The effect of Oxytocin administration on patient-therapist alliance congruence: Results from a randomized controlled trial.

OBJECTIVES: The effects of oxytocin (OT) administration on psychotherapeutic processes have thus far been elusive. This study explored the effect of OT administration on patient-therapist congruence of the working alliance. METHOD: Inpatients with mental disorders (N = 87) participating in a randomized controlled trial received OT (n = 44) or placebo (n = 43) intranasally twice a day, for four weeks. Patients and therapists rated the alliance after each session. RESULTS: Oxytocin significantly moderated the level of agreement (b = -0.56, SE = 0.25, t = -2.30, p = 0.02), such that patients receiving OT demonstrated lower discrepancy (b = -0.73, p < 0.001) than did those receiving placebo (b = -1.30, p < 0.001). On the other hand, the mutual covariance of patient-therapist ratings across sessions was positive and significant for patients receiving placebo (b = 0.26, p = 0.01) but not for patients in the OT group (b = -0.06, p = .56). CONCLUSION: Oxytocin can reduce discrepancies of patient-therapist perceptions of the alliance, although additional studies are needed to explore OT's effect on alliance development over time. As alliance congruence is associated with therapy outcomes, such intervention may lead to enhancement of therapeutic gains.

Shedding light on the effects of supportive techniques on nonverbal synchrony and their moderators in psychotherapy for depression.

Objective: Accumulating research demonstrates the importance of utilizing supportive techniques in psychotherapy; however, little is known about therapeutic processes that are set in motion following the use of supportive techniques. The present study examined the effects of supportive techniques on nonverbal synchrony, both at the sample level and at the individual differences level.Method: The sample consisted of 86 patients from a randomized controlled trial for treatment of depression. Supportive techniques were rated by patients and therapists after every session, and nonverbal synchrony was quantified by motion energy analysis (MEA) for each session. The ability of supportive techniques to predict subsequent nonverbal synchrony was examined using polynomial regression and response surface analysis.Results: The findings suggest that, at the sample level, greater use of supportive techniques was a significant predictor of subsequent higher levels of nonverbal synchrony. At the individual differences level, this effect was significant for patients with low levels of depression severity and personality disorders, yet not significant for patients with high levels.Conclusion: The present study demonstrates that greater use of supportive techniques in treatment may facilitate a process that manifests as higher levels of synchrony, especially for patients with lower levels of personality disorders and depression.

Investigating patient-specific mechanisms of change in SET vs. EFT for depression: study protocol for a mechanistic randomized controlled trial.

BACKGROUND: Major depressive disorder (MDD) is the leading cause of disability worldwide and one of the most heterogeneous mental health disorders. Although there are effective treatments for MDD, about 50% of patients do not respond to treatment. One of the greatest challenges in improving current treatments is identifying the mechanisms responsible for therapeutic change in MDD. The proposed study aims to identify patient-specific mechanisms of change in two treatments for MDD by investigating whether subpopulations of patients differ in the mechanisms of change that operate when receiving a given treatment. Based on theories of targeting weakness and building on strength, we will examine whether the mechanism of change operating when a treatment is provided depends on whether the treatment targets the patient's strength or weakness. METHOD: To test our hypothesis that two treatments, supportive-expressive treatment (SET) and emotion-focused treatment (EFT), differ in their mechanisms of change and to explore whether focusing on the patient's strength or weakness will result in better treatment outcome, we conduct a mechanistic randomized controlled trial. One hundred and twenty-four individuals diagnosed with MDD are randomized to 16 sessions of either SET or EFT. The two treatments are theorized to differ in their main mechanism of change: SET places emphasis on insight as its main mechanism of change, and EFT places emphasis on emotional processing. Both can serve as strength- or weakness-focused treatments, based on the patient's baseline levels of insight and emotional processing. The primary outcome is the Hamilton Rating Scale for Depression. Additional measures include self-report measures and clinical interviews, hormonal, motion, acoustic, physiological, and neuroimaging assessments, performance on cognitive tasks, and narrative material (collected from the sessions and interviews). DISCUSSION: The RCT will expand our understanding of mechanisms of change in psychotherapy, from one-size-fits-all to patient-specific mechanisms of change. By informing therapists about which of the two approaches is most effective with patients based on their baseline characteristics, the RCT will contribute to progress toward personalized treatment. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT04576182 submitted on October 1st 2020. FUNDING: The Israel Science Foundation. Trial status: Recruitment is ongoing.

