Narrative reconstruction therapy for prolonged grief disorder: Basic interventions and mechanisms of change.

Narrative reconstruction is a time-limited integrative therapy, originally developed in the context of post-traumatic stress disorder and adjusted for the treatment of prolonged grief disorder (PGD). It consists of exposure to the loss memory and narrating a detailed written reconstruction of it. In this paper, we describe narrative reconstruction interventions and modifications for the treatment of PGD as well as the underlying mechanisms of change including integration of the loss episode into the life narrative. A case demonstration of narrative reconstruction with a patient with PGD presented for illustration and the integrative nature of narrative reconstruction for PGD is discussed.

A quasi-experimental trial of narrative reconstruction for prolonged grief disorder: Symptomatic improvement and enhanced memory integration.

BACKGROUND: Prolonged grief disorder (PGD) was recently approved as a formal diagnosis in the DSM-5-TR. The implementation of bereavement interventions is frequently requested, but their effectiveness has been controversial. Narrative reconstruction (NR) is a time-limited integrative therapy, originally developed for the treatment of post-traumatic stress disorder (PTSD) and adapted for the treatment of PGD. NR consists of exposure to the loss memory, a detailed written reconstruction of the loss memory narrative, and an elaboration of the personal significance of that memory for the bereaved. OBJECTIVES: In this study we evaluated the efficacy of NR for PGD. METHOD: In this study, 33 participants with PGD were quasi-randomized-that is, assigned to an immediate (n = 20) or delayed (n = 13) 16-session NR intervention. PGD, intrusion, avoidance and depression symptoms, as well as levels of the loss memory integration, were assessed at pretreatment, post-treatment, and at a 3-month follow-up. RESULTS: Mixed linear models showed significant intervention effects for PGD and intrusive symptomatology. Results also showed an increase in integration of the loss memory, and improvements remained stable for all outcomes at follow-up. CONCLUSION: In this study we established NR as an effective intervention for PGD and call for further validation in future studies. Integrating this intervention into the routine care of people with PGD seems important and beneficial.

Narrative Reconstruction as an Intervention for Posttraumatic Stress Disorder: A Pilot Delayed Intervention Quasi-Randomized Controlled Trial.

Although empirically supported treatments for posttraumatic stress disorder (PTSD) exist, many patients fail to complete therapy, are nonresponsive, or remain symptomatic following treatment. This paper presents the results of a delayed intervention quasi-randomized controlled study that evaluated the efficacy of narrative reconstruction as an integrative intervention for PTSD. During narrative reconstruction, the patient and therapist reconstruct an organized, coherent, and detailed written narrative of the patient's traumatic experience. Additionally, narrative reconstruction focuses on arriving at the subjective meaning of the traumatic experience for the patient as related to their personal history. Thus, the therapist asks the patient about associations between the traumatic event and other memories and life events. In the present study, 30 participants with PTSD were randomly assigned to an immediate (n = 17) or delayed (n = 13) 15-session narrative reconstruction intervention. Participants in the immediate narrative reconstruction group were evaluated using self-report measures and structured interviews at baseline, posttreatment, and 15-week follow-up. Participants in the delayed narrative reconstruction group were evaluated at baseline, postwaitlist/pretreatment, and posttreatment assessments. Data from the pretreatment evaluation showed no significant differences between groups. Mixed linear models showed significant intervention effects for posttraumatic symptom severity, d = 1.17, from pre- to posttreatment. Although preliminary, these promising findings suggest that narrative reconstruction may be an effective standalone therapy or an add-on to current effective treatment strategies.

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).

Enhancement of self compassion in psychotherapy: The role of therapists' interventions.

