner Interdependence Model, with clients self-reporting their functioning level before and after each session, as the moderator.

RESULTS

Therapists' RSA at one time point negatively associated with clients' RSA at the next, and vice-versa, indicating interpersonal regulation. Clients' RSA at one time point was positively associated with their RSA at the next, indicating intrapersonal regulation. However, only interpersonal regulation was significantly moderated by clients' pre-to-post session functioning. Specifically, sessions where clients led positive dyadic RSA associations showed greater improvement in clients' functioning than those led by therapists.

CONCLUSION

Physiological interpersonal regulation, measured by RSA, may be a catalyst for change in depression treatment. Therapists who are responsive to clients' arousal levels may help clients improve their functioning.

Cortisol interdependence during psychotherapy in major depressive disorder

The current study explored cortisol interdependence between patients and therapists during psychotherapy, the possible moderating effect of patient alliance ratings on this interdependence, and the associations between cortisol interdependence and treatment outcome. While cortisol interdependence was explored in other interpersonal contexts, its presence in psychotherapy has remained unexplored. We hypothesized that (a) patients' and therapists' cortisol levels at pre-session will predict their own and their partner's subsequent cortisol levels at post-session, (b) patient ratings of their relationship with their therapists will moderate these partner effects, and (c) cortisol interdependence will be associated with better treatment outcome. Fifty dyads undergoing 16 weeks of psychodynamic treatment for major depressive disorder participated in this study. Patient-therapist salivary cortisol samples were collected at eight time points, alongside a post-session patient-rated alliance questionnaire and a symptom severity interview. For analyses we employed the actor-partner interdependence model. Results revealed that (a) patients' and therapists' cortisol levels before sessions predicted their own post-session cortisol changes. However, significant cortisol interdependence was observed in patients' pre-session cortisol levels predicting therapists' post-session cortisol levels. Furthermore, (b) poorer alliance ratings associated with more pronounced cortisol interdependence, and (c) in dyads where patient pre-session cortisol predicted therapist's post-session cortisol, a better treatment outcome was found. This study found novel evidence of cortisol interdependence in psychotherapy and is partially in line with other studies inspecting cortisol interdependence in adjacent research fields. These findings emphasize the intricate psychophysiological interactions within therapeutic relationships and their associations with treatment outcome.

Leveraging Novel Technologies and Artificial Intelligence to Advance Practice-Oriented Research

Mental health services are experiencing notable transformations as innovative technologies and artificial intelligence (AI) are increasingly utilized in a growing number of studies and services.These cutting-edge technologies carry the promise of substantial improvements in the field of mental health. Nevertheless, questions emerge about the alignment of novel technologies and AI systems with human needs, especially in the context of vulnerable populations receiving mental healthcare. The practice-oriented research (POR) model is pivotal in seamlessly integrating these emerging technologies into clinical research and practice. It underscores the importance of tight collaboration between clinicians and researchers, all driven by the central goal of ensuring and elevating client well-being. This paper focuses on how novel technologies can enhance the POR model and highlights its pivotal role in integrating these technologies into clinical research and practice. We discuss two key phases: pre-treatment, and during treatment. For each phase, we describe the challenges, present the major technological innovations, describe recent studies exemplifying technology use, and suggest future directions. Ethical concerns and the importance of aligning humans and technology are also considered, in addition to implications for practice and training.

Therapy matchmaking: Patient-therapist match in personality traits and attachment style

OBJECTIVE

This study examined the relationships between patient-therapist similarity and therapy outcome. We aimed to explore whether patient-therapist match in personality and attachment styles leads to a better therapy outcome.

METHOD

We collected data from 77 patient-therapist dyads in short-term dynamic therapy. Patients' and therapists' personality traits (Big-5 Inventory) and attachment styles (ECR) were assessed prior to beginning therapy. Outcome was measured on the OQ-45.

RESULTS

When patients and therapists scored either high or low on neuroticism and conscientiousness we found a decrease in symptoms from beginning to end of therapy. When patients' and therapists' combined scores were either high or low on attachment anxiety, we found an increase in symptoms.

CONCLUSION

Match or mismatch on personality and attachment style in therapy dyads contributes to therapy outcome.

