Empathy, Challenge, and Psychophysiological Activation in Therapist-Client Interaction

Could neurofeedback improve therapist-patient communication? Considering the potential for neuroscience informed examinations of the psychotherapeutic relationship

Empathic communication between a patient and therapist is an essential component of psychotherapy. However, finding objective neural markers of the quality of the psychotherapeutic relationship have been elusive. Here we conceptualize how a neuroscience-informed approach involving real-time neurofeedback, facilitated via existing functional magnetic resonance imaging (fMRI) and electroencephalography (EEG) technologies, could provide objective information for facilitating therapeutic rapport. We propose several neurofeedback-assisted psychotherapy (NF-AP) approaches that could be studied as a way to optimize the experience of the individual patient and therapist across the spectrum of psychotherapeutic treatment. Finally, we consider how the possible strengths of these approaches are balanced by their current limitations and discuss the future prospects of NF-AP.

Data mining techniques in psychotherapy: applications for studying therapeutic alliance

Therapeutic Alliance (TA) has been consistently reported as a robust predictor of therapy outcomes and is one of the most investigated therapy relational factors. Research on therapists' and clients' contributions to the alliance development and the alliance-outcome relationship had shown mixed results. The relation of the therapist's and client's biological markers with the alliance is an important and under-investigated topic. Taking advantage of data mining techniques, this exploratory study aimed to investigate the role of different therapist and client factors, including heart rate (HR) and electrodermal activity (EDA), in relation to TA. Twenty-two dyads with 6 therapists and 22 clients participated in the study. The Working Alliance Inventory (WAI) was used to evaluate the client's and therapist's perception of the alliance at the end of each session and through the therapy processes. The Cross-Industry Standard Process for Data Mining (CRISP-DM) was used to explore patterns that may contribute to TA. Machine Learning (ML) models have been employed to provide insights into the predictors and correlates of TA. Our results showed that Linear Regression (LR) was the best technique for predicting the therapist's TA, with client "Diagnostic" and therapy "Termination" being identified as significant predictors of the therapist's TA. In addition, for clients' TA, the Random Forest (RF) was shown to have the best performance. The therapist's TA and therapy "Outcome" were observed as the most influential predictors for the client's TA. In addition, while the Heart Rate (therapist) was negatively associated with the therapist's TA, EDA in the client was a physiological indicator related to the client's TA. Overall, these findings can assist in identifying key factors that therapists should focus on to enhance the quality of therapeutic alliance. Results are discussed in terms of their consistency with empirical literature, innovative and interdisciplinary research on the therapeutic alliance field, and, in particular, the use of the Data Mining approach in a psychotherapy context.

Discursive angles on the relationship in psychotherapy

Research on the psychotherapy relationship has been dominated by quantitative-statistical paradigms that focus on relationship elements and their (evidence-based) effectiveness regarding the psychotherapy process. In this mini review, we complement this existing line of research with a discursive-interactional view that focuses on how the relationship is accomplished between therapists and clients. Our review highlights some of the main studies that use micro-analytic, interactional methods to explore relationship construction of the following elements: Affiliation, cooperation (Alignment), empathy and Disaffiliation-Repair. We not only provide a summary of important discursive work that provides a unique lens on how the relationship may be established and maintained, but also suggest that this kind of micro-analytic approach can offer more nuanced conceptualizations of the relationship by showing how different elements work together in a synergistic manner.

A Systematic Review of the Use of T-Pattern and T-String Analysis (TPA) With Theme: An Analysis Using Mixed Methods and Data Mining Techniques

In recent years, research interest in human and non-human behavioral analysis has increased significantly. One key element in the resulting studies is the use of software that facilitates comparative analysis of behavioral patterns, such as using T-Pattern and T-String analysis -TPA- with THEME. Furthermore, all these studies use mixed methods research. Results from these studies have indicated a certain amount of similarity between the biological, temporal, and spatial patterns of human social interactions and the interactions between the contents of their constituent cells. TPA has become an important, widely-used technique in applied behavioral science research. The objectives of the current review were: (1) To identify the results of research over the last 4 years related to the concepts of T-Pattern, TPA, and THEME, since it is in this period in which more publications on these topics have been detected (2) To examine the key concepts and areas in the selected articles with respect to those concepts, applying data and text mining techniques. The results indicate that, over the last 4 years, 20% of the studies were laboratory focused with non-humans, 18% were in sports environments, 9% were in psychological therapy environments and 9% were in natural human contexts. There were also indications that TPA is beginning to be used in workplace environments, which is a very promising setting for future research in this area.

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.

