Mental health care equity and access: A group therapy solution.

Mental health services are experiencing unprecedented levels of demand from clients during COVID resulting in longer wait lists and therapist burnout. As Nemoyer et al. (2019) point out, minorities experience a higher burden of mental illness while having less access and lower quality treatments. COVID has increased demands for mental health services even further, creating bottlenecks of care, therapist burnout, and leading to ever longer wait lists. This article will argue that inefficient supply of services is created by mental health providers being incentivized toward individual therapy. Group therapy offers a solution because it is a "triple E treatment"-efficient, effective, and equivalent to individual therapy in terms of outcomes (Burlingame & Strauss, 2021). Group interventions also address systemic racism and the needs of minorities who have been marginalized and cope with minority stress. This article will utilize a labor and financial impact analysis to demonstrate how increasing group therapy by 10% nationally, particularly in private practice and primary care integration settings, would increase treatment access for over 3.5 million people while reducing the need for 34,473 additional new therapists and simultaneously saving over $5.6 billion. It will discuss how incentivizing groups while holding therapists accountable for training, competency when working with people from diverse backgrounds, and outcomes can result in improved efficiency. This will allow therapists greater freedom to collaboratively select the most effective treatments for those from underserved and minority backgrounds and create easier access to quality treatments. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

New horizons in group psychotherapy research and practice from third wave positive psychology: a practice-friendly review.

Group psychotherapy has been shown to be equivalent to individual therapy for many disorders, including anxiety, depression, grief, eating disorders, and schizophrenia (Burlingame & Strauss, 2021). In addition to effectiveness in reducing symptoms, group offers members a sense of belonging, purpose, hope, altruism, and meaning throughout treatment (Yalom & Leszcz, 2020). These additional outcomes are especially important considering the COVID-19 pandemic and national/international conflicts, given the trauma, disruptions, and losses people have experienced. Applying recent developments in positive psychology to group therapy can enhance treatment. A practice-friendly review examined recent advances in the positive psychology literature, demonstrating how group therapy offers members unique growth opportunities in addition to reducing symptoms. Key findings from studies applying positive psychological constructs to group therapy outcomes are synthesized. Our review sheds light on the relevance of third wave positive psychology to enrich group therapy (Lomas et al., 2021). Specifically, group therapy can facilitate the development of vitalizing psychological virtues, and these can be used to assess treatment outcome: humanity, wisdom, transcendence, courage, temperance, and justice. Interrelatedly, we present support for including attachment theory and mentalization within a positive psychological group framework. Implications are explored for group therapy research, clinical work, and training.

Ruptures and Repairs in Group Psychotherapy: From Theory to Practice.

The group climate, cohesion, and alliance with the leaders are critical elements of effective group psychotherapy. Although there has been significant attention to these curative mechanisms, there has been less attention to ruptures in the group relationships or the repair of them. The current special issue is devoted to theory, research, training, and practice regarding ruptures and repairs in group treatment. Contemporary and more traditional theorists describe how ruptures facilitate change in group therapy. Researchers apply the empirical findings on ruptures in individual therapy to group therapy and describe how ruptures can be measured. Group therapists also address how group leaders can contribute to ruptures and their subsequent repair. This introduction to the special issue concludes with the implications for practice and a call for future research that will help us fully understand how ruptures affect group process and outcomes in group work.

Repeated terminations: Transferring therapists in psychotherapy.

Therapists engage in transfers-a specific type of termination-with clients who will be continuing treatment with new therapists after they depart. Consequently, new therapists begin treatments in the shadow of the loss of outgoing therapist. These transfer experiences frequently occur in yearlong training settings, where therapists-in-training encounter some of their first therapy experiences and subsequently move on to other training settings or graduation. Transfers also occur in clinical settings when therapists retire, become ill, or need to end the treatment prematurely. In this article, the authors address transfer terminations using attachment theory and the literature applying attachment theory to psychotherapy. The authors incorporate relevant literature, research, and case examples that highlight how therapists can best address these losses and transitions in treatment. This article concludes by offering recommendations for supervisors of students in training settings and detailing some of the unique benefits for clients who experience multiple transfer terminations in treatment. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Carrying Jeremy Safran into sessions: relying on internal representations of researchers to facilitate emotion regulation, clinical intervention, and self-efficacy.