Impact of facemasks on psychotherapy: Clinician's confidence and emotion recognition

OBJECTIVES

Facial emotion recognition is a key component of human interactions, and in clinical relationships contributes to building and maintaining the therapeutic alliance with patients. The introduction of facemasks has reduced the availability of facial information in private and professional relationships. This study aimed to assess the impact of facemasks on clinicians' perception of clinical interactions as well as their ability to read facial expressions.

METHODS

In this cross-sectional study, a purposive sample of 342 clinical psychologists or psychotherapists completed an online survey including the assessment of burnout, alexithymia, emotion dysregulation, and self-perceived ability to build effective relationships and communication with patients with/without facemasks. Participants were randomly assigned to the standardized facial emotion recognition task Diagnostic Analysis of Nonverbal Accuracy FACES 2-Adult Faces including 24 faces representing anger, fear, sadness, and happiness.

RESULTS

Facemasks impaired the self-perceived ability of clinicians to build effective relationships and communicate with patients and reduced satisfaction in clinical encounters. The ability of clinicians to recognize facial emotions is significantly reduced for masked happy and angry faces, but not for sad and afraid ones. The perceived difficulty in building good relationships and communication with patients had a positive correlation with alexithymia and emotion dysregulation; higher levels of discomfort when wearing facemasks had a positive correlation with burnout and emotion dysregulation.

CONCLUSION

Facemasks reduced clinicians' self-confidence in clinical encounters with patients wearing facemasks, but their facial emotion recognition performance was only partially impaired.

Facilitating dyadic synchrony in psychotherapy sessions: Systematic review and meta-analysis

Objective: This paper highlights the facilitation of dyadic synchrony as a core psychotherapist skill that occurs at the non-verbal level and underlies many other therapeutic methods. We define dyadic synchrony, differentiate it from similar constructs, and provide an excerpt illustrating dyadic synchrony in a psychotherapy session. Method: We then present a systematic review of 17 studies that have examined the associations between dyadic synchrony and psychotherapy outcomes. We also conduct a meta-analysis of 8 studies that examined whether there is more synchrony between clients and therapists than would be expected by chance. Results: Weighted box score analysis revealed that the overall association of synchrony and proximal as well as distal outcomes was neutral to mildly positive. The results of the meta-analysis indicated that real client-therapist dyad pairs exhibited synchronized behavioral patterns to a much greater extent than a sample of randomly paired people who did not actually speak. Conclusion: Our discussion revolves around how synchrony can be facilitated in a beneficial way, as well as situations in which it may not be beneficial. We conclude with training implications and therapeutic practices.

It's not what you said, it's how you said it: An analysis of therapist vocal features during psychotherapy

Psychotherapy is a conversation, whereby, at its foundation, many interventions are derived from the therapist talking. Research suggests that the voice can convey a variety of emotional and social information, and individuals may change their voice based on the context and content of the conversation (e.g., talking to a baby or delivering difficult news to patients with cancer). As such, therapists may adjust aspects of their voice throughout a therapy session depending on if they are beginning a therapy session and checking in with a client, conducting more therapeutic "work," or ending the session. In this study, we modeled three vocal features-pitch, energy, and rate-with linear and quadratic multilevel models to understand how therapists' vocal features change throughout a therapy session. We hypothesized that all three vocal features would be best fit with a quadratic function - starting high and more congruent with a conversational voice, decreasing during the middle portions of therapy where more therapeutic interventions were being administered, and increasing again at the end of the session. Results indicated a quadratic model for all three vocal features was superior in fitting the data, as compared to a linear model, suggesting that therapists begin and end therapy using a different style of voice than in the middle of a session.

multiSyncPy: A Python package for assessing multivariate coordination dynamics

In order to support the burgeoning field of research into intra- and interpersonal synchrony, we present an open-source software package: multiSyncPy. Multivariate synchrony goes beyond the bivariate case and can be useful for quantifying how groups, teams, and families coordinate their behaviors, or estimating the degree to which multiple modalities from an individual become synchronized. Our package includes state-of-the-art multivariate methods including symbolic entropy, multidimensional recurrence quantification analysis, coherence (with an additional sum-normalized modification), the cluster-phase 'Rho' metric, and a statistical test based on the Kuramoto order parameter. We also include functions for two surrogation techniques to compare the observed coordination dynamics with chance levels and a windowing function to examine time-varying coordination for most of the measures. Taken together, our collation and presentation of these methods make the study of interpersonal synchronization and coordination dynamics applicable to larger, more complex and often more ecologically valid study designs. In this work, we summarize the relevant theoretical background and present illustrative practical examples, lessons learned, as well as guidance for the usage of our package - using synthetic as well as empirical data. Furthermore, we provide a discussion of our work and software and outline interesting further directions and perspectives. multiSyncPy is freely available under the LGPL license at: https://github.com/cslab-hub/multiSyncPy , and also available at the Python package index.