Sprechen und Schweigen in der Psychotherapie

Das Gespräch hat in jeder Psychotherapie eine zentrale Stellung. „Gesprächstherapie“ ist deshalb irreführend für eine besondere Art der Therapeutik. Im Folgenden wird von Analytiker(in) gesprochen, wenn diese Tradition gemeint ist, ansonsten von Therapeut(en) und Therapeutin. Probleme der Vertraulichkeit bei der Erforschung von Gesprächen können gut und sicher gelöst werden. Die Erforschung der therapeutischen Konversation ist weit vorangetrieben, von psychoanalytischer Seite und anderen weltweit. Da so wichtige Gesprächsmomente wie Schweigen und Erzählen vertieft verstanden werden konnten, wird ein „communicative turn“ vorgeschlagen: nicht länger eine jeweilige Psychotherapietheorie als Ausgangspunkt einer Untersuchung zu wählen, sondern das Gespräch selbst. Dazu werden Forschungsergebnisse mit Bezug zur klinischen Arbeit vorgestellt. Sie sind klinisch gehaltvoll.

Autonomic changes as reaction to experimental social stress in an inpatient psychosomatic cohort

OBJECTIVES

Patients with psychosomatic disorders suffer from social isolation that might further lead to destabilization and exacerbation of bodily symptoms via autonomic pathways. We aimed to investigate the influence of controlled social stress (model of social ostracism) on the autonomic nerve system (ANS) in an inpatient cohort with psychosomatic disorders.

METHODS

We examined heart rate variability (HRV), skin conductance (SC) and skin temperature (ST) as well as ECG-derived respiration rate (EDR) and subjective reports on stress during exposure to experimental social stress (cyberball game). Data were collected from 123 participants (f:m = 88:35, 42.01 ± 13.54 years) on admission and upon discharge from the university psychosomatic clinic. All data were recorded during baseline, inclusion and exclusion phases of the cyberball game as well as during the recovery phase.

RESULTS

We found significant changes between admission and discharge with a decline in parasympathetic-related HRV parameters (SDRR -3.20 ± 1.30 ms, p = 0.026; RMSSD: -3.77 ± 1.28 ms, p = 0.007) as well as a decrease in SC (-0.04 ± 0.17 μS, p = 0.019) and EDR (-0.01 ± 0.01 Hz, p = 0.007), suggesting a drop in sympathetic tonus, with no changes in ST (p = 0.089) and subjective stress levels (p = 0.322). HRV parameters decreased during the cyberball game (SDRR p = 0.026; RMSSD p = 0.002; lnHF p < 0.001). In contrast, both SC (p < 0.001) and EDR (p < 0.001) increased during the game with SC being slightly lower during the exclusion phase. This can point toward a stimulation of sympathetic nervous system during game participation, which was concordant with the rise in subjective stress values (p < 0.001). ST showed a continuous, unspecific rise over time (p < 0.001).

CONCLUSION

Our data demonstrate the decrease of ANS parameters during experimental social stress when data upon discharge were compared to those upon admission. These results are partially contradictory to previous studies that showed a rise in HRV in a psychiatric cohort over the course of (outpatient) treatment. Further research is required to help attributing these differences to effects of treatment or acute states relating to admission to or discharge from a psychosomatic department.

Doing Contrariness: Therapeutic Talk-In-Interaction in a Single Therapy Session With a Traumatized Child

Conversation analysis (CA) of children-adult-interaction in various contexts has become an established field of research. However, child therapy has received limited attention in CA. In child therapy, the general psychotherapeutic practice of achieving empathy faces particular challenges. In relation to this, our contribution sets out three issues for investigation and analysis: the first one is that practices of achieving empathy must be preceded by efforts aiming to establish which kind of individualized conversation works with this child (Midgley, 2006). Psychotherapy process researchers in adult therapy (Stiles et al., 2015) have found that therapists "invent" a new therapy for each patient (Norcross and Wampold, 2018). The second issue is that it can be difficult for adults to understand the ways in which children express their conflicts and issues. In particular, play activities in therapy, e.g., with dolls, can open up additional scenarios of interaction. The play scenario can be used to disclose unformulated problems masked in everyday and family interactions. The third issue is how to respect the child's higher degree of vulnerability, compared with adult patients. How is it communicated and dealt with in therapy? We present an interaction analysis of a single case study of the first 20 min of a child therapy session with an adopted girl aged 4 years brought to treatment because of "unexplainable rage." The session was videotaped; parents granted permission. We analyze this session using an applied version of CA. In our analysis, we describe "doing contrariness," as a conversational practice producing epistemic and affiliative disruptions, while "avoiding doing contrariness" and "remedying contrariness" are strategies for preserving or restoring the affiliative dimension of a relationship (in child therapy). We show how these practices operate in various modes and how they are used by both parties in our case study to variously aid and impedethe achievement of empathy and understanding.