Aim: Self Compassion (SC) has been consistently linked to decreased emotional distress and is offered as a mechanism of change in several therapeutic approaches. The current study aimed to identify therapists' interventions that enhance clients' SC within individual psychodynamic psychotherapy. We examined a diverse set of interventions as predictors of clients' SC, on treatment and session levels. We hypothesized that improvement in SC will be associated with greater use of directive or common factor interventions. Method: Client/therapist (N = 89) dyads from a university-based community clinic participated in the study. Therapists' interventions and changes in clients' SC level were monitored at each psychotherapy session. Results: Clients' SC in a given session was not predicted by therapist use of interventions from any of the three clusters in the previous session. However, positive change in SC across treatment was predicted by greater use of directive interventions. Furthermore, among clients with low pretreatment SC, a positive change in SC across treatment was predicted by lesser use of common factor interventions. Discussion: The results highlight the importance of understanding clients' pretreatment characteristics when selecting therapeutic interventions and suggest that the integration of directive interventions into the psychodynamic therapeutic practice may be beneficial in enhancing clients' SC.

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.

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

The association between self-compassion and treatment outcomes: Session-level and treatment-level effects.

OBJECTIVE: Self-compassion (SC) has been consistently linked to less psychopathology; however, the link between changes in client's SC levels and psychotherapy outcomes has yet to be explored. METHOD: Clients at a university-based community clinic completed SC and outcome measures session by session (N = 112) as well as pre- to posttreatment (N = 70). RESULTS: Increases in clients' SC levels across the entire therapeutic process were associated with improvement in all posttreatment outcomes. Additionally, session-to-session increases in SC levels predicted improved symptoms and functioning at the session level; these effects were significant above and beyond the effects of the therapeutic alliance. CONCLUSION: The results of the current study highlight SC as a possible process variable in psychotherapy.

Metacognitive Reflection and Insight Therapy (MERIT) Among People With Schizophrenia: Lessons From Two Case Studies.

People with schizophrenia spectrum disorder face a major challenge in the ability to reflect on their own and others' mental activities and about specific psychological problems in their lives. These deficits are associated with increased symptoms and lower functioning. Specific interventions have been designed to enhance these abilities, one of which is metacognitive reflection and insight therapy (MERIT). Several case studies and a recent pilot study have shown increased metacognitive abilities and a decrease in symptoms among clients after MERIT. This article presents two case studies of clients diagnosed with schizoaffective disorder whose psychotherapy, conducted in Israel, incorporated the MERIT protocol. Outcome measures were taken before and after treatment, and metacognitive abilities were assessed at five time points throughout treatment. Clinical implications and limitations are discussed.

The Mediating Role of Integration of Loss in the Relationship Between Dissociation and Prolonged Grief Disorder.

OBJECTIVE: Findings from the field of trauma have shown that there is a negative relationship between dissociation and integration of loss into the self-narrative. At the same time, an increasing amount of literature on grief has stressed the importance of an integrated self-narrative in the grieving process. Accordingly, the current study examined the possible mediating role played by the extent to which individuals have integrated their loss into their self-narrative in the relationship between dissociation and symptoms of prolonged grief disorder (PGD). METHOD: The Prolonged Grief Disorder Scale (PGD-13), the Outcome Questionnaire, the Integration of Stressful Life Experiences Scale, the Dissociative Experiences Scale, and a sociodemographic questionnaire were administered to 66 individuals who had lost a loved one. RESULTS: The hypothesized mediation model of integration was confirmed. CONCLUSION: The effect of people's dissociative tendencies on their PGD symptoms seems to occur via the impairment of their ability to integrate the memory of their loss into their general autobiographical memory. Empirical and clinical implications are discussed.

Neural oscillations while remembering traumatic memories in post-traumatic stress disorder.

OBJECTIVE: The current study investigated the oscillatory brain activity of PTSD patients during directed and imaginal exposure to the traumatic memory using magnetoencephalography (MEG), in a paradigm resembling exposure therapy. METHODS: Brain activity of healthy trauma-exposed controls and PTSD participants was measured with MEG as they listened to individualized trauma narratives as well as to a neutral narrative and as they imagined the narrative in detail. Source localization analysis by frequency bands was conducted in order to map neural generators of oscillatory activity. RESULTS: Elicitation of traumatic memories resulted in a distinct neural pattern in PTSD patients compared to healthy trauma-exposed individuals. In response to trauma scripts PTSD patients showed increases in high-gamma band power in visual areas, increased frontal and temporal theta as well as prefrontal alpha and medial temporal beta power relative to neutral scripts. CONCLUSIONS: Results suggest that when recollecting and imagining traumatic memories PTSD patients attempt to engage control or inhibition mechanisms. However, these are either not successfully recruited or inefficient leading to heightened responses and recollection. SIGNIFICANCE: Investigating the oscillatory neural dynamics of PTSD patients can help us better understand the processes underlying trauma re-experiencing.

