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Psychotherapy - Vol 54, Iss 2

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Psychotherapy Theory, Research, Practice, Training Psychotherapy: Theory, Research, Practice, Training publishes a wide variety of articles relevant to the field of psychotherapy. We strive to foster interactions among training, practice, theory, and research because all are essential to psychotherapy.
Copyright 2017 American Psychological Association
  • Therapeutic alliance, subsequent change, and moderators of the alliance–outcome association in interpersonal psychotherapy for depression.
    The therapeutic alliance has historically emerged as a pantheoretical correlate of favorable psychotherapy outcomes. However, uncertainty remains about the direction of the alliance–outcome link, and whether it is affected by other contextual variables. The present study explored (a) if early alliance quality predicted subsequent symptom change while controlling for the effect of prior symptom change in interpersonal psychotherapy (IPT) for depression, and (b) whether baseline patient characteristics moderated the alliance–outcome relation (to help specify conditions under which alliance predicts change). Data derived from an open trial of 16 sessions of individual IPT delivered naturalistically to adult outpatients (N = 119) meeting criteria for major depression. Patients rated their sociodemographic, clinical, and interpersonal characteristics at baseline, their alliance with their therapist at Session 3, and their depressive symptoms at baseline, after every session, and at posttreatment. Data were analyzed using hierarchical linear modeling. Results indicated that alliance quality did not predict subsequent depression change, controlling for prior depression change. However, a significant education by alliance interaction emerged in predicting quadratic depression change (γ = .0007, p = .03); patients with higher levels of education who reported good early alliances with their therapists had the most positively accelerated change trajectory (i.e., faster depression reduction), whereas patients with higher levels of education who reported poorer early alliances had the most negatively accelerated change trajectory (i.e., slower depression reduction). The findings may help clarify a specific condition under which alliance quality influences subsequent improvement in an evidence-based treatment for depression. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Therapeutic alliance and treatment outcome in the outpatient treatment of urban adolescents: The role of callous–unemotional traits.
    Callous–unemotional (CU) traits designate a unique subset of youth with externalizing psychopathology who have a severe pattern of aggressive behavior and tend to have worse outcomes in treatment. However, little research has addressed how CU traits relate to different components of psychotherapy, such as the therapeutic alliance. The current study examined the role of CU traits in predicting therapeutic alliance in 59 adolescents (M age = 15.3, 51% female, 64% Hispanic American, 15% African American) who were part of a larger randomized naturalistic trial of outpatient behavioral psychotherapy. Multilevel regression analysis further investigated the role of therapeutic alliance in predicting treatment outcome (as measured by self-reported delinquency) and the moderating role of CU traits. Results suggested that regardless of the severity of their externalizing problems, youth with higher levels of CU traits reported more positive ratings of therapeutic alliance. In addition, a positive therapeutic alliance predicted reductions in delinquent behavior, and this association was even stronger for youth higher in CU traits. Our results suggest that CU traits are related to improvement in the formation of the therapeutic alliance among youth with externalizing psychopathology, perhaps because these youth lack many of the social and emotional deficits that other youth with conduct problems possess. Adolescents high in CU traits should not be viewed as untreatable. Indeed, the therapeutic alliance may be an important mechanism for affecting meaningful change in these adolescents’ lives. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Is affect experiencing therapeutic in major depressive disorder? Examining associations between affect experiencing and changes to the alliance and outcome in intensive short-term dynamic psychotherapy.
    Affect experiencing (AE), defined as the facilitation of client in-session bodily arousal and visceral experiencing of affect, is a distinct theoretical process presumed to contribute to therapeutic improvement. This study examined the role of AE in the treatment of major depressive disorder by exploring its association to client distress and therapeutic alliance on a session-by-session basis. A case series design was used to conduct an intensive analysis of the treatment process of 4 clients who received time-limited intensive short-term dynamic psychotherapy, 2 of whom were considered “recovered” and 2 who showed “no change” based upon posttreatment outcomes. Consistent with our hypothesis, we found that cross-correlations between AE and client distress discriminated between “recovered” and “no change” clients. In “recovered” clients, there was evidence that higher in-session peak affect experience was associated with reduced distress 7 days later. The results did not provide consistent evidence for a reverse effect, showing that lower distress during the preceding week predicted higher AE in that session. Finally, there was evidence that AE is an in-session activity that can promote the strengthening of the therapeutic alliance. These collective findings suggest that AE is an important treatment process that contributes to alliance formation and psychotherapeutic improvement. Clinical implications include further evidence that psychodynamic therapists can utilize AE as an active change ingredient for depression. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Patients’ crying experiences in psychotherapy: Relationship with the patient level of personality organization, clinician approach, and therapeutic alliance.