Relying on positive internal representations facilitates our ability to feel safe and secure when taking risks and provides a road map to guide us during interpersonal exchanges. Although most graduate programs encourage students to engage in research, we rarely link participating in research as directly influencing positive internal representations that can influence treatment. We used a qualitative method to examine how watching videos of Jeremy Safran, coding therapy sessions using his model, and reading his articles on ruptures and repairs influenced students' ability to self-soothe, take risks, and engage when patients confront them or withdraw. Results revealed that students often thought of Jeremy Safran and his colleagues during a session and recalled how he addressed ruptures in the videos they watched. When they were anxious during a session, they reported relying on the video coding training to facilitate emotion regulation during sessions. Having the research experience increased their clinical skills and overall clinical self-efficacy. Implications of our findings and future recommendations are discussed.

Introduction to special issue: Feedback in group psychotherapy.

The current issue highlights the necessity of feedback in group psychotherapy-both monitoring group member feedback during treatment and providing feedback to group members before and during group therapy. Regardless of the orientation or type of group, collecting members' perceptions and experiences influences how the group leader identifies members who are struggling in the group or are at risk of dropping out. Providing group members with feedback during the pregroup preparation and throughout the therapy process is also helpful to group members as they work to obtain their goals in the group. The author describes what types of measures are useful, how collecting this information impacts the treatment process such as repairing ruptures, and how feedback relates to treatment outcome. Group leaders will be able to apply these articles and feedback processes to their groups, and group researchers will be able to identify future studies that are needed to move the field forward. (PsycINFO Database Record

Counselors' attachment anxiety and avoidance and the congruence in clients' and therapists' working alliance ratings.

OBJECTIVE: To determine how counselors' attachment anxiety and avoidance related to congruence between counselors' and clients' Working alliance (WA) ratings. Congruence strength was defined as the regression coefficient for clients' WA ratings predicting counselors' WA ratings. Directional bias was defined as the difference in level between counselors' and clients' WA ratings. METHOD: Twenty-seven graduate student counselors completed an attachment measure and they and their 64 clients completed a measure of WA early in therapy. The truth-and-bias analysis was adapted to analyze the data. RESULTS: As hypothesized counselors' WA ratings were significantly and positively related to clients' WA ratings. Also as hypothesized, counselors' WA ratings were significantly lower than their clients' WA ratings (directional bias). Increasing counselor attachment anxiety was related to increasing negative directional bias; as counselors' attachment anxiety increased the difference between counselors and clients WA ratings became more negative. There was a significant interaction between counselor attachment anxiety and congruence strength in predicting counselor WA ratings. There was a stronger relationship between client WA ratings and counselor WA ratings for counselors low versus high in attachment anxiety. CONCLUSION: Counselors' attachment anxiety is realted to their ability to accurately percieve their clients' WA.

Fostering engagement during termination: Applying attachment theory and research.

Therapists often struggle to determine the most important things to focus on during termination. Reviewing the treatment, identifying plans for the future, summarizing positive gains, and saying goodbye receive the most attention. Despite our best intentions, termination can end up becoming intellectualized. Attachment theory and recent developments in neuroscience offer us a road map for facilitating endings that address client's underlying relational needs, direct us to foster engagement, and help us facilitate new relational experience that can be transformative for clients. We argue that endings in therapy activate client's and therapist's attachments and these endings trigger emotion regulating strategies that can elicit client's engagement or more defensiveness. The current paper will highlight through de-identified case examples how clients automatically respond termination and how therapists can foster rich relational experiences in the here-and-now that clients can take with them. (PsycINFO Database Record

Therapists-in-training experiences of working with transfer clients: One relationship terminates and another begins.

Data from interviews with 12 graduate-level trainees about their experiences of working with clients who had been transferred to them from another therapist were analyzed using consensual qualitative research. Trainees reported a range of helpful and hindering aspects about the transfer experience related to the client (e.g., client had experienced a prior termination and transfer, client had severe character pathology), the prior therapist (e.g., prior therapist prepared client for transfer, prior therapists did not process their termination with client), themselves (e.g., participant was open to addressing grief, participant was fearful of rejection), supervision (e.g., the supervisor provided important feedback on dealing with loss, the supervisor failed to address the unique nature of transferring), training (e.g., there was not adequate readings on termination and transfer, there was no readings on transfers), and clinic practices (e.g., meeting with the prior therapist and current therapist facilitated process, having clients end treatment with debt hindered the development of the new relationship). Participants also provided recommendations for improving the transfer process. Implications of these findings for clinical practice, training, and research are addressed. (PsycINFO Database Record

Attachment in Group Psychotherapy: Bridging Theories, Research, and Clinical Techniques.

Attachment theory is influencing the research and practice of group psychotherapy. The current issue highlights some of the bridges attachment theory has made both to contemporary group theories that include interpersonal theory and polyvagal theory and to approaches to group work that include mentalization-based group treatment. In addition, attachment theory is facilitating a richer understanding of group leadership, group cohesion, and the process of change that occurs during group interactions. The authors, who are researchers and group clinicians, reveal how attachment theory can be used to prepare members for group, to identify members who struggle to engage in conversations related to diversity, and to make sense of increasing disorganization that may occur as members become more intimate with one another during the group process. Group leaders will be able to apply these theories and techniques to their groups, and group researchers will be able to identify future studies that are needed to move the field forward.

