Physiological regulation processes differentiate the experience of ruptures between patient and therapist.

The empirical and clinical literature emphasizes the importance of alliance ruptures, signaling therapeutic processes occurring within and between the partners of the therapeutic dyad. However, knowledge about the underlying regulatory processes that occur amid ruptures is scarce. Identifying the underlying physiological markers may shed light on these regulatory processes. The overarching goal of the present study was to explore physiological markers of withdrawal and confrontation ruptures, within the patient and the therapist. Given the little known on the subject, we used a single-case design (94 episodic segments) to explore biologically based regulatory processes in the face of a rupture, contrasting confrontation ruptures versus withdrawal ruptures versus control episodes (emotional and neutral episodes). Findings showed that the patient and the therapist had contrasting physiological responses to the ruptures, depending on the type. During withdrawal ruptures, the patient exhibited high regulation, while the therapist did not show a clear physiological reaction. During confrontation ruptures, the patient exhibited low regulation, while the therapist exhibited high regulation. The different physiological regulation processes at times of ruptures suggest that, in withdrawal, the patient relied on intrapersonal regulation, contrasting with the interpersonal regulation observed in confrontation ruptures. Findings remained robust after controlling for speech turns and 10,000 Monte Carlo permutations to assess chance-level results. These findings provide initial evidence for the link between arousal and behavior in ruptures, offering valuable psychoeducational material for therapists to improve their handling of these challenging moments. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The role of affect dynamics as mechanisms of change in mental health interventions: Integrating applied and basic science.

In recent years, there has been growing empirical interest in examining the role of affect dynamics in mental health. However, research on affect has largely progressed independently in the basic and applied sciences, yielding significant advances in each domain but little cross-disciplinary integration. This special issue addresses this gap by showcasing some of the most promising recent developments in the field. The articles featured in this special issue offer insights into key innovations in affect dynamics and their potential implications for mental health interventions. Comprising a total of 17 articles, the issue is divided into two sections: Daily Life Assessment of Affect, encompassing seven articles, and In-Treatment Assessment of Affect, comprising 10 articles. In this editorial, we synthesize the contributions of these articles and propose a set of fundamental principles for conducting and interpreting research on the role of affect dynamics as mechanisms of change in mental health interventions. These principles encompass (a) the content of affect research related to mental health and its treatment (the What), (b) the timing of the assessment (the When), (c) the target populations under investigation (the Who), and (d) the methodologies employed (the How). The synthesis presented here, along with the articles featured in this special issue, holds significant potential to inform clinical research and practice on the role of affect dynamics in mental health interventions and stimulate future scientific inquiry in this important area. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Thinking Transtheoretically About Alliance and Rupture: Implications for Practice and Training.

Repairing alliance ruptures has the potential to serve as a powerful mechanism of change in psychotherapy. In this article, a transtheoretical individual-specific framework for repairing alliance ruptures is proposed. According to the proposed framework, at the intake session, the therapist evaluates the trait-like tendencies of individual patients to face ruptures in interpersonal relationships. We propose a typology based on which patients are assigned to one of the following therapeutic strategies: (a) a treatment where alliance rupture and repair is the main mechanism of change (Type A), (b) an added module that augments another treatment, focusing on rupture and repair (Type B), or (c) treatment where no rupture resolution work is carried out (Type C). The proposed framework is based on cumulative clinical knowledge, and its validity and utility need to be assessed in future research.

Cortisol Synchrony in Psychotherapy for Major Depressive Disorder.

INTRODUCTION: Accumulating research emphasizes the role of interpersonal coordination in arousal levels, which may manifest as cortisol synchrony, in interpersonal interactions. While the role of cortisol has been investigated in psychotherapy, cortisol synchrony and its characteristics and effect on treatment progress remain a relatively unexplored area. This study aims to explore the existence of distinct patterns of cortisol coordination throughout psychotherapy and test the associations of different coordination patterns with patients' pre-treatment characteristics and treatment progress measures. METHODS: Fifty patient-therapist dyads participated in 16 weeks of psychodynamic treatment for major depressive disorder. Salivary cortisol samples were collected before and after each session at four time points. Self-report questionnaires and treatment session video-coding were used to characterize and differentiate between patterns of cortisol coordination. RESULTS: Three patterns of cortisol coordination were identified: synchronized, unsynchronized and stable-therapist. These patterns differed in patient characteristics and treatment progress measures in that patients exhibiting a synchronized pattern tended to be more anxious and dominant in their relationships and were more prone to withdrawal ruptures. CONCLUSIONS: Results provide novel evidence regarding variability in patient-therapist cortisol patterns and its putative associations with treatment progress.

