Reactivity and stability in facial expressions as an indicator of therapeutic alliance strength.

Objective: Aspects of our emotional state are constantly being broadcast via our facial expressions. Psychotherapeutic theories highlight the importance of emotional dynamics between patients and therapists for an effective therapeutic relationship. Two emotional dynamics suggested by the literature are emotional reactivity (i.e., when one person is reacting to the other) and emotional stability (i.e., when a person has a tendency to remain in a given emotional state). Yet, little is known empirically about the association between these dynamics and the therapeutic alliance. This study investigates the association between the therapeutic alliance and the emotional dynamics of reactivity and stability, as manifested in the facial expressions of patients and therapists within the session. Methods: Ninety-four patients with major depressive disorder underwent short-term treatment for depression (N = 1256 sessions). Results: Both therapist reactivity and stability were associated with the alliance, across all time spans. Patient reactivity was associated with the alliance only in a short time span (1 s). Conclusions: These findings may potentially guide therapists in the field to attenuate not only their emotional reaction to their patients, but also their own unique presence in the therapy room.

Biological marker of withdrawal ruptures: Dyadic pattern of incongruence in oxytocin release.

Despite widespread clinical, theoretical, and empirical support for the importance of alliance ruptures, little is known about the underlying biological level at times of rupture. The overarching goal of the present study was to investigate dyadic patterns of in-session oxytocin (OT) change between patients and therapists (e.g., patient's OT increases more than therapist's OT) as markers of withdrawal ruptures. Hypothesis 1 construed that OT incongruence (e.g., larger patient increase in OT in comparison to their therapist OT increase) will mark the occurrence of withdrawal ruptures. Hypothesis 2 construed that this effect of OT incongruence will be more pronounced when anxious attachment orientation is low. Surface analysis was conducted on 628 saliva samples that were gathered before and after therapeutic sessions of 53 patient-therapist dyads enrolled in a randomized control trial treating major depression. Only Hypothesis 2 received empirical support, meaning it was only when anxious attachment orientation was low that there were significantly more withdrawal ruptures when the patient's OT increase was higher than their therapist's OT increase. This is consistent with the literature, suggesting that in times of withdrawal ruptures, the patient and therapist are in an incongruent state. Findings suggest that this incongruence is mirrored at the biological level only when anxious attachment orientation is low. Results shed light on what may be happening between patients and therapists on a biological level during a withdrawal rupture. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A systematic review of the association between interpretations and immediate, intermediate, and distal outcomes.

Interpretations are a hallmark of psychodynamic treatment and a method used in other theoretical orientations as well. Therapists use interpretations to increase patients' insight concerning unconscious and preconscious elements in their lives, with the ultimate aim to reduce mental pain and suffering and improve mental health. This systematic review focuses on the association between the therapists' use and accuracy of interpretation and immediate (within-session), intermediate (between-session), and distal (end-of-treatment) outcomes. This synthesis of the research literature is based on 18 independent samples of 1,011 total patients in individual psychotherapy. The results suggest that the use and accuracy of interpretations were associated, in half the studies, with patient disclosure of emotions and increased insight at the immediate, moment-to-moment enfolding of the session. At the intermediate postsession outcome, the use of interpretations was associated with a stronger alliance and greater depth, in half the studies. At the end of treatment, however, while there is some evidence for a positive effect of the use of interpretations on treatment success, there are also neutral effects and even evidence that interpretations have the potential to be harmful in some particular situations. The article concludes with training implications and therapeutic practices based on the integration of clinical experience and research evidence. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Alliance rupture profiles by personality disorder pathology in psychotherapy for depression: Tendencies, development, and timing.

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.

Nonverbal synchrony as a marker of alliance ruptures.