The alliance in mental health care: conceptualization, evidence and clinical applications

The concept of alliance reflects the collaborative relationship between a clinician and a patient, defined as consisting of three elements: a) the agreement on the goals of treatment; b) the agreement on a task or series of tasks; c) the development of a bond. Although much of the theory and research on the alliance comes from the domain of psychotherapy, the concept is applicable to any practice involving a person seeking help and a socially sanctioned healer. An extensive research evidence suggests that the alliance (typically measured at the third or fourth session) is a robust predictor of the outcomes of various forms of psychotherapy, even when prior symptom improvement and other factors are considered. Both the clinician and the patient bring to the therapy situation different capacities to form an alliance. Factors concerning the patient include, among others, the diagnosis, attachment history and style, motivation, and needs for affiliation. However, the benefits of the alliance have been found to be mostly due to the therapist's contribution, in particular his/her facilitative interpersonal skills, including verbal fluency, communication of hope and positive expectations, persuasiveness, emotional expression; warmth, acceptance and understanding; empathy, and alliance rupture-repair responsiveness. Placebo studies have allowed to experimentally manipulate aspects of the relationship between a therapist and a patient in non-psychotherapy contexts. In these settings, two components of the relationship have emerged: an emotional one (involving being cared for and understood by the clinician) and a cognitive one (including the belief in the competence of the therapist to select and administer an effective treatment). Here we propose a model that describes three pathways through which the alliance creates benefits, named CARE (caring, attentive, real and empathic), EXPECTANCY, and SPECIFIC. Although research and clinical attention have mostly focused on the alliance between a clinician and a patient in face-to-face interactions, there is preliminary evidence concerning the alliance between patients and other clinic staff, systems of care, or the program in Internet-mediated services. These new research areas clearly require further development.

Understanding the role of emotion and expertise in psychotherapy: An application of dynamical systems mathematical modeling to an entire course of therapy

Introduction

The therapeutic relationship continues to be one of the most important factors in therapeutic outcomes. Given the place of emotion in the definition of the therapeutic relationship, as well as the demonstrated positive impact that emotional expression has on therapeutic process and outcome, it stands to reason that studying the emotional exchange between the therapist and client further would be warranted.

Methods

This study used a validated observational coding system--the Specific Affect Coding System (SPAFF) and a theoretical mathematical model to analyze behaviors which make up the therapeutic relationship. Specifically, the researchers used to codify relationship-building behaviors between an expert therapist and his client over the course of six sessions. Dynamical systems mathematical modeling was also employed to create "phase space portraits" depicting the relational dynamics between the master therapist and his client over six sessions.

Results

Statistical analysis was used to compare SPAFF codes and model parameters between the expert therapist and his client. The expert therapist showed stability in affect codes over six sessions while the client's affect codes appeared to be more flexible over time, though model parameters remained stable across the six sessions. Finally, phase space portraits depicted the evolution of the affective dynamics between the master therapist and his client as the relationship matured.

Discussion

The clinician's ability to stay emotionally positive and relatively stable across the six sessions (relative to the client) was noteworthy. It formed the basis for a stable base from which she could explore alternative methods to relate to others that she had allowed to dictate her actions, which is in keeping with previous research on the role of therapist facilitation of the therapeutic relationship, emotional expression within the therapeutic relationship, and influence of these on client outcomes. These results provide a valuable foundation for future research on emotional expression as a key component of the therapeutic relationship in psychotherapy.

Withdrawal ruptures in adolescents with borderline personality disorder psychotherapy are marked by increased speech pauses-can minimal responses be automatically detected?