Patients' individual differences in implicit and explicit expectations from the therapist as a function of attachment orientation.

Patients' attachment orientation was found to be an important predictor of the process and outcome of psychotherapy. The present study is the first to examine whether patients' attachment orientation toward significant others predicts their implicit and explicit expectations from the therapist, and whether this effect is moderated by the extent to which the therapist has become an attachment figure. In two studies (N = 308), we developed measures of implicit (lexical decision task) and explicit expectations from therapist, and tested the presence of individual differences in expectations as a function of the patients' attachment orientation, early and late in treatment. Whereas individuals higher on attachment anxiety did not report having fewer positive expectations from therapist early in treatment, they showed lower accessibility of positive expectations when measured implicitly. As treatment progressed, the extent to which the therapist has become an attachment figure may mitigate the adverse effects of pretreatment attachment anxiety. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Therapists' interventions as a predictor of clients' emotional experience, self-understanding, and treatment outcomes.

Clients' emotional experience (EE) and self-understanding (SU) are two clients' processes thought to play a key role in many therapeutic approaches, especially psychodynamic (PD) psychotherapy. Previous studies exploring client processes and the interventions assumed to promote them have found that both processes and interventions are related to a reduction in symptoms. However, the complex associations between the use of specific interventions, clients' processes and symptomatic outcomes have rarely been investigated. Using data collected on a session-by-session basis, we explored (a) the temporal associations between clients' processes (EE and SU) and treatment outcomes (clients' level of functioning), (b) the associations between therapists' AF and PD interventions and clients' processes, and (c) the direct and indirect associations among therapists' interventions, clients' processes, and clients' functioning. Clients (N = 115) undergoing PD psychotherapy reported their general functioning presession using the Outcome Rating Scale, and their EE and SU postsession using the Emotional Experience Self-Report and Self-Understanding Scale, respectively. Therapists reported their use of interventions postsession using the Multitheoretical List of Interventions. Longitudinal multilevel models indicated that higher EE and SU scores predicted subsequent change in functioning. Moderate (vs. high or low) use of AF interventions predicted an increase in clients' EE. Greater use of PD interventions predicted an increase in clients' SU, which also mediated improvement in functioning. These findings highlight the importance of adjusting therapists' use of interventions to promote clients' therapeutic processes and outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Tracing Metacognition in Psychotherapy: Associations With Symptoms of General Distress and Depression.

Deficits in metacognition have often been identified as a central feature in various forms of psychopathology. The current study explores changes in metacognition and symptoms during the process of psychodynamic-oriented psychotherapy conducted in a community setting among people with diverse psychological challenges. We examined the associations between metacognition and symptoms at both the within-client and the between-clients level. Nine good-outcome and nine poor-outcome cases of psychodynamic treatment were analyzed. In terms of metacognitive abilities, results showed that clients who were part of the good-outcome group had higher levels of decentration than did clients who were part of the poor-outcome group. In addition, clients' ability to understand the other's mind improved significantly only for clients in the good-outcome group. Furthermore, sessions in which clients' self-reflectivity was higher were followed by increased symptom levels (in the next session) beyond group (poor or good outcome group). Clinical implications regarding the improvement of metacognitive abilities and their associations with outcome measures are discussed.

Growth curves of clients' emotional experience and their association with emotion regulation and symptoms.

OBJECTIVE: Emotional experience during psychotherapy is considered a core mechanism of change. Yet the sheer experience itself may not necessarily be beneficial; instead, the trajectories of emotional experience need to be explored as possible predictors of treatment outcomes. This study investigated whether clients' pre-treatment levels of emotion regulation and symptoms predicted patterns of session-to-session change in emotional experience. We also explored which patterns better predict clients' improvement in emotion regulation and symptoms from pre- to post treatment. METHOD: One-hundred and seven clients undergoing psychodynamic psychotherapy completed questionnaires on their symptoms and emotion regulation at pre- and post- treatment. They also reported their level of emotional experience at the end of each session. RESULTS: Pre-treatment symptoms and difficulties in emotion regulation predicted greater instability in emotional experience. Higher mean levels of emotional experience during treatment were associated with an improvement in emotion regulation, and greater stability during treatment was associated with improvement in emotion regulation and symptoms. CONCLUSIONS: These findings lend weight to the idea that experiencing emotion in the therapeutic environment has significant implications for clients' ability to manage their emotions outside the session. However, emotions experienced in an unstable manner within therapy are associated with poorer outcomes. Clinical and methodological significance of this article: Therapists can benefit from observing the patterns and not only the level of their clients' emotional experiences. The identification of clients' difficulties early in treatment may help therapists guide clients through the delicate process of carefully attending to their emotions.