    The present study sought to further understand patients’ crying experiences in psychotherapy. We asked 64 clinicians to randomly request one patient in their practice to complete a survey concerning crying in psychotherapy as well as a measure of therapeutic alliance. All clinicians provided information regarding their practice and patient diagnostic information. Fifty-five (85.93%) patients cried at least once, and 18 (28.1%) had cried during their most recent session. Patients’ frequency of crying episodes in therapy was negatively related with psychotic level of personality organization, while patients’ tendency to feel more negative feelings after crying was positively related to lower levels of personality organization. Patients’ feeling more in control after crying was positively related with an interpersonal therapeutic approach, while patients’ perception of therapists as more supportive after crying was positively related to a psychodynamic approach. Patients’ tendency to experience more negative feelings after crying was significantly related with both lower levels of personality organization and patients’ perception of the therapeutic alliance as weak. In regard to their most recent crying event in treatment, therapeutic alliance was related to gaining a new understanding of experience not previously recognized by the patient. Further, patients’ experiences of having never told anyone about their experience related to a crying episode, as well as their realization of new ideas and feeling of having communicated something that words could not express was positively related to the goal dimension of alliance. Patients’ perception of crying as a moment of genuine vulnerability, greater feelings of self-confidence and self-disclosure as well as having had a therapist response that was compassionate and supportive, was positively related with the bond dimension of alliance. Clinical implications and future research directions regarding patient crying experiences in psychotherapy are discussed. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Therapist effects on outcome and alliance in inpatient psychotherapy: The contribution of patients’ symptom severity.
    Therapists differ in their effectiveness regarding their patients’ symptomatic improvement as well as their therapeutic alliances, but little is known about influencing factors. The current study aimed to investigate therapist effects on outcome and alliance in inpatient psychotherapy and to estimate the influence of patient severity on the magnitude of therapist effects in this specific setting. We examined differences between individual psychotherapists in their patients’ early alliance and outcome at discharge in a psychotherapy setting of a psychiatric hospital. The sample included 33 therapists and 3,051 patients, and minimum caseload was 30 patients. Outcome was measured as patient-rated symptoms and interpersonal problems as well as therapist-rated impairment. Similarly, alliance was assessed from the patients’ and the therapists’ perspective. First, we estimated the amount of variance that was owing to therapists for patients with average symptom severity. Next, we examined whether the therapist effect was influenced by initial patient severity. Therapist effects on patient-rated symptomatic outcome and alliance were not significantly different from zero. Therapist differences were considerably larger for therapist-rated measures. Patient severity did not significantly influence the therapist effect for patient-rated outcome or alliance. However, there was a u-shaped association for therapist-rated severity and the therapist effect in therapist-rated alliance. Here, therapist differences were larger for patients with either very low or very high initial severity. The magnitude of the therapist outcome effect was smaller in inpatient therapy compared with outpatient settings. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Patients’ affective processes within initial experiential dynamic therapy sessions.
    Research has indicated that patients’ in-session experience of previously avoided affects may be important for effective psychotherapy. The aim of this study was to investigate patients’ in-session levels of affect experiencing in relation to their corresponding levels of insight, motivation, and inhibitory affects in initial Experiential Dynamic Therapy (EDT) sessions. Four hundred sixty-six 10-min video segments from 31 initial sessions were rated using the Achievement of Therapeutic Objectives Scale. A series of multilevel growth models, controlling for between-therapist variability, were estimated to predict patients’ adaptive affect experiencing (Activating Affects) across session segments. In line with our expectations, higher within-person levels of Insight and Motivation related to higher levels of Activating Affects per segment. Contrary to expectations, however, lower levels of Inhibition were not associated with higher levels of Activating Affects. Further, using a time-lagged model, we did not find that the levels of Insight, Motivation, or Inhibition during one session segment predicted Activating Affects in the next, possibly indicating that 10-min segments may be suboptimal for testing temporal relationships in affective processes. Our results suggest that, to intensify patients’ immediate affect experiencing in initial EDT sessions, therapists should focus on increasing insight into defensive patterns and, in particular, motivation to give them up. Future research should examine the impact of specific inhibitory affects more closely, as well as between-therapist variability in patients’ in-session adaptive affect experiencing. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Countertransference when working with narcissistic personality disorder: An empirical investigation.