Changing attachment orientation: Uncovering the role of shifting the emotion regulation tendency.

Changes in the individual's attachment orientation toward greater security are considered an important clinical goal. One promising underlying process of change in attachment orientation is shifting the emotion regulation tendency, in which the individual progresses from overreliance on the self or on the other to regulate emotional arousal. The present study utilized a computational approach to study shifts in the emotion regulation tendency as these manifest in the patient's and therapist's vocally encoded emotional arousal. The study examined whether shifts in the regulation tendency are associated with decreases in the level of insecure attachment and in strengthening of the therapeutic alliance. Shifts in the regulation tendency were examined throughout the early stages of treatment (Sessions 1-4) using 11,710 talk turns within 52 patient-therapist dyads. Findings suggest that shifts in the emotion regulation tendency are associated with greater strengthening of the therapeutic alliance and a decrease in the level of attachment avoidance. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Development of the Therapeutic Alliance in Alternative Settings to Psychiatric Hospitalization: An Open Comparative Study.

Patient-therapist alliance in two alternative treatment settings developed similarly to that in traditional psychiatric hospitalization.

Factors That Predict Magnitude, Timing, and Persistence of Placebo-Like Response in Patients With Irritable Bowel Syndrome.

BACKGROUND AND AIMS: Placebo response impedes the development of novel irritable bowel syndrome (IBS) therapies and the interpretability of randomized clinical trials. This study sought to characterize the magnitude, timing, and durability of IBS symptom relief in patients undergoing a non-drug placebo-like control. METHODS: One hundred forty-five Rome III-diagnosed patients (80% F, M age = 42 years) were assigned to education/nondirective support delivered over a 10-week acute phase. Treatment response was based on the IBS version of the Clinical Global Improvement Scale completed 2 weeks after treatment ended. Candidate predictors were assessed at baseline (eg, emotion regulation, pain catastrophizing, distress, neuroticism, stress, somatization, gastrointestinal-specific anxiety) or clinically relevant points during treatment (patient-provider relationship, treatment expectancy/credibility). RESULTS: Midtreatment response was associated with lower levels of stress and somatization at baseline and greater patient-provider agreement on treatment tasks (P < .001). Treatment response was associated with baseline gastroenterologist-rated IBS severity, anxiety, ability to reappraise emotions to reduce their impact [cognitive reappraisal], and agreement that provider and patient shared goals from provider perspective (P < .001). The day-to-day ability to reappraise emotions at baseline distinguished rapid from delayed placebo responders (P = .011). CONCLUSION: Patient beliefs (eg, perceived stress, cognitive reappraisal) impacted the magnitude, timing, and persistence of placebo response measured at midway point of acute phase and 2 weeks after treatment discontinuation. Baseline beliefs that patients could alter the impact of stressful events by rethinking their unpleasantness distinguished rapid vs delayed placebo responders. Collaborative agreement between doctor and patient around shared tasks/goals from the clinician perspective predicted placebo response.

Cognitive Function and Participation of Stroke Survivors Living With Companion Animals: A Cross-Sectional Study.

INTRODUCTION/OBJECTIVES: Companion animals (CAs) may benefit human health, but few studies have examined their impact on stroke survivors. This study examines participation, quality of life (QoL), attachment, cognition, and executive function differences between stroke survivors living with and without CAs. METHODS: In this cross-sectional, community-setting study, 25 stroke survivors with a CA and a matched group of 27 without a CA completed standard tools. RESULTS: Stroke survivors with a CA scored significantly higher in participation and 1 cognitive performance test. No significant differences were found in other cognitive measures or QoL, and attachment to a CA was not correlated with participation or QoL within the research group. However, lower attachment avoidance correlated with better participation in survivors living with dogs. CONCLUSION: Living with CAs, especially dogs, might be associated with some cognitive function and participation benefits among stroke survivors. The link between CAs and cognitive function is unclear: Survivors with higher cognitive functioning might be more capable of caring for a CA, or having and caring for a CA might promote better cognitive function. Attachment patterns also might explain stroke survivors' participation levels. Further study is warranted.

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.

Intrusive Traumatic Re-Experiencing Domain: Functional Connectivity Feature Classification by the ENIGMA PTSD Consortium.