Alliance ruptures of the withdrawal type are prevalent in adolescents with borderline personality disorder (BPD). Longer speech pauses are negatively perceived by these patients. Safran and Muran's rupture model is promising but its application is very work intensive. This workload makes research costly and limits clinical usage. We hypothesised that pauses can be used to automatically detect one of the markers of the rupture model i.e. the minimal response marker. Additionally, the association of withdrawal ruptures with pauses was investigated. A total of 516 ruptures occurring in 242 psychotherapy sessions collected in 22 psychotherapies of adolescent patients with BPD and subthreshold BPD were investigated. Trained observers detected ruptures based on video and audio recordings. In contrast, pauses were automatically marked in the audio-recordings of the psychotherapy sessions and automatic speaker diarisation was used to determine the speaker-switching patterns in which the pauses occur. A random forest classifier detected time frames in which ruptures with the minimal response marker occurred based on the quantity of pauses. Performance was very good with an area under the ROC curve of 0.89. Pauses which were both preceded and followed by therapist speech were the most important predictors for minimal response ruptures. Research costs can be reduced by using machine learning techniques instead of manual rating for rupture detection. In combination with other video and audio derived features like movement analysis or automatic facial emotion detection, more complete rupture detection might be possible in the future. These innovative machine learning techniques help to narrow down the mechanisms of change of psychotherapy, here specifically of the therapeutic alliance. They might also be used to technologically augment psychotherapy training and supervision.

Connecting and Healing: The Role of Existential Isolation in Mediating the Impact of the Therapeutic Relationship on Canadian Men's Mental Health Outcomes

The therapeutic relationship has emerged as one of the most important components of successful treatment outcomes, regardless of the specific form of therapy. Research has now turned its attention to better understanding how the therapeutic relationship contributes to patient improvement. Extant literature contends that a strong therapeutic relationship may help reduce a patient's sense of existential isolation (i.e., a sense of not feeling understood by others). Research indicates that existential isolation might be especially problematic for men, potentially increasing their risk for suicidality. This study investigated the association between strength of the therapeutic relationship and psychological distress and suicidality among men who received psychotherapy, and whether existential isolation mediated this association. A total of 204 Canadian men who had previously attended psychotherapy participated in a cross-sectional survey, completing measures of the quality of their most recent therapeutic relationship, existential isolation, depression and anxiety symptoms, and suicidality. Regression with mediation analysis was conducted. Two models were tested; one with depression/anxiety symptoms as the dependent variable and the other with suicidality as the dependent variable. Both mediation models emerged as significant, indicating an indirect effect for quality of the therapeutic relationship on symptoms of anxiety/depression and suicidality through existential isolation. The findings suggest that a positive therapeutic relationship can contribute to men feeling less isolated in their experiences in life (i.e., less existentially isolated), thereby helping mitigate psychological distress and suicidality.

The therapeutic alliance in cognitive-behavioral therapy for obsessive-compulsive disorder: A systematic review and meta-analysis

Background

The therapeutic alliance has been recognized as one of the most researched key elements of treatment across different therapeutic approaches and diagnostic domains. Despite its importance, our current understanding of its clinical relevance in patients with obsessive-compulsive disorder (OCD) is still debated. This study aimed to examine empirical evidence on the effect of alliance on treatment outcomes in Cognitive Behavioral Therapy (CBT) in patients with OCD in a systematic review and meta-analysis.

Methods

Original peer-reviewed articles until March 2022 were included if they were (1) written in English; (2) included a clinical group with a current primary OCD diagnosis; (3) involved individual CBT; (4) used a validated therapeutic alliance scale that was related to the outcome measurement; (5) reported an effect size.

Results

Thirteen studies were included, six of which contained sufficient statistical information to be included in the meta-analysis. A total of 897 patients took part in all reviewed studies. We found a modest effect of alliance on post-treatment outcome [Tau 2 = -0.1562 (C.I. 95%: -0.2542 to -0.0582)].

Discussion

The results show the existence of considerable variability and methodological inconsistencies across studies. We discuss the role of methodological factors that could account for this divergence, the research limitations, and the implications for current research.

Systematic review registration

[https://osf.io/dxez5/?view_only=bc2deaa7f0794c8dbef440255b2d4b3b].

A Qualitative Study on Patients’ Use of Emotion Regulation Strategies During Therapeutic Relationships

Introduction

Emotion regulation may be an important tool that therapists and patients use to build and maintain therapeutic relationships. This exploratory study investigates how patients use intrapersonal and interpersonal emotion regulation strategies during interactions with occupational therapists and physiotherapists.

Methods

A two-staged qualitative study was conducted. In the first stage 11 patients were interviewed regarding their use of emotion regulation during their therapeutic relationships. In the second stage, 14 patient/therapist dyads were observed during the course of the therapeutic relationship and then interviewed individually at the end of the relationship.

