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Cirasola A, Szegedi D, Fonagy P, Midgley N. "You can't really have a relationship with them because they just ask you questions": understanding adolescent dropout - an empirical single case study. Front Psychol 2024; 15:1381901. [PMID: 38533210 PMCID: PMC10963658 DOI: 10.3389/fpsyg.2024.1381901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 02/23/2024] [Indexed: 03/28/2024] Open
Abstract
Introduction High dropout rates are common in youth psychotherapy, including psychoanalytic psychotherapy, yet the reasons behind this trend remain obscure. A critical focus to enhance adolescent engagement could be the therapeutic alliance, particularly in resolving alliance ruptures. This study sought to clarify the complex relationships between the therapeutic alliance, encompassing alliance ruptures and resolutions, and dropout within the context of poor outcome. It investigated a single case of an adolescent with depression who dropped-out of Short-Term Psychoanalytic Psychotherapy, without showing clinical improvement. Method Data was garnered from diverse sources, including questionnaires, interviews, and session recordings, and analyzed through a mixed-method longitudinal framework. This encompassed views from the adolescent, therapist, parents, and external evaluators. Results The study identifies several factors impacting the decision to drop out, including initial profound distrust toward the therapist, a complex and difficult therapeutic relationship characterized by unresolved alliance ruptures, and sporadic attendance. External factors including minimal parental engagement with therapy were also seen as detrimental to the adolescent's involvement and progress. Discussion The research underscores the challenges in engaging adolescents, especially when there may be distrust of professionals, and in the absence of parental involvement with treatment.
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Affiliation(s)
- Antonella Cirasola
- Research Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom
- Anna Freud National Centre for Children and Families, London, United Kingdom
| | - Dora Szegedi
- Research Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom
- Anna Freud National Centre for Children and Families, London, United Kingdom
| | - Peter Fonagy
- Research Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom
- Anna Freud National Centre for Children and Families, London, United Kingdom
| | - Nick Midgley
- Research Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom
- Anna Freud National Centre for Children and Families, London, United Kingdom
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Difficulties in interpersonal regulation of emotions (DIRE) questionnaire: Psychometric Properties of the Italian Version and Associations with psychopathological symptoms. JOURNAL OF PSYCHOPATHOLOGY AND BEHAVIORAL ASSESSMENT 2022; 44:1126-1134. [PMID: 35967513 PMCID: PMC9362436 DOI: 10.1007/s10862-022-09992-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2022] [Indexed: 01/10/2023]
Abstract
The goal of this research was to validate an Italian adaptation of the questionnaire Difficulties in Interpersonal Regulation of Emotions (DIRE) and to investigate its associations with psychopathology. An Italian sample (N = 630) completed the DIRE and the Symptom Checklist-90 (SCL-90). We tested the factorial structure of the DIRE using explorative and confirmatory factorial analyses; we analysed the convergent validity in terms of zero-order correlations with SCL-90 dimensions; and, we conducted multiple regressions to test the predictivity of DIRE factors on specific SCL-90 dimensions. The Italian DIRE replicated the four-factor structure of the original measure, with two interpersonal (Vent and Reassurance-seek) and two intrapersonal (Accept and Avoid) factors. Interpersonal factors resulted correlated with SCL-90 global indexes of psychopathology. Moreover, specific association between DIRE factors and SCL-90 dimensions were found. The Italian DIRE is a reliable and valid measure to evaluate clinically-relevant forms of emotion dysregulation.