    Narcissistic personality disorder (NPD) is one of the most challenging clinical syndromes to treat in psychotherapy, especially due to the difficulties of establishing a good enough therapist–patient relationship. Countertransference responses to NPD can be particularly intense, frustrating, and difficult to manage, as is often reported in the clinical literature though not clearly supported empirically. The aims of this study were to (a) investigate the relationship between patients’ NPD and therapists’ responses; (b) examine the associations between patient, clinician, therapy variables and clinicians’ reactions during treatment of NPD patients; and (c) provide an empirically derived portrait of countertransference with NPD. A sample of psychiatrists and clinical psychologists (N = 67) completed the Therapist Response Questionnaire to identify patterns of countertransference, the Shedler–Westen Assessment Procedure-200, and the Global Assessment of Functioning Scale to assess the personality pathology and psychosocial functioning of a patient in their care. The results showed that NPD was positively associated with hostile/angry, criticized/devalued, helpless/inadequate, and disengaged countertransference and negatively associated with therapists’ positive response, regardless of patients’ personality and psychosocial functioning. NPD patients with stronger traits of cluster B personality pathology tended to elicit more negative and heterogeneous countertransference reactions than NPD patients without these features. The countertransference patterns with NPD patients were not strongly influenced by the variables of clinicians and therapy, with the exception of clinical experience. Overall, the portrait of therapists’ reactions to NPD provided a clinically nuanced and empirically founded description strongly resembling theoretical–clinical accounts. The therapeutic implications of these findings were discussed. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • Therapist adherence is associated with outcome in cognitive–behavioral therapy for bulimia nervosa.
    Studies of therapist adherence in relation to treatment outcome have produced mixed results. The aim of the present study was to investigate change in therapist adherence to cognitive–behavioral therapy (CBT) for bulimia nervosa over time, and to investigate the relationship between adherence and client outcome in early, middle, and late phases of treatment. Thirty-six clients received the focused form of “enhanced” CBT (CBT-E) for bulimia nervosa. Trained observers rated audiotapes of 92 full-length therapy sessions from early (Session 3), middle (Session 11), and late phases (Session 20) of treatment using the Cognitive–Behavioral Therapy Treatment Protocol Adherence Scale. Change in adherence across the 3 treatment phases was examined using multilevel analysis. The relationship between early, middle, and late adherence levels and end-of-treatment binging frequency was examined using multilevel Poisson regression analysis. Adherence decreased significantly over the course of treatment. Higher levels of therapist adherence in early and middle phases of treatment were associated with reduced binging frequency, whereas higher levels of adherence measured late in treatment was not. Results indicate that therapists’ adherence to the CBT-E treatment protocol decreases over time and that high levels of protocol adherence in early and middle phases of treatment are more important for positive client outcomes than high levels of adherence in the end of treatment. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • The relationship between clients’ depression etiological beliefs and psychotherapy orientation preferences, expectations, and credibility beliefs.
    The purpose of this study was to examine the relationship between clients’ etiological beliefs for depression and treatment preferences, credibility beliefs, and outcome expectations for five different depression treatments—behavioral activation, cognitive therapy, interpersonal psychotherapy, pharmacotherapy, and psychodynamic psychotherapy. Adult psychotherapy clients (N = 98) were asked to complete an online survey that included the Reasons for Depression Questionnaire, a brief description of each of the five treatment options, and credibility, expectancy, and preference questions for each option. On average, the participating clients rated pharmacotherapy as significantly less credible, having a lower likelihood of success, and being less preferred than the four types of psychotherapy. In general, interpersonal psychotherapy was also rated more negatively than the other types of psychotherapy. However, these findings depended somewhat on whether the participating client was personally experiencing depression. Credibility beliefs, outcome expectations, and preferences for pharmacotherapy were positively associated with biological beliefs for depression; however, the other hypothesized relationships between etiological beliefs and treatment attitudes were not supported. Although the study is limited based on the specific sample and treatment descriptions that were used, the results may still have implications for psychotherapy research, training, and practice. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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  • An empirical analysis of mental state talk and affect regulation in two single-cases of psychodynamic child therapy.
    Literature has shown the importance of mentalizing techniques in symptom remission and emotional understanding; however, no study to date has looked at the dynamic relations between mental state talk and affect regulation in the psychotherapy process. From a psychodynamic perspective, the emergence of the child’s capacity to regulate affect through the therapist’s reflection on the child’s mental states is a core aspect of treatment. In an empirical investigation of 2 single cases with separation anxiety disorder, who were treated in long-term psychodynamic play therapy informed with mentalization principles, the effect of therapists’ and children’s use of mental state talk on children’s subsequent capacity to regulate affect in play was assessed. One case was a positive outcome case, whereas the other did not show symptomatic improvement at the end of treatment. Children’s and therapists’ utterances in the sessions were coded using the Coding System for Mental State Talk in Narratives, and children’s play was coded by Children’s Play Therapy Instrument, which generated an index of children’s “affect regulation.” Time-series Granger Causality tests showed that even though both therapists’ use of mental state talk significantly predicted children’s subsequent affect regulation, the association between child’s mental state talk and affect regulation was only supported for the child who showed clinically significant symptom reduction. This study provided preliminary support that mental state talk in psychodynamic psychotherapy facilitates emotion regulation in play. (PsycINFO Database Record (c) 2017 APA, all rights reserved)
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