Results

Patients utilise the full range of intrapersonal emotion regulation strategies that can be categorised in Gross’s (1998) process model of emotion regulation including situation selection, situation modification, attentional deployment, cognitive reappraisal and response modulation. They used interpersonal emotion regulation strategies to a lesser extent, only reporting using strategies that fit into one of the four interpersonal emotion regulation strategies identified Williams’ (2007), altering the situation.

Conclusions

This study makes an important contribution to research on patients’ contribution to therapeutic relationship development/maintenance. It is the first study to explore patients use of intrapersonal and interpersonal emotion regulation in response to negative and positive emotions arising from interactions with therapists.

Studying Physiological Synchrony in Couple Therapy through Partial Directed Coherence: Associations with the Therapeutic Alliance and Meaning Construction

In line with the growing recognition of the role of embodiment, affect and implicit processes in psychotherapy, several recent studies examine the role of physiological synchrony in the process and outcome of psychotherapy. This study aims to introduce Partial Directed Coherence (PDC) as a novel approach to calculating psychophysiological synchrony and examine its potential to contribute to our understanding of the therapy process. The study adopts a single-case, mixed-method design and examines physiological synchrony in one-couple therapy in relation to the therapeutic alliance and a narrative analysis of meaning construction in the sessions. Interpersonal Physiological Synchrony (IPS) was calculated, via a windowed approach, through PDC of a Heart Rate Variability-derived physiological index, which was measured in the third and penultimate sessions. Our mixed-method analysis shows that PDC quantified significant moments of IPS within and across the sessions, modeling the characteristics of interpersonal interaction as well as the effects of therapy on the interactional dynamics. The findings of this study point to the complex interplay between explicit and implicit levels of interaction and the potential contribution of including physiological synchrony in the study of interactional processes in psychotherapy.

Covert therapeutic micro-processes in non-recovered eating disorders with childhood trauma: an interpersonal process recall study

METHOD

To uncover therapeutic micro-processes from the perspectives of eating disorder (ED) treatment non-responders with childhood trauma (CT) late effects, we explored in-session experiences of poor long-term outcome patients. Female inpatients aged 28-59 (M = 40.2, SD = 5.0) from a randomised trial comparing Compassion Focused Therapy for EDs (n = 3) with Cognitive Behavioural Therapy for EDs (n = 3) were interviewed with video-assisted recall about a self-selected session. Data were analysed through Interpretative Phenomenological Analysis (IPA) with Grounded Theory (GT) elements.

RESULTS

Covert patient strategies included self-effacement, regulating therapeutic distance to open up, and engaging with reflective rather than experiential interventions. First, self-effacement included submissive, passive or pretend responses to perceived criticising or violating therapist behaviours as well as other orientation and submission for approval. Second, some preferred a close patient-therapist alliance with therapist self-disclosure and reciprocity was a requirement for opening up; others required distance. Third, informants detached from experiential trauma work while engaging in joint reflection on post-trauma responses.

CONCLUSION

Informants were preoccupied with calibrating the emotional-relational landscape in session; we hypothesized that psychological insecurity and affective intolerance from CT limit their freedom to explore own in-session experiences.

Healing in a Social Context: The Importance of Clinician and Patient Relationship

When a patient presents to a health provider, the course of the disorder is composed of three effects: natural effects, specific effects, and contextual effects. Part of the contextual effect is due to the relationship between the healer and the patient. Social healing appears to be present in eusocial species and particularly well-developed in humans. Evidence for the importance of the relationship in healing is found in placebo studies, including placebo analgesics, medicine, and psychotherapy. Although the theory for how the relationship is therapeutic is not well-developed, four possible mechanisms are discussed. The implications for health care and the treatment of pain are discussed.