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Bate J, Tsakas A. Facilitative interpersonal skills are relevant in child therapy too, so why don’t we measure them? RESEARCH IN PSYCHOTHERAPY: PSYCHOPATHOLOGY, PROCESS AND OUTCOME 2022; 25. [PMID: 35532023 PMCID: PMC9153756 DOI: 10.4081/ripppo.2022.595] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 05/05/2022] [Indexed: 12/30/2022]
Abstract
One of the consistent findings from psychotherapy process research has been the impact of therapist effects on patient change and the therapeutic alliance. The Facilitative Interpersonal Skills (FIS) paradigm is a task in which participants respond to standardized videos of actors playing patients in interpersonally challenging moments as if they were the therapist, which was designed to assess therapist effects. Participants’ video recorded responses are coded for eight skills: verbal fluency, emotional expressiveness, warmth/acceptance/understanding, empathy, persuasiveness, hope/positive expectations, alliance-bond capacity, and rupture-repair responsiveness. Performance-based procedures like the FIS minimize self-report bias and systematically control for client-related variability while maintaining strong clinical relevance. Research has shown that therapist FIS predicts the quality of the therapeutic alliance and outcome in adult psychotherapy. This paper describes the development and first adaptation of the FIS task using child and adolescent patients as the stimuli, and reports findings from a pilot study testing the reliability. The FIS-Child (FIS-C) task was administered to 10 therapists with a range of clinical backgrounds. Participants also completed the original FIS task and self-report measures of their empathy, social skills, and playfulness. Adequate interrater reliability was achieved on the FIS-C. There were no significant differences between participants’ ratings on the FIS-C compared to the original FIS, although there were minor differences in the correlations between the FISC and self-report measures compared to the original FIS. Findings support moving forward with utilizing the FIS-C to empirically study therapist effects that may be common factors across treatment models.
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Cirasola A, Martin P, Fonagy P, Eubanks C, Muran JC, Midgley N. Alliance ruptures and resolutions in short-term psychoanalytic psychotherapy for adolescent depression: An empirical case study. Psychother Res 2022; 32:951-968. [PMID: 35436179 DOI: 10.1080/10503307.2022.2061314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
ABSTRACTMost research on alliance rupture-repair processes in psychotherapy has been carried out with adults and little is known about the alliance dynamics with adolescents, especially in psychodynamic treatments.Objective: This study aimed to better understand the process of alliance rupture-resolution and its role in a good-outcome case of a depressed adolescent treated with short-term psychoanalytic-psychotherapy (STPP).Method: A longitudinal, mixed-methods empirical single-case approach was employed. Multiple sources of information (questionnaires, interviews, sessions recordings) from various perspectives (adolescent, therapist, observer) were assembled and analysed.Results: The different sources of evidence converged and showed that, despite the presence of frequent alliance ruptures, patient and therapist managed to resolve these and develop a good and collaborative relationship. Both patient and therapist regarded the evolution in their relationship as the treatment factor mainly responsible for the positive changes experienced by the adolescent. Based on both theoretical and empirical data, a preliminary model of how to explore and repair alliance ruptures in STPP is presented.Conclusion: This study illustrates one way of applying an empirical, mixed-method approach to a single case. Its finding supports the idea that the process of repairing ruptures is an important mechanism of change. Strengths, limitations, and possible implications are discussed.
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Affiliation(s)
| | - Peter Martin
- Applied Health Research, University College London, London, UK
| | - Peter Fonagy
- Psychology and Language Sciences, University College London, London, UK
| | | | - J Christopher Muran
- Gordon F. Derner School of Psychology, Adelphi University, Garden City, NY, USA
| | - Nick Midgley
- Psychology and Language Sciences, University College London, London, UK
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Lipsitz-Odess I, Benisty H, Dolev-Amit T, Zilcha-Mano S. Alliance rupture profiles by personality disorder pathology in psychotherapy for depression: Tendencies, development, and timing. Clin Psychol Psychother 2021; 29:1125-1134. [PMID: 34871469 DOI: 10.1002/cpp.2700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Clinical and theoretical considerations presume that patients with different personality disorder (PD) clusters will be associated with distinct alliance rupture profiles; however, there is scarce empirical literature examining this. The present study adopted a systematic framework for investigating profiles of alliance ruptures for individuals belonging to each of the three PD clusters. METHOD The sample consisted of 94 patients from a randomized controlled trial for treatment of depression. PD cluster features were assessed at intake and ruptures were assessed across treatment. Three sets of multilevel analyses were conducted to test differences between the PD clusters in the general tendency to show a rupture profile, rupture development throughout the treatment, and timing of predicting ruptures by PD within sessions. RESULTS The three clusters were associated with distinct profiles of alliance ruptures. Clusters A and B were characterized by a general tendency to show more withdrawal and confrontation ruptures. Cluster A had a greater decrease in confrontation ruptures over the course of treatment, while cluster B had a greater decrease in withdrawal ruptures. Cluster C was characterized by a general tendency to show fewer withdrawal and confrontation ruptures, with a greater increase in both ruptures over the course of treatment. For withdrawal ruptures, the differences between clusters were evident from the beginning of sessions, whereas for confrontation ruptures, there was less of a difference between beginning and end of sessions. CONCLUSION The distinct profiles of alliance ruptures for each PD cluster may contribute to progress towards tailoring treatment to individuals with PDs.