Narrative reconstruction therapy for prolonged grief disorder - a pilot study.

Background: Prolonged grief disorder (PGD) is a chronic and disabling condition that affects approximately 10% of non-traumatically bereaved people. Narrative reconstruction (NR), originally designed for the treatment of posttraumatic stress disorder (PTSD), is a time-limited integrative therapy consisting of exposure to the loss memory, detailed written reconstruction of the loss memory narrative, and an elaboration of the personal significance of that memory for the bereaved. Objective: This pilot study examined the efficacy of NR therapy in reducing symptoms in bereaved people diagnosed with PGD. Method: Ten PGD patients participated in the study and were treated with 16 weekly sessions of NR. PGD, PTSD, and depression symptoms, as well as levels of loss integration, were assessed at pre-treatment, post-treatment, and at a 3-month follow-up. Results: Following NR, participants showed significant reductions in PGD, depression, and PTSD symptoms, and elevated levels of trauma integration. Symptoms showed further improvement at the three-month follow-up. Conclusions: These findings provide preliminary evidence for the feasibility and efficacy of NR in treating PGD. Narrative reconstruction therapy requires further evaluation in randomized controlled trials.

Antecedentes: El trastorno de duelo prolongado (PGD en su sigla en inglés) es una condición crónica y discapacitante que afecta aproximadamente al 10% de las personas que experimentan un duelo no traumático. La reconstrucción narrativa (NR en su sigla en inglés) fue diseñada originalmente para el tratamiento del trastorno de estrés postraumático (TEPT), es una terapia integrativa de tiempo limitado que consiste en la exposición a la memoria de la pérdida, la reconstrucción escrita detallada de la memoria narrativa de la pérdida, y una elaboración del significado personal de esa memoria para la persona experimentando el duelo.Objetivo: Este estudio piloto examina la eficacia de la terapia NR en reducir los síntomas en las personas experimentando duelo que han sido diagnosticadas con el PGD.Método: Diez pacientes con PGD participaron en el estudio y fueron tratados con 16 sesiones semanales de NR. Los síntomas de PGD, TEPT, y depresión, como también los niveles de integración de la pérdida, fueron evaluados previo al tratamiento, luego del tratamiento, y a los 3 meses de seguimiento.Resultados: Siguiendo NR, los participantes mostraron reducciones significativas en los síntomas de PGD, depresión, y TEPT, y niveles elevados de integración del trauma. Los síntomas mostraron mayores mejoras a los tres meses de seguimiento.Conclusión: Estos hallazgos proveen evidencia preliminar para la factibilidad y eficacia del NR en tratar el PGD. La terapia de reconstrucción narrativa requiere mayor evaluación en ensayos controlados aleatorizados.

Therapeutic technique diversity is linked to quality of working alliance and client functioning following alliance ruptures.

OBJECTIVE: The current investigation aimed to examine the possible association between therapists' flexibility in use of therapeutic techniques from different therapy orientations (i.e., therapeutic technique diversity; TTD) and subsequent improvement in client-reported (a) global functioning, as well as (b) quality of the working alliance, following sessions in which alliance ruptures occurred. METHOD: Clients (n = 81) who received time-limited psychodynamic therapy in a community clinic, completed session-by-session reports of working alliance and global functioning. Therapists (n = 56) completed session-by-session reports of working alliance and their use of therapeutic techniques across different therapeutic orientations, using the Multitheoretical List of Interventions (MULTI-30). RESULTS: We found a curvilinear association between TTD in rupture sessions and client-reported global functioning at the sessions subsequent to rupture sessions, such that moderate levels of TTD were associated with greater subsequent improvement in functioning, compared with low and high levels of TTD. However, TTD was not significantly associated with subsequent changes in the quality of working alliance. CONCLUSIONS: Our results suggest that moderate levels of TTD in the face of alliance ruptures are tied to clients' global functioning improvement during psychodynamic psychotherapy. These findings highlight the importance of further investigation of a varied delivery of therapeutic techniques, especially in the face of alliance ruptures. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Surgical procedures and pediatric medical traumatic stress (PMTS) syndrome: Assessment and future directions.