Physiological responses to proposals during dyadic decision-making conversations

A novel conversation-analytically informed paradigm was used to examine how joint decision-making interaction, with its various types of proposal sequences, is reflected in the physiological responses of participants. Two types of dyads–dyads with one depressed and one non-depressed participant (N = 15) and dyads with two non-depressed participants (N = 15)–engaged in a series of conversational joint decision-making tasks, during which we measured their skin conductance (SC) responses. We found that the participants’ SC response rates were higher and more synchronized during proposal sequences than elsewhere in the conversation. Furthermore, SC response rates were higher when the participant was in the role of a proposal speaker (vs. a proposal recipient), and making a proposal was associated with higher SC response rates for participants with depression (vs. participants without depression). Moreover, the SC response rates in the proposal speaker were higher when the recipient accepted (vs. not accepted) the proposal. We interpret this finding with reference to accepting responses suggesting a commitment to future action, for which the proposal speaker may feel specifically responsible for. A better understanding of the physiological underpinnings of joint decision-making interaction may help improve democratic practices in contexts where certain individuals experience challenges in this regard.

A quasi-experimental pilot study to the effects of Responsive Aggression Regulation Therapy (Re-ART) Outpatient for young adults

It is important to provide treatment for juvenile and young adult violent offenders, since no or (too) late treatment increases the risk of recidivism and persistent aggressive behavior in adulthood. In this study, we investigated the efficacy of the intervention Responsive Aggression Regulation Therapy (Re-ART) Outpatient, which has been developed for adolescents and young adults between 16 and 24 years old with severe aggression problems. This quasi-experimental (pilot) study compared the effects of Re-ART Outpatient (n = 47) with a control group (n = 29) receiving treatment as usual on measures regarding risk of violent recidivism, impulsivity, emotional/personal functioning, family functioning, motivation, handling anger, self-reported problem behavior, coping skills, and cognitive distortions. Re-ART showed significantly better results than the control group on risk of violent recidivism, impulsivity, emotional/personal functioning, motivation, handling anger, certain coping skills, and certain cognitive distortions. Family functioning and self-reported rule-breaking behavior did not differ significantly between the groups. The results implicate that Re-ART is a promising outpatient intervention for young adults with severe aggressive behavior. The results can be explained by the fact that Re-ART treats both systemically and individually and pays specific attention to stress reduction and the improvement of executive functions.

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.

A Mixed Methods Framework for Psychoanalytic Group Therapy: From Qualitative Records to a Quantitative Approach Using T-Pattern, Lag Sequential, and Polar Coordinate Analyses

Conducted within a mixed methods framework, this study focuses on the conversation-facilitation role of a lead therapist during group psychotherapy with adolescents. Conversation is an essential component of psychoanalytic psychotherapies and there is growing interest in describing and studying the impact of conversational techniques. One way to do this is to report on specific approaches, such as questioning, paraphrasing, and mentalization in intervention turns and to analyze their impact on the therapist-patient relationship. The main aim of this study was to investigate differences in communication strategies used by a lead therapist in the early and late stages of therapy with six adolescents aged 13-15 years. We employed a mixed methods design based on systematic direct observation supplemented by indirect observation. The observational methodology design was nomothetic, follow-up, and multidimensional. The choice of methodology is justified by our use of an ad hoc observation instrument for communication strategies combining a field format and a category system. We analyzed interobserver agreement quantitatively by Cohen's kappa using GSEQ5 software. Following confirmation of the reliability of the data, we analyzed the lead therapist's conversation-facilitation techniques in sessions 5 and 29 of a 30-session program by quantitatively analyzing what were initially qualitative data using T-pattern detection (THEME v.6 Edu software), lag sequential analysis (GSEQ5 software), and polar coordinate analysis (HOISAN v. 1.6.3.3.6. software and R software). The results show changes in the techniques used from the start to the end of therapy. Of the 28 communication strategies analyzed, three were particularly common: questioning and paraphrasing in session 5 and questioning and mentalization in session 29. This mixed methods study shows that combined use of T-pattern detection, lag sequential analysis, and polar coordinate analysis can offer meaningful and objective insights into group psychotherapy through the lens of the therapist.