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Affiliation(s)
| | - Hadas Benisty
- The Department of Neuroscience, Yale University, New Haven, Connecticut, USA
| | - Tohar Dolev-Amit
- The Department of Psychology, University of Haifa, Haifa, Israel
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Zimmermann R, Fürer L, Kleinbub JR, Ramseyer FT, Hütten R, Steppan M, Schmeck K. Movement Synchrony in the Psychotherapy of Adolescents With Borderline Personality Pathology - A Dyadic Trait Marker for Resilience? Front Psychol 2021; 12:660516. [PMID: 34276484 PMCID: PMC8277930 DOI: 10.3389/fpsyg.2021.660516] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 05/14/2021] [Indexed: 11/13/2022] Open
Abstract
Movement synchrony describes the coordination of body movements. In psychotherapy, higher movement synchrony between therapist and patient has been associated with higher levels of empathy, therapeutic alliance, better therapy outcome, and fewer drop-outs. The current study investigated movement synchrony during the psychotherapeutic treatment of female adolescents with borderline personality disorder. It was hypothesized that there are higher levels of movement synchrony in the analyzed therapy sessions compared to pseudo-interactions. Further, we tested whether higher levels of movement synchrony correlate with stronger patients' symptom reduction and whether higher movement synchrony predicts higher post-session ratings. A total of 356 sessions from 16 completed psychotherapies of adolescent patients with BPD were analyzed. Movement synchrony was assessed with motion energy analysis and an index of synchrony was calculated by lagged cross-correlation analysis. As hypothesized, the findings support higher levels of movement synchrony in therapy sessions compared to pseudo-interactions (Cohen's d = 0.85). Additionally, a correlation of movement synchrony with better therapy outcome was found (standardized beta = -0.43 indicating stronger personality functioning impairment reduction). The post-session ratings were negatively associated with higher levels of movement synchrony (standardized beta = -0.1). The relevance of movement synchrony and potential implications for clinical practice are discussed.
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Affiliation(s)
- Ronan Zimmermann
- Child and Adolescent Psychiatric Research Department, Psychiatric University Hospitals, University of Basel, Basel, Switzerland.,Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
| | - Lukas Fürer
- Child and Adolescent Psychiatric Research Department, Psychiatric University Hospitals, University of Basel, Basel, Switzerland
| | - Johann R Kleinbub
- Department of Philosophy, Sociology, Education and Applied Psychology, University of Padova, Padova, Italy
| | - Fabian T Ramseyer
- Department of Clinical Psychology and Psychotherapy, Institute of Psychology, University of Bern, Bern, Switzerland
| | - Rahel Hütten
- Child and Adolescent Psychiatric Research Department, Psychiatric University Hospitals, University of Basel, Basel, Switzerland
| | - Martin Steppan
- Child and Adolescent Psychiatric Research Department, Psychiatric University Hospitals, University of Basel, Basel, Switzerland.,Division of Personality and Developmental Psychology, Department of Psychology, University of Basel, Basel, Switzerland
| | - Klaus Schmeck
- Child and Adolescent Psychiatric Research Department, Psychiatric University Hospitals, University of Basel, Basel, Switzerland
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Midgley N, Mortimer R, Cirasola A, Batra P, Kennedy E. The Evidence-Base for Psychodynamic Psychotherapy With Children and Adolescents: A Narrative Synthesis. Front Psychol 2021; 12:662671. [PMID: 33986713 PMCID: PMC8110733 DOI: 10.3389/fpsyg.2021.662671] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/17/2021] [Indexed: 12/26/2022] Open
Abstract
Despite a rich theoretical and clinical history, psychodynamic child and adolescent psychotherapy has been slow to engage in the empirical assessment of its effectiveness. This systematic review aims to provide a narrative synthesis of the evidence base for psychodynamic therapy with children and adolescents. Building on two earlier systematic reviews, which covered the period up to 2017, the current study involved two stages: an updated literature search, covering the period between January 2017 and May 2020, and a narrative synthesis of these new studies with those identified in the earlier reviews. The updated search identified 37 papers (28 distinct studies). When combined with papers identified in the earlier systematic reviews, this resulted in a combined total of 123 papers (82 distinct studies). The narrative synthesis of findings indicates that there is evidence of effectiveness for psychodynamic therapy in treating a wide range of mental health difficulties in children and adolescents. The evidence suggests this approach may be especially effective for internalizing disorders such as depression and anxiety, as well as in the treatment of emerging personality disorders and in the treatment of children who have experience of adversity. Both the quality and quantity of empirical papers in this field has increased over time. However, much of the research demonstrates a range of methodological limitations (small sample sizes, lack of control groups etc.), and only 22 studies were Randomized Controlled Trials. Further high-quality research is needed in order to better understand the effectiveness of psychodynamic psychotherapy for children and young people.