Can we collaborate? Mistakes made when group and individual therapists ignore multiple realities.

Often, group therapists collaborate with individual therapists in conjoint treatment. Many of these patients start in individual therapy and are referred to the group to help facilitate the treatment and address interpersonal and relational issues that either cannot or will not be addressed in the individual work. Although this has the potential to foster incredible growth for patients, it may also cause problems in treatment when collaboration between therapists falls apart. The current paper will examine mistakes made when multiple realities about a patient are ignored during the pregroup screening and preparation, and feedback from group treatment is not integrated into individual therapy. Clinical examples will be used with specific recommendations for combined treatment planning and interventions. (PsycINFO Database Record

Emphasizing the complexity of the relationship: the next decade of attachment-based psychotherapy research.

This article focuses on the future of attachment-based psychotherapy research and begins with a brief summary of the research that has been done and then explores 8 predictions for the future. The main emphasis of these predictions is the growing complexity in our research needed to capture the mechanisms that facilitate or hinder the therapy process for patients with different attachment styles. Future researchers will focus more on the interactions between the patient and therapist within the sessions, will apply more complex statistical analyses to study the dyad, and will integrate different research methods. In addition, attachment researchers will focus studies on the changing landscape of psychotherapy and explore how attachment can inform Internet-based treatments and misperceptions of attachment based on the patients' culture. All in all, attachment researchers will start to tackle the more practical issues clinicians face, and their work has the potential to significantly improve psychotherapy treatment.

Novice therapist attachment and perceived ruptures and repairs: a pilot study.

Although extensively discussed in theoretical articles, empirical studies of therapist attachment and perceptions of ruptures and repairs are lacking. The present study examined the relationship between therapist attachment anxiety and avoidance and their perceptions of rupture tension, effort, and repair. Twenty-two novice therapists completed a measure of adult romantic attachment and a measure to assess perceptions of ruptures and repairs following the eighth session with their first clients. Results revealed that there was a strong positive correlation between therapist attachment anxiety and effort spent focused on perceived ruptures and a moderate positive correlation between attachment anxiety and rupture tension. There was no significant relationship between attachment anxiety and perceived repairs of ruptures. Attachment avoidance was not significantly correlated with either perceptions of the ruptures or repairs. Therapists who were higher on anxiety and avoidance, more fearful therapists, reported the most ruptures. Limitations and implications of the findings are presented.

Neurosciences and adult health behaviors: recent findings and implications for counseling psychology.

The current review comprehensively examines recent advances in 2 innovative areas of neuroscience research on healthy adults regarding neuropsychosocial interactions on human cognition and behavior, as well as implications for counseling psychologists conducting research and in practice. Advances in how oxytocin influences prosocial behavior and the mitigation of social stress, and the influence of environmentally mediated gene expressions on the development of attachment disorders are surveyed and discussed in terms of how counseling psychologists might best integrate recent neuroscience research into a framework for therapeutic intervention.

The insecure psychotherapy base: Using client and therapist attachment styles to understand the early alliance.

The purpose of this study was to test the notion that complementary attachments are best for achieving a secure base in psychotherapy. Specifically, we predicted third to fifth session alliance from client- and therapist-rated attachment style interactions. Using a combined sample of 46 therapy dyads from a community mental health clinic and university counseling center, the client- and therapist-perceived therapy alliance, attachment anxiety, and attachment avoidance were examined at the beginning of therapy. The results of an Actor-Partner Interdependence Model (APIM; Kenny & Cook, 1999, Partner effects in relationship research: Conceptual issues, analytic difficulties, and illustrations. Personal Relationships, 6, 433-448.) indicated that there was no direct effect of either client or therapist attachment style on therapist or client early ratings of the alliance. One significant interaction emerged and indicated that client-perceived alliance was influenced by therapist and client attachment anxiety. The client-perceived early alliance was higher when more anxious therapists worked with clients with decreasing anxiety. The client early alliance was higher when less anxious therapists worked with clients with increasing anxiety. The findings partially support the notion that different attachment configurations between the therapist and client facilitate greater alliance, but this was the case only when assessing client-perceived early alliance and only with regards to the dimension of attachment anxiety. There were no significant main effects or interactions when exploring therapist-perceived alliance. Implications of the findings are discussed along with recommendations for future study and clinical training.

Fostering new relational experience: clinical process in couple psychotherapy.