Incorporating physiology into the study of psychotherapy process

Increasing evidence indicates that psychological factors important to therapy effectiveness are associated with physiological activity. Knowledge of the physiological correlates of therapy process variables has the potential to provide unique insights into how and why therapy works, but little is currently known about the physiological underpinnings of specific therapy processes that facilitate client growth and change. The goal of this article is to introduce therapy process researchers to the use of physiological methods for studying therapy process variables. We do this by (a) presenting a conceptual framework for the study of therapy process variables, (b) providing an introductory overview of physiological systems with particular promise for the study of therapy process variables, (c) introducing the primary methods and methodological decisions involved in physiological research, and (d) demonstrating these principles and methods in a case of therapeutic presence during couple therapy. We close with a discussion of the promise and challenges in the study of physiological correlates of therapy process variables and consideration of future challenges and open questions in this line of research. Online supplemental materials include additional resources for therapy process researchers interested in getting started with physiological research. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

A Dual Route Model for Regulating Emotions: Comparing Models, Techniques and Biological Mechanisms

The aim of this article is to present recent applications of emotion regulation theory and methods to the field of psychotherapy. The term Emotion Regulation refers to the neurocognitive mechanisms by which we regulate the onset, strength, and the eventual expression of our emotions. Deficits in the regulation of emotions have been linked to most, if not all, psychiatric disorders, with patients presenting either dysregulated emotions, or dysfunctional regulatory strategies. We discuss the implications of regulating emotions from two different theoretical perspectives: the Cognitive Emotion Regulation (CER), and the Experiential-Dynamic Emotion Regulation (EDER) model. Each proposes different views on how emotions are generated, dysregulated and regulated. These perspectives directly influence the way clinicians treat such problems. The CER model views emotional dysregulation as due to a deficit in regulation mechanisms that prioritizes modifying or developing cognitive skills, whilst the EDER model posits emotional dysregulation as due to the presence of dysregulatory mechanisms that prioritizes restoring natural regulatory processes. Examples of relevant techniques for each model are presented including a range of cognitive-behavioral, and experiential (including both dynamic and cognitive) techniques. The aim of the paper is to provide a toolbox from which clinician may gain different techniques to enhance and maintain their patient’s capacity for emotional regulation. Finally, the biological mechanisms behind the two models of emotion regulation are discussed as well as a proposal of a dual route model of emotion regulation.

Psychodynamic Psychotherapy Process Research: A quick ride through what you should know about process (research)

This paper gives an overview of psychoanalytic process research, which brings to light the complexity of psychotherapy sessions. This complexity is so rich that many instruments intended to make the process measurable failed in the past because they initially used a strategy of complexity reduction. This method however did not help to further our understanding of the complexity involved. Three former presidents of the Society for Psychotherapy Research (Stiles, Hill, Elliot 2015) decided to solve the following equivalence paradox: many therapies work successfully though they all follow different theories, produce a heterogeneity of processes and often enough a misfit between what theories maintain to be a good process and their realization in the treatment room. As theories are often compared to maps, a driver would wonder which route to take. But therapists-as-drivers go undaunted - and nevertheless achieve their goals together with their patients. Norcross and Wampold (2018) found that good therapists invent new therapies with every new patient. They hypothesize that it is because of conversation. This is in accord with the 3 former presidents' proposal to return to detailed single case analyses including the micro-analytic power of conversation analysis of which a few insights are outlined in this article.

Emotions in play: young people's and clinicians' experience of 'Thinking about Emotions' group

PURPOSE

Emotional difficulties in young people (YP) with anorexia nervosa (AN) are well recognised. Improved strategies are needed to support inpatients to tolerate group therapy and to help them to better identify and manage their emotions. Cognitive Remediation and Emotion Skills Training (CREST) for AN adults, aimed at improving emotional processing skills, has been found beneficial in adult AN groups. A case series of CREST was conducted in an inpatient ward for YP (CREST-YP) to evaluate its suitability for a younger population.

METHODS

A mixed-methods assessment was used. Thirty-two YP and 3 facilitators took part in qualitative interviews. YP (n = 32) also completed pre- and post-self-report questionnaires assessing emotional functioning.

RESULTS

Preliminary qualitative results showed that YP found it helpful to learn about emotion processes. More support is needed to clarify the link between emotions and AN. Quantitative results showed no significant changes in YP's self-perceived emotional functioning. Although no statistically significant changes were observed, a small increase in YP's use of both reappraisal (standardised mean changes scores, SMCC 0.22) and suppression (SMCC - 0.22) as a means to regulate their emotions was found.

CONCLUSIONS

Pilot findings suggest that CREST-YP is a suitable intervention for YP with AN. Age-appropriate adaptations are needed to improve YP's engagement in group CREST.

LEVEL OF EVIDENCE

Level IV: Evidence obtained from multiple time series.