Background: Intrusive traumatic re-experiencing domain (ITRED) was recently introduced as a novel perspective on posttraumatic psychopathology, proposing to focus research of posttraumatic stress disorder (PTSD) on the unique symptoms of intrusive and involuntary re-experiencing of the trauma, namely, intrusive memories, nightmares, and flashbacks. The aim of the present study was to explore ITRED from a neural network connectivity perspective. Methods: Data were collected from 9 sites taking part in the ENIGMA (Enhancing Neuro Imaging Genetics through Meta Analysis) PTSD Consortium (n= 584) and included itemized PTSD symptom scores and resting-state functional connectivity (rsFC) data. We assessed the utility of rsFC in classifying PTSD, ITRED-only (no PTSD diagnosis), and trauma-exposed (TE)-only (no PTSD or ITRED) groups using a machine learning approach, examining well-known networks implicated in PTSD. A random forest classification model was built on a training set using cross-validation, and the averaged cross-validation model performance for classification was evaluated using the area under the curve. The model was tested using a fully independent portion of the data (test dataset), and the test area under the curve was evaluated. Results: rsFC signatures differentiated TE-only participants from PTSD and ITRED-only participants at about 60% accuracy. Conversely, rsFC signatures did not differentiate PTSD from ITRED-only individuals (45% accuracy). Common features differentiating TE-only participants from PTSD and ITRED-only participants mainly involved default mode network-related pathways. Some unique features, such as connectivity within the frontoparietal network, differentiated TE-only participants from one group (PTSD or ITRED-only) but to a lesser extent from the other group. Conclusions: Neural network connectivity supports ITRED as a novel neurobiologically based approach to classifying posttrauma psychopathology.

Individual-Specific Animated Profiles of Mental Health.

How important is the timing of the pretreatment evaluation? If we consider mental health to be a relatively fixed condition, the specific timing (e.g., day, hour) of the evaluation is immaterial and often determined on the basis of technical considerations. Indeed, the fundamental assumption underlying the vast majority of psychotherapy research and practice is that mental health is a state that can be captured in a one-dimensional snapshot. If this fundamental assumption, underlying 80 years of empirical research and practice, is incorrect, it may help explain why for decades psychotherapy failed to rise above the 50% efficacy rate in the treatment of mental-health disorders, especially depression, a heterogeneous disorder and the leading cause of disability worldwide. Based on recent studies suggesting within-individual dynamics, this article proposes that mental health and its underlying therapeutic mechanisms have underlying intrinsic dynamics that manifest across dimensions. Computational psychotherapy is needed to develop individual-specific pretreatment animated profiles of mental health. Such individual-specific animated profiles are expected to improve the ability to select the optimal treatment for each patient, devise adequate treatment plans, and adjust them on the basis of ongoing evaluations of mental-health dynamics, creating a new understanding of therapeutic change as a transition toward a more adaptive animated profile.

Members' goal orientation and working alliance in group therapy: A response surface analysis.

Research suggests that a client's achievement goal orientation and alliance are important for positive treatment outcomes. However, it is currently unknown how a member's goal orientation and alliance in tandem relate to members' improvement in group therapy, despite conceptual wisdom regarding the additive effect of a high alliance and a mastery or approach goal orientation. Therefore, this study sought to examine the congruence between members' goal orientation and the member-group alliance on members' perceived improvement in group therapy. Data for this study came from 99 clients across 10 interpersonal process groups. Polynomial regression and response surface analysis were used to test the congruent and discrepant effects of members' goal orientation (i.e., approach-performance, avoidance-performance, and mastery orientation) and group alliance on their perceived improvement in group therapy. As hypothesized, members who reported congruent high group alliance and high mastery orientation or approach orientation compared to congruent low alliance and low mastery or approach orientation reported high levels of improvement in group therapy. Regarding discrepant effects, discrepant high alliance and low avoidance orientation compared to low alliance and high avoidance was positively related to improvement in group therapy, and discrepant high alliance and low approach orientation compared to low alliance and high approach was positively related to improvement in group therapy. Last, discrepant high alliance and low mastery and low alliance and high mastery were positively related to improvement in group therapy, suggesting a compensatory effect between mastery orientation and alliance on improvement. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Cortisol interdependence during psychotherapy in major depressive disorder.