Findings from the past 5 decades of empirical research on the working alliance suggest its importance in psychotherapy. Recent studies have sought to identify markers of the alliance, of which one of the most promising candidates is nonverbal synchrony. Delving into processes that constitute the alliance, such as alliance ruptures, may shed light on underlying mechanisms of the association between nonverbal synchrony and the therapeutic relationship. The present study examines whether nonverbal synchrony can serve as a marker of alliance ruptures. To achieve this aim, 418 sessions of 75 therapeutic dyads were coded for ruptures, using the Rupture Resolution Rating System, and for nonverbal synchrony, using motion energy analysis. A mixed-method analysis, integrating multilevel nested models with a case study analysis, was implemented. The results of the multilevel nested models suggest that nonverbal synchrony is significantly associated with confrontational ruptures, whereas withdrawal ruptures showed no such association. The findings of the case analysis suggest that moments of especially high nonverbal synchrony during a rupture are those in which the therapist made great efforts to be attentive to the patient when the patient acted in a confrontational manner. The findings of the present study demonstrate the potential of nonverbal synchrony to serve as a marker of confrontational ruptures. The findings support the social glue assumption, according to which therapists may seek higher levels of nonverbal synchrony with patients to maintain a strong alliance in the face of difficulties. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

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).

Relationships of biomedical beliefs about depression to treatment-related expectancies in a treatment-seeking sample.

Like other mental disorders, major depression is increasingly explained as a biomedical illness. We examined, in a treatment-seeking sample, whether attributing one's depression to biomedical causes would be associated with pessimistic psychotherapy treatment expectancies. Individuals seeking psychotherapy for depression rated their endorsement of biomedical explanations for their symptoms, expectations regarding treatment outcome, and expectations about forming a working alliance with a therapist. We found that treatment seekers' endorsement of biomedical explanations for their symptoms was associated with pessimism about treatment being successful. This pessimism was, in turn, associated with holding more negative expectancies about one's ability to form a strong therapeutic alliance with a therapist. Given the ascendancy of biomedical explanations for depression and the influence of patient expectancies on clinical outcomes, strategies for disassociating biomedical attributions from pessimistic expectancies may be needed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Oxytocin synchrony between patients and therapists as a mechanism underlying effective psychotherapy for depression.

OBJECTIVE: Oxytocin (OT) synchrony has been suggested as a key mechanism by which bonds are formed and strengthened in various species, including those between mother and infant and between romantic partners. It is unknown whether such biological synchrony also plays a role in psychotherapy efficacy, where it may underlie the adverse effect of social impairment on the efficacy of treatment of depression. METHOD: Five hundred eighty OT saliva samples were collected from 37 patient-therapist dyads on a fixed schedule over a 16-session ongoing randomized controlled trial for psychotherapy for depression. Biological synchrony was operationalized as the correlation between changes occurring repeatedly over treatment in patient and therapist OT levels pre- to postsession. RESULTS: OT synchrony between patients and therapists was found to be associated with effective treatment. The findings support the proposed mediation model: (a) poorer social functioning at baseline predicted lower levels of patient-therapist synchrony in OT changes from pre- to postsession over the course of treatment; (b) lower levels of therapist-patient OT synchrony, in turn, predicted less reduction in depressive symptoms during treatment; and (c) based on quasi-Bayesian Monte Carlo simulations, the levels of therapist-patient synchrony significantly mediated the association between social impairment and reduction in depressive symptoms. Findings were replicated using robust inferential methods. CONCLUSIONS: The findings suggest that OT synchrony between patient and therapist may be a biological mechanism by which impaired interpersonal functioning undermines treatment outcome. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A randomized controlled trial for identifying the most suitable treatment for depression based on patients' attachment orientation.