INTRODUCTION: Surgical procedures involve traumatic stress. Children may develop chronic psychological distress and dysfunction after surgery, with consequent reluctance to comply with medical follow-up care. A literature review of this topic shows that it has been understudied. Our study aims to assess the frequency and characteristics of symptoms of persistent psychological distress in children following surgery, which have not been documented before, in order to promote its awareness and its early identification. METHODS: Parents of 79 children (aged 1-6) that were hospitalized in a pediatric surgical ward, comprising a representative sample, completed three validated questionnaires assessing their children's psychological symptoms 3-5months after the hospitalization. RESULTS: A significant portion of children suffer from psychological distress 3-5months after hospitalization. Moreover, 10.39% of the children exhibited symptoms of PTSD, and 28.6% of parents reported that the child's distress causes dysfunction. Additionally, our findings emphasize the parents' concerns regarding the child's behavior, function, and health following hospitalization. CONCLUSION: Since a significant prevalence of hospitalization-related traumatic stress is documented, the awareness to it has to be improved, in order to reduce its frequency and increase adherence to medical follow-up care. TYPE OF STUDY: Prognosis study. LEVEL OF EVIDENCE: 1.

Emotional experience and alliance contribute to therapeutic change in psychodynamic therapy.

Accumulating evidence suggests that the therapeutic alliance and clients' contact with emotions during therapy sessions can be effective in reducing their suffering outside of sessions. However, the complex associations among these determinants are not yet clear. Using data collected in therapy on a session-by-session basis, this study explored (a) the temporal associations between emotional experience and the therapeutic alliance; (b) the temporal associations between emotional experience and clients' level of functioning; and (c) the direct and indirect associations among emotional experience, the therapeutic alliance, and functioning. Clients (N = 101) undergoing psychodynamic therapy completed a functioning and distress measure prior to each session, and reported on their emotional experience and perceived alliance strength following each session. Longitudinal multilevel models indicated that higher therapeutic alliance scores at the end of 1 session predicted a greater emotional experience in the next session but that emotional experience did not predict subsequent levels of alliance. The results provided evidence of reciprocal prediction in which a previous emotional experience predicted a subsequent change in functioning and vice versa. Finally, the alliance predicted emotional experience, which, in turn, predicted functioning; hence, alliance strength indirectly predicted clients' level of functioning. Findings indicate that emotional experience and the therapeutic alliance are important determinants of the therapeutic process, which contribute to predict clients' improvement in functioning within psychodynamic treatment.

Therapist-client agreement in assessments of clients' functioning.

OBJECTIVE: We aimed to assess the extent to which therapists' reports of client functioning track their clients' changing experience of their own functioning from session to session (temporal congruence) as well as the extent to which they over- or underestimate their clients' functioning (level or directional bias) and to examine whether these indices predict treatment outcomes. METHOD: The participants included 384 clients who were treated by 77 therapists. Both clients and therapists rated the clients' functioning each session. The clients also completed pre- and posttreatment outcome measures. RESULTS: Using multilevel modeling, we found that therapists' reports regarding their clients' functioning tended to be temporally congruent from session to session with their clients' reported functioning. In addition, on average, therapists did not show a level bias (i.e., did not over- or underestimate their clients' functioning). Finally, temporal congruence (but not level bias) predicted better treatment outcomes. CONCLUSION: These findings highlight the importance of tracking clients' fluctuating symptoms over time. Thus, we discuss their implication for the policy and practice of providing session-by-session feedback to therapists. (PsycINFO Database Record

Narrative reconstruction therapy for prolonged grief disorder-rationale and case study.