The current study explored cortisol interdependence between patients and therapists during psychotherapy, the possible moderating effect of patient alliance ratings on this interdependence, and the associations between cortisol interdependence and treatment outcome. While cortisol interdependence was explored in other interpersonal contexts, its presence in psychotherapy has remained unexplored. We hypothesized that (a) patients' and therapists' cortisol levels at pre-session will predict their own and their partner's subsequent cortisol levels at post-session, (b) patient ratings of their relationship with their therapists will moderate these partner effects, and (c) cortisol interdependence will be associated with better treatment outcome. Fifty dyads undergoing 16 weeks of psychodynamic treatment for major depressive disorder participated in this study. Patient-therapist salivary cortisol samples were collected at eight time points, alongside a post-session patient-rated alliance questionnaire and a symptom severity interview. For analyses we employed the actor-partner interdependence model. Results revealed that (a) patients' and therapists' cortisol levels before sessions predicted their own post-session cortisol changes. However, significant cortisol interdependence was observed in patients' pre-session cortisol levels predicting therapists' post-session cortisol levels. Furthermore, (b) poorer alliance ratings associated with more pronounced cortisol interdependence, and (c) in dyads where patient pre-session cortisol predicted therapist's post-session cortisol, a better treatment outcome was found. This study found novel evidence of cortisol interdependence in psychotherapy and is partially in line with other studies inspecting cortisol interdependence in adjacent research fields. These findings emphasize the intricate psychophysiological interactions within therapeutic relationships and their associations with treatment outcome.

How getting in sync is curative: Insights gained from research in psychotherapy.

We are all constantly going in and out of sync with the people we meet in our lives: significant others, incidental encounters, and strangers. Synchrony is a ubiquitous phenomenon, considered an evolution-based mechanism of survival. In recent years, technological development has made it possible to collect much data on synchrony across disciplines. The collected data show great potential to shed light on the benefits of this universal phenomenon. At the same time, mixed results emerged, stressing the need for a theory to navigate research inquiries and discoveries. It is proposed here that synchrony serves as an individual-specific mechanism for making relationships curative in all life circumstances, especially therapeutic ones-hence its special relevance for psychotherapy. A synthesis of the majority of the literature across disciplines reveals two implicit assumptions about synchrony, resulting in two separate bodies of knowledge: (a) synchrony is a trait-like signature characterizing individuals; and (b) synchrony is a state-like phenomenon that can be manipulated in the lab. It is proposed here to personalize synchrony research by integrating the two assumptions into a comprehensive theory according to which individuals have a trait-like signature for getting in sync, which determines their physical and mental health, and that this deterministic reality can be subject to state-like manipulation. Individuals can deviate from their trait-like signature. When the deviation is toward normative activation, mental health improves, and the state-like changes are defined as therapeutic. This article calls for research to investigate how trait-like signature of synchrony develops and how it can be therapeutically changed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Smaller total and subregional cerebellar volumes in posttraumatic stress disorder: a mega-analysis by the ENIGMA-PGC PTSD workgroup.

Although the cerebellum contributes to higher-order cognitive and emotional functions relevant to posttraumatic stress disorder (PTSD), prior research on cerebellar volume in PTSD is scant, particularly when considering subregions that differentially map on to motor, cognitive, and affective functions. In a sample of 4215 adults (PTSD n = 1642; Control n = 2573) across 40 sites from the ENIGMA-PGC PTSD working group, we employed a new state-of-the-art deep-learning based approach for automatic cerebellar parcellation to obtain volumetric estimates for the total cerebellum and 28 subregions. Linear mixed effects models controlling for age, gender, intracranial volume, and site were used to compare cerebellum volumes in PTSD compared to healthy controls (88% trauma-exposed). PTSD was associated with significant grey and white matter reductions of the cerebellum. Compared to controls, people with PTSD demonstrated smaller total cerebellum volume, as well as reduced volume in subregions primarily within the posterior lobe (lobule VIIB, crus II), vermis (VI, VIII), flocculonodular lobe (lobule X), and corpus medullare (all p-FDR < 0.05). Effects of PTSD on volume were consistent, and generally more robust, when examining symptom severity rather than diagnostic status. These findings implicate regionally specific cerebellar volumetric differences in the pathophysiology of PTSD. The cerebellum appears to play an important role in higher-order cognitive and emotional processes, far beyond its historical association with vestibulomotor function. Further examination of the cerebellum in trauma-related psychopathology will help to clarify how cerebellar structure and function may disrupt cognitive and affective processes at the center of translational models for PTSD.

A multi-modality and multi-dyad approach to measuring flexibility in psychotherapy.

INTRODUCTION: Flexibility, the ability of an individual to adapt to environmental changes in ways that facilitate goal attainment, has been proposed as a potential mechanism underlying psychopathology and psychotherapy. In psychotherapy, most findings are based on self-report measures that have important limitations. We propose a multimodal, multi-dyad approach based on a nonlinear dynamical systems framework to capture the complexity of this concept. METHOD: A new research paradigm was designed to explore the validity of the proposed conceptual model. The paradigm includes a psychotherapy-like social interaction, during which body movement and facial expressiveness data were collected. We analyzed the data using Hankel Alternative View of Koopmann analysis to reconstruct attractors of the observed behaviors and compare them. RESULTS: The patterns of behavior in the two cases differ, and differences in the reconstructed attractors correspond with differences in self-report measures and behavior in the interactions. CONCLUSIONS: The case studies show that information provided by a single modality is not enough to provide the full picture, and multiple modalities are needed. These observations can serve as an initial support for our claims that a multi-modal and multi-dyad approach to flexibility can address some of the issues of measurement in the field.