OBJECTIVE: Many active treatments exist for major depressive disorder (MDD), but little is known about their differential effects for various subpopulations of patients to guide precision medicine. This is the first randomized controlled trial (RCT) designed to identify differential treatment effects based on patients' attachment orientations. We tested an a priori preregistered hypothesis of the potential moderating effect of patients' attachment orientation on the outcome of supportive therapy (ST) versus supportive-expressive therapy (SET). METHODS: The RCT was conducted between 2015 and 2021. Individuals with MDD were randomly assigned to 16-week ST or SET. The predefined primary outcome measure was the Hamilton Rating Scale for Depression. Hypotheses were formulated and preregistered before data collection. RESULTS: One hundred patients with MDD were enrolled, 57% women, average age 31.2 (SD = 8.25). Data were analyzed using the intention-to-treat approach. Our hypothesis that attachment anxiety is a significant moderator of treatment outcome was supported (B = -0.09, p = .016): Patients with higher levels of attachment anxiety showed greater treatment efficacy following SET than ST. Although the hypothesis regarding a potential moderating effect of avoidant attachment was not supported, sensitivity analyses revealed that individuals with disorganized attachment orientation (higher scores on both anxious and avoidant attachment) benefited more from SET than from ST (B = -0.07, p = .04). CONCLUSION: The findings support the clinical utility of patients' attachment orientation in selecting the most suitable treatment for individuals and demonstrate the methodological utility of RCTs predesigned to test theoretically based models of personalized treatment. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Achieving successful resolution of alliance ruptures: for whom and when?

Contemporary theories and the empirical literature stress the importance of successful resolution of alliance ruptures for the process and outcome of treatment. Yet, little empirical work has examined what leads to successful resolutions. The aim of the present study was to examine which patients are more likely to achieve successful resolutions of ruptures and under which circumstances.Sixty-five patients completed measures assessing their trait-like pretreatment characteristics (alliance expectations and general attachment orientation), and state-like changes in treatment (working alliance, therapist serving as an attachment figure, and the implementation of common factor techniques). Successful resolutions were coded using observer behavioral coding at four time points.State-like changes, but not trait-like characteristics significantly contributed to successful resolution. Stronger working alliance and the therapist as an attachment figure, and the implementation of common factors techniques were found to contribute to successful resolutions.The current findings emphasize the importance of the process that occurs within treatment, and the therapeutic context in which the resolution process take place for the ability to achieve successful resolutions.

A moderating factor for patients with vindictive interpersonal problems.

Individuals high in vindictive interpersonal problems tend to experience and express anger and irritability. In treatment, they have poor prognosis for alliance and outcome. We propose that positive expectation may serve as a moderating factor for these patients. In the current study, we examined the ability of expected alliance to act as a moderating factor in the early process and early progress of treatment for patients with vindictive interpersonal problems. A sample of 65 patients received short-term dynamic psychotherapy. At intake, before meeting the therapist, participants completed assessments for vindictive interpersonal problems and expected alliance. All therapy sessions were videotaped, and Session 2 was coded for confrontation ruptures. Early progress was assessed using the improvement from intake to Week 2 in the measure of distress from interpersonal relations. Our results show that, at high levels of vindictive interpersonal problems, higher expected alliance was associated with fewer confrontation ruptures. At high levels of vindictive interpersonal problems, higher expected alliance was associated with greater early improvement in distress from interpersonal relations. The findings demonstrate how positive expectations may function as a moderating factor that enables patients with vindictive tendencies to achieve a positive process and progress early in treatment. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Oxytocin as a biomarker of the formation of therapeutic alliance in psychotherapy and counseling psychology.

The therapeutic alliance is one of the most consistent predictors of therapeutic change, including symptom reduction and improvement in wellbeing and quality of life, across a variety of mental health interventions. Yet, little is known about its biological mechanisms. Oxytocin (OT) has been suggested as a biological mechanism by which bonds are formed and strengthened across species. This article is intended to demonstrate the potential of OT as a biomarker of therapeutic change in psychotherapy and counseling psychology, especially of the therapeutic alliance. We delineate three main potential paths of investigation based on the most recent research on OT in parent-child and romantic partner dyads. For each path, we provide a detailed explanation for whom, when, and how OT should be measured. Each path is illustrated using data collected in a randomized controlled trial of psychotherapy for major depressive disorder. These illustrations demonstrate the great potential of OT as a biomarker of (a) trait-like characteristics of the patients and the therapists, (b) the processes of therapeutic change, and (c) the dyadic synchrony between patients and their therapists. The potential clinical contribution of OT as a biomarker for each of these three paths is further demonstrated using a case study. Practical suggestions and directions for future research are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).