One of the most critical goals for couple psychotherapy is to foster a new relational experience in the session where the couple feels safe enough to reveal more vulnerable emotions and to explore their defensive withdrawal, aggressive attacking, or blaming. The lived intimate experience in the session offers the couple an opportunity to gain integrative insight into their feelings, expectations, and behaviors that ultimately hinder intimacy. The clinical processes that are necessary include empathizing with the couple and facilitating safety within the session, looking for opportunities to explore emotions, ruptures, and unconscious motivations that maintain distance in the relationship, and creating a new relational experience in the session that has the potential to engender integrative insight. These clinical processes will be presented with empirical support. Experts from a session will be used to highlight how these processes influence the couple and promote increased intimacy. (PsycINFO Database Record (c) 2014 APA, all rights reserved).

Empirical research on attachment in group psychotherapy: moving the field forward.

Despite a large literature applying attachment to individual, family, and couple psychotherapy, it has taken much longer for clinicians to apply attachment theory to group psychotherapy. The lack of research attention in this area makes these three studies in this special section even more important to the field. They contribute significant findings that have the potential to help group leaders facilitate more cohesive and effective treatments for patients as well as move the field forward. Not only do we see the long-term impact of group treatment for those with insecure attachments, but we also learn how attachment anxiety impacts the group process, and how the attachment to the therapy group itself relates to changes in group member's personal attachment styles. The greatest contribution is the drawing of our attention to the many future studies that are needed to fully understand how group therapy facilitates change and how attachment theory plays a critical role in this process. Clinical implications are presented.

Client and therapist therapeutic alliance, session evaluation, and client reliable change: a moderated actor-partner interdependence model.

Actor-partner interdependence modeling (APIM; Kashy & Kenny, 2000) was used to study the early therapeutic alliance in 74 clients being treated by 29 therapists to explore the relationship between the alliance and treatment progress, while prioritizing the dyadic nature of the alliance. The APIM examines collaboration/influence by modeling the impact of one dyad member's alliance ratings on the other member's session impact rating (partner effects). In terms of the alliance, the results revealed significant client-actor effects for client ratings of session depth and positivity as well as significant therapist-actor effects for therapist ratings of session smoothness and positivity. For client-rated alliance, there were also significant client-partner effects for therapist ratings of session depth. For clients who made a reliable change in treatment, an increase in client-reported alliance was related to therapist reporting more arousal in the 3rd session. For clients who did not make a reliable change in treatment, client-reported alliance was not related to therapist arousal. Limitations of the study and implications of the findings are discussed. (PsycINFO Database Record (c) 2014 APA, all rights reserved).

Adult attachment anxiety: using group therapy to promote change.

Group therapy can facilitate changes for members with greater attachment anxiety who tend to struggle with negative self-perceptions, difficulties regulating emotions, poor reflective functioning, and compromised interpersonal relationships. A clinical example of a therapy group with members who had elevated attachment anxiety and who were diagnosed with binge eating disorder demonstrates how attachment theory can be applied to group treatment. The clinical material from the beginning, middle, and end of group is presented to highlight how attachment anxiety influences members' emotional reactions and behaviors in the group, how group factors facilitate change, and how the leader fosters the development of a secure base within the group. Pre- to posttreatment outcomes indicate positive changes in binge eating, depressive symptoms, and attachment avoidance and anxiety. To facilitate change in individuals with greater attachment anxiety, group therapists may foster a secure base in the group through group cohesion, which will facilitate down regulation of emotions, better reflective functioning, and relationships that are less preoccupied with loss and more secure.

Adult attachment, attachment to the supervisor, and the supervisory alliance: how they relate to novice therapists' perceived counseling self-efficacy.

The supervisory relationship is one of the most important components in training therapists' professional development, and it is a frequent area of training-focused research. The current study explored how 57 training therapists' adult romantic attachments relate to the attachment to the supervisor and the supervisory working alliance. Additionally, we explored how both adult attachment and supervisory attachment relate to trainees' perceptions of their counseling self-efficacy (CSE). Results revealed that therapists with higher levels of fearful attachment to the supervisors and avoidant attachment in adult romantic relationships had less perceived CSE. Hierarchical regression revealed that it was the avoidant adult romantic attachment and the supervisory working alliance that accounted for the most significant variance in CSE, not the attachment to the supervisor. Path analysis using structural equation modeling was used to explore both the direct and indirect paths to CSE. When all variables were explored together, only the path from romantic attachment avoidance to fearful attachment to the supervisor was significant. Adult romantic attachment no longer directly related to CSE when including all the variables in the model. Implications of the findings will be discussed with regard to future research that is needed, the use of attachment-based supervisory interventions, and the application of the findings in clinical training.