Exploring Conversational and Physiological Aspects of Psychotherapy Talk

This study is part of a larger exploration of 'talk and cure' that combines the examination of talk-in-interaction with nonverbal displays and measurements of the client's and therapist's autonomic arousal during therapy sessions. A key assumption of the study is that psychotherapy entails processes of intersubjective meaning-making that occur across different modalities and take place in both verbal/explicit and nonverbal/implicit domains. A single session of a psychodynamic psychotherapy is analyzed with a focus on the expression and management of affect, with an aim to describe key interactive events that promote change in both semantic and procedural domains. The clinical dialog is analyzed discursively, with a focus on the conversational processes through which new meanings are jointly constructed and affective states shared; detailed attention is paid to nonverbal displays of affiliation and affect. Furthermore, we explore whether the interactional patterns implicated in joint meaning-making, as revealed by analyzing the therapeutic conversation, have correlates in the autonomic arousal of the two protagonists, as reflected in their heart rates. Conversation analysis has still untapped potential to illuminate interactional patterns that underlie the practice of psychotherapy. In this exploratory study we suggest that discursive analyses of talk-in-interaction can be enriched through detailed focus on nonverbal displays as well as measures of physiological arousal. Drawing upon the analysis, we suggest that bringing the methodological strengths of language-based analysis into fertile dialog with embodied quantitative data can help our explorations of what's really going on in psychotherapy.

Schema therapy versus cognitive behavioral therapy versus individual supportive therapy for depression in an inpatient and day clinic setting: study protocol of the OPTIMA-RCT

BACKGROUND

Major depressive disorder represents (MDD) a major cause of disability and disease burden. Beside antidepressant medication, psychotherapy is a key approach of treatment. Schema therapy has been shown to be effective in the treatment of psychiatric disorders, especially personality disorders, in a variety of settings and patient groups. Nevertheless, there is no evidence on its effectiveness for MDD in an inpatient nor day clinic setting and little is known about the factors that drive treatment response in such a target group.

METHODS

In the current protocol, we outline OPTIMA (OPtimized Treatment Identification at the MAx Planck Institute): a single-center randomized controlled trial of schema therapy as a treatment approach for MDD in an inpatient and day clinic setting. Over the course of 7 weeks, we compare schema therapy with cognitive behavioral therapy and individual supportive therapy, conducted in individual and group sessions and with no restrictions regarding concurrent antidepressant medication, thus approximating real-life treatment conditions. N = 300 depressed patients are included. All study therapists undergo a specific training and supervision and therapy adherence is assessed. Primary outcome is depressive symptom severity as self-assessment (Beck Depression Inventory-II) and secondary outcomes are clinical ratings of MDD (Montgomery-Asberg Depression Rating Scale), recovery rates after 7 weeks according to the Munich-Composite International Diagnostic Interview, general psychopathology (Brief Symptom Inventory), global functioning (World Health Organization Disability Assessment Schedule), and clinical parameters such as dropout rates. Further parameters on a behavioral, cognitive, psychophysiological, and biological level are measured before, during and after treatment and in 2 follow-up assessments after 6 and 24 months after end of treatment.

DISCUSSION

To our knowledge, the OPTIMA-Trial is the first to investigate the effectiveness of schema therapy as a treatment approach of MDD, to investigate mechanisms of change, and explore predictors of treatment response in an inpatient and day clinic setting by using such a wide range of parameters. Insights from OPTIMA will allow more integrative approaches of psychotherapy of MDD. Especially, the identification of intervention-specific markers of treatment response can improve evidence-based clinical decision for individualizing treatment.

TRIAL REGISTRATION

Identifier on clinicaltrials.gov : NCT03287362 ; September, 12, 2017.

Supervised Speaker Diarization Using Random Forests: A Tool for Psychotherapy Process Research

Speaker diarization is the practice of determining who speaks when in audio recordings. Psychotherapy research often relies on labor intensive manual diarization. Unsupervised methods are available but yield higher error rates. We present a method for supervised speaker diarization based on random forests. It can be considered a compromise between commonly used labor-intensive manual coding and fully automated procedures. The method is validated using the EMRAI synthetic speech corpus and is made publicly available. It yields low diarization error rates (M: 5.61%, STD: 2.19). Supervised speaker diarization is a promising method for psychotherapy research and similar fields.

Learning from clinicians' positive inclination to suicidal patients: A grounded theory model

Despite experts' contention that clinicians' positive inclination is essential to successful treatment of patients at risk for suicide (PRS), research in the area is lacking. This study used grounded theory to develop a model of clinicians' positive inclination based on interviews with 12 clinicians who "liked" working with PRS. The core process identified, a state of emotional synchrony through deep connection between clinicians and PRS, appeared to provide an intersubjective emotion regulation, associated with distress reduction in patients and deep satisfaction in clinicians. Findings suggest clinicians' deep sense of satisfaction and PRS' clinical improvement in treatment could be interdependent.