BACKGROUND: Prolonged grief disorder (PGD) is a potentially disabling condition affecting approximately 10% of bereaved people. It has been suggested that the impaired integration of the loss memory, as expressed in recurrent memories of the loss and disorganization of memory, is involved in the development of PGD. Narrative reconstruction (NR), originally designed for the treatment of posttraumatic stress disorder (PTSD) in an integrative therapy module, and consisting of exposure to the loss memory, detailed written reconstruction of the loss memory narrative and an elaboration of the personal significance of that memory for the bereaved, has been shown to be effective in the treatment of intrusion symptoms. OBJECTIVE: In light of findings that cognitive behavior therapy (CBT), including cognitive restructuring and exposure, is effective in the treatment of PGD, we suggest the implementation of a somewhat novel therapy module, NR, for the treatment of intrusive phenomena in bereaved patients. METHOD: The rationale for the implementation of NR for PGD and a case study of the treatment of a woman suffering from PGD after the death of her father are presented. Therapy took place in a university outpatient training clinic. RESULTS: Evaluations conducted before and after treatment and at a 3-month follow-up demonstrated the effectiveness of NR in reducing symptoms of PGD and depression. The analysis of spontaneous narratives recorded before and after treatment showed an increased organization of the narratives. CONCLUSIONS: This case report demonstrates an adaptation of NR for the treatment of PGD. The results provide preliminary support for the effectiveness of NR for PGD. The significance of the study and its limitations are discussed.

Neural correlates of attention bias in posttraumatic stress disorder.

OBJECTIVE: Patients suffering from posttraumatic stress disorder (PTSD) exhibit hyper arousal symptoms and attention problems which were frequently investigated using the P3 event-related potentials (ERPs). Our study aimed at providing more precise knowledge of the functional significance of the P3 alteration seen in PTSD by revealing its spatio-temporal dynamics. METHODS: Fifteen PTSD patients and fifteen healthy trauma-exposed controls participated in a three-tone "oddball" task while their brain activity was recorded by magnetoencephalography (MEG). They were asked to detect rare target tones and ignore standard tones and infrequent threatening distractors. An adaptive spatial-filter method (SAM beamformer) was applied for source estimation. RESULTS: Compared with controls, PTSD patients had more incorrect responses to standard stimuli. On the brain level, PTSD patients showed hyperactivity in the dorsolateral prefrontal cortex and anterior cingulate cortex in response to standard sounds, decreased activity in those regions in response to threatening distractors, and decreased orbitofrontal activity in response to target stimuli. CONCLUSIONS: Increased frontal activation in response to standard, neutral, stimuli may reflect greater resource allocation dedicated to cognitive control mechanisms during routine functioning in PTSD. Decreased frontal activation in response to rare stimuli may reflect subsequently reduced residual resources for detecting rare stimuli and for emotion regulation. This may explain the hypervigilance and attention problems commonly reported by patients. SIGNIFICANCE: The current findings contribute to a better understanding of the mechanisms underlying the attention deficiency in PTSD, and highlight altered activity in specific frontal regions as potential biomarkers.

Embodied simulation in exposure-based therapies for posttraumatic stress disorder-a possible integration of cognitive behavioral theories, neuroscience, and psychoanalysis.

Exposure to the trauma memory is the common denominator of most evidence-based interventions for posttraumatic stress disorder (PTSD). Although exposure-based therapies aim to change associative learning networks and negative cognitions related to the trauma memory, emotional interactions between patient and therapist have not been thoroughly considered in past evaluations of exposure-based therapy. This work focuses on recent discoveries of the mirror-neuron system and the theory of embodied simulation (ES). These conceptualizations may add a new perspective to our understanding of change processes in exposure-based treatments for PTSD patients. It is proposed that during exposure to trauma memories, emotional responses of the patient are transferred to the therapist through ES and then mirrored back to the patient in a modulated way. This process helps to alleviate the patient's sense of loneliness and enhances his or her ability to exert control over painful, trauma-related emotional responses. ES processes may enhance the integration of clinical insights originating in psychoanalytic theories-such as holding, containment, projective identification, and emotional attunement-with cognitive behavioral theories of learning processes in the alleviation of painful emotional responses aroused by trauma memories. These processes are demonstrated through a clinical vignette from an exposure-based therapy with a trauma survivor. Possible clinical implications for the importance of face-to-face relationships during exposure-based therapy are discussed.