Multiplicity and mutuality in the transition of patient and therapist's self-states: Comparison of good vs. poor outcome groups.

Objective: According to the Assimilation Model, the self is consisted of multiple internal voices which are sometimes conflicted, or even dissociated, from one another. Thus, a key therapeutic goal is to create awareness and dialogue between a patient's various internal voices, in order to facilitate positive change. A recent development of this theoretical line suggests that clinically addressing both the patients' and therapists' internal voices, and their mutual influences, contributes significantly to the treatment outcome. Current study aims to examine: (a) Patients' progression throughout treatment in their quality of movement of self-states, from lower levels of dissociation to higher ones of dialectics, and whether this pattern is associated with positive outcomes; (b) temporal congruence in patient-therapist quality of movement of self-states and its association with session outcome. Method: Nine good and nine poor-outcome cases of psychodynamic treatment were analyzed (N = 18) for both the patient and the therapist using the TPA, an expansion of the assimilation of problematic experiences scale (APES). Patients completed the Outcome Rating Scale (i.e., ORS), a session-by-session measure that assesses overall functioning, and symptomatic pre-and-post treatment measures (BDI). Results: A quadratic pattern of change was observed on the TPA of patients from the good-outcome cases: Patients showed more conflict in the beginning, avoidance between self-states in the middle phase, and dialectics towards the end. Additionally, the patient-therapist TPA temporal congruence was significantly related to session outcome of the good-outcome group. Conclusion: These findings emphasize the importance of combining an intra-psychic and inter-psychic set of lenses when inquiring therapeutic processes.

Emotional congruence between clients and therapists and its effect on treatment outcome.

The present study aimed to (a) explore 2 indices of emotional congruence-temporal similarity and directional discrepancy-between clients' and therapists' ratings of their emotions as they cofluctuate session-by-session; and (b) examine whether client/therapist emotional congruence predicts clients' symptom relief and improved functioning. The sample comprised 109 clients treated by 62 therapists in a university setting. Clients and therapists self-reported their negative (NE) and positive emotions (PE) after each session. Symptom severity and functioning level were assessed at the beginning of each session using the clients' self-reports. To assess emotional congruence, an adaptation of West and Kenny's (2011) Truth and Bias model was applied. To examine the consequences of emotional congruence, polynomial regression, and response surface analyses were conducted (Edwards & Parry, 1993). Clients and therapists were temporally similar in both PE and NE. Therapists experienced less intense PE on average, but did not experience more or less intense NE than their clients. Those therapists who experienced more intense NE than their clients were more temporally similar in their emotions to their clients. Therapist/client incongruence in both PE and NE predicted poorer next-session symptomatology; incongruence in PE was also associated with lower client next-session functioning. Session-level symptoms were better when therapists experienced more intense emotions (both PE and NE) than their clients. The findings highlight the importance of recognizing the dynamic nature of emotions in client-therapist interactions and the contribution of session-by-session emotional dynamics to outcomes. (PsycINFO Database Record

Integrating exploration and prediction in computational psychotherapy science: proof of concept.

Introduction: Psychotherapy research has long preferred explanatory over predictive models. As a result, psychotherapy research is currently limited in the variability that can be accounted for in the process and outcome of treatment. The present study is a proof-of-concept approach to psychotherapy science that uses a datadriven approach to achieve robust predictions of the process and outcome of treatment. Methods: A trial including 65 therapeutic dyads was designed to enable an adequate level of variability in therapist characteristics, overcoming the common problem of restricted range. A mixed-model, data-driven approach with cross-validation machine learning algorithms was used to predict treatment outcome and alliance (within- and between-clients; client- and therapist-rated alliance). Results and discussion: Based on baseline predictors only, the models explained 52.8% of the variance for out-of-sample prediction in treatment outcome, and 24.1-52.8% in therapeutic alliance. The identified predictors were consistent with previous findings and point to directions for future investigation. Although limited by its sample size, this study serves as proof of the great potential of the presented approach to produce robust predictions regarding the process and outcome of treatment, offering a potential solution to problems such as p-hacking and lack of replicability. Findings should be replicated using larger samples and distinct populations and settings.