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Affiliation(s)
- Nick Midgley
- Research Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom.,Child Attachment and Psychological Therapies Research Unit (ChAPTRe), Anna Freud National Centre for Children and Families, London, United Kingdom
| | - Rose Mortimer
- Child Attachment and Psychological Therapies Research Unit (ChAPTRe), Anna Freud National Centre for Children and Families, London, United Kingdom
| | - Antonella Cirasola
- Research Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom.,Child Attachment and Psychological Therapies Research Unit (ChAPTRe), Anna Freud National Centre for Children and Families, London, United Kingdom
| | - Prisha Batra
- Child Attachment and Psychological Therapies Research Unit (ChAPTRe), Anna Freud National Centre for Children and Families, London, United Kingdom
| | - Eilis Kennedy
- Research and Development Unit, Tavistock and Portman NHS Trust, London, United Kingdom
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Schenk N, Fürer L, Zimmermann R, Steppan M, Schmeck K. Alliance Ruptures and Resolutions in Personality Disorders. Curr Psychiatry Rep 2020; 23:1. [PMID: 33305340 PMCID: PMC7728649 DOI: 10.1007/s11920-020-01212-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW This review provides an overview of the state of research on alliance ruptures and resolutions in the treatment of personality disorders (PDs). We discuss frequently used instruments to measure alliance ruptures and resolutions. We discuss the effectiveness of rupture resolution processes and highlight possible avenues for research to explore. Innovative assessments with the potential to reveal the link of ruptures and resolutions and mechanisms of psychotherapeutic change are discussed. RECENT FINDINGS The assessment of alliance rupture and resolutions is heterogeneous. Instruments vary largely with respect to a direct or indirect assessment, the time resolution of assessment (integral therapy, phase, session, event), session sampling strategy and perspectives (patient, therapist, observer). The heterogeneity in the instruments and study designs impedes comparability and interpretation of the findings. Results support the hypothesis that ruptures are more frequent in PD. Results also point towards beneficial effects of rupture resolution patterns, early alliance quality, and resolution complexity. Few studies control findings for pretreatment factors. Evidence points to the direction that rupture resolution processes can be considered a general principle of change in the treatment of PD. The concept of alliance ruptures and resolutions provides a useful tool for the management of the therapeutic alliance and its moments of deteriorations throughout the treatment course. Dimensional pretreatment personality functioning is considered a key variable in future studies to highlight what works for whom.
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Affiliation(s)
- Nathalie Schenk
- Child and Adolescent Psychiatric Research Department, Psychiatric University Hospitals of the University of Basel, Basel, Switzerland
| | - Lukas Fürer
- Child and Adolescent Psychiatric Research Department, Psychiatric University Hospitals of the University of Basel, Basel, Switzerland
| | - Ronan Zimmermann
- Child and Adolescent Psychiatric Research Department, Psychiatric University Hospitals of the University of Basel, Basel, Switzerland
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
| | - Martin Steppan
- Child and Adolescent Psychiatric Research Department, Psychiatric University Hospitals of the University of Basel, Basel, Switzerland
| | - Klaus Schmeck
- Child and Adolescent Psychiatric Research Department, Psychiatric University Hospitals of the University of Basel, Basel, Switzerland.
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