The development of the Epistemic Trust Rating System (ETRS).

OBJECTIVE: The present study introduces and validates the Epistemic Trust Rating System (ETRS), an observer-based measure designed to assess epistemic trust (ET) within psychotherapy. ET in psychotherapy has gained much theoretical attention as a critical component in the therapeutic context, given its inherent link to social communication. However, its empirical validation remains pending, largely due to the absence of a refined instrument to gauge ET levels within the therapy environment. Therefore, this study aimed to translate ET's theoretical construct into tangible markers within the therapeutic context. METHOD: One hundred eighteen patients enrolled in a randomized controlled trial received psychodynamic psychotherapy for depression. Incorporating top-down theoretical considerations with bottom-up empirical observations yielded an overall ETRS score accompanied by three distinct sub-scales, each assessing a singular ET element: one gauges the patient's propensity to share; another measures the degree to which "we-mode" moments are achieved within the session; and the third evaluates the patient's receptiveness to learning. RESULTS: The findings demonstrate the psychometric robustness of the ETRS, with good internal consistency, interrater reliability (ICC(1,8) = .86-.90), and convergent (r = .23-.29) and discriminant validity (r = -.10). CONCLUSION: The current study highlights the ETRS as a promising tool bridging theory and empirical exploration, enhancing our understanding of epistemic trust in psychotherapy.

Pretreatment insight as a predictor of alliance strengthening in supportive vs. supportive-expressive treatment.

OBJECTIVE: The available literature points to the potential therapeutic benefits of alliance strengthening during treatment. Both supportive and expressive techniques have been suggested to be associated with strengthening of the alliance. The present study investigates whether patients may show different effects of supportive vs. expressive techniques in improving alliance as a function of their pretreatment insight levels. METHOD: Fifty-five patients were randomly assigned to either supportive treatment (ST) or supportive-expressive treatment (SET), as part of a larger randomized controlled trial. Clinical interviews were administered at pretreatment to evaluate the patients' level of insight. The working alliance was measured after each of the 16 sessions. A multilevel model, including a 3-way interaction of pretreatment insight by treatment condition (ST vs. SET) by time, was used to predict alliance strengthening. RESULTS: The findings suggest that, for individuals receiving ST, those with higher levels of insight show greater alliance strengthening. For individuals receiving SET, those with lower levels of insight show greater alliance strengthening. CONCLUSION: The current study suggests that one size may not fit all and, whereas some individuals may benefit more from ST to achieve alliance strengthening, others may benefit more from SET.

Identifying who benefits most from supportive versus expressive techniques in psychotherapy for depression: Moderators of within- versus between-individual effects.

OBJECTIVE: A recent randomized controlled trial (RCT) indicated that individuals with higher levels of attachment anxiety exhibited better treatment outcomes in supportive-expressive therapy (SET) relative to supportive therapy (ST). But to gain insight into within-patient therapeutic changes, a within-individual design is required. The present study contrasts previous findings based on theory-driven between-patient moderators with data-driven moderators of within-patient processes to investigate whether findings converge or diverge across these two approaches. METHOD: We used data of 118 patients from the pilot and active phases of a recent RCT for patients with major depressive disorder, comparing ST with SET, a time-limited psychodynamic therapy. The predefined primary outcome measure was the Hamilton Rating Scale for Depression. Supportive versus expressive techniques were rated based on patients' end-of-session perspective. We compared previous findings based on moderators of between-patient effects with a data-driven approach for identifying moderators of within-patient effects of techniques on subsequent outcome. RESULTS: After false discovery rate corrections, of 10 preselected moderators, patients' attachment anxiety and domineering style remained significant. Of these, bootstrap resampling revealed significant differences between ST and SET techniques for the attachment anxiety moderator: Those with higher attachment anxiety benefited more from greater use of ST than SET techniques in a particular session, as evidenced by lower levels of symptoms at the subsequent session. CONCLUSIONS: Our within-individual findings diverge from previously published between-individual analyses. This proof-of-concept study demonstrates the importance of complementing between-individuals with within-individual analyses to achieve better understanding of who benefits most from specific treatment techniques. (PsycInfo Database Record (c) 2024 APA, all rights reserved).