I see you as recognizing me; therefore, I trust you: Operationalizing epistemic trust in psychotherapy.

Epistemic trust (ET) is one's ability to trust others and relies on the information they convey as being relevant and generalizable. This concept has received considerable theoretical and clinical attention, suggesting it is a promising factor in effective psychotherapy, possibly consisting of three elements: sharing, we-mode, and learning. However, for it to be used in clinical practice and research, it is imperative to (a) enhance our clinical understanding of how ET may manifest in the context of treatment and (b) understand how the process of change may occur in the course of treatment. The present study aims to identify patients' trait-like ET characteristics upon initiating treatment and explore the possible state-like changes in ET characteristics throughout treatment. Taking a discovery-oriented approach, we examined how therapists can identify a patient's level of ET at the beginning of treatment. We also examined how, within a treatment for individuals with poor pretreatment ET, the therapist and patient work interactively to bring about a positive change in ET. Identifying the process in which the therapist implements techniques in response to the patient's reactions may enable the active mechanism to be isolated and promote the first formulation of the way changes in ET occur in sequence. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The experience of closeness and distance in the therapeutic relationship of patients with different attachment classifications: an exploration of prototypical cases.

Background: Individuals with different attachment classifications (Secure, Avoidant and Preoccupied) may experience emotional closeness differently, in their intimate relationships but also as clients in psychotherapy. However, evidence for this assumption almost exclusively comes from research with self-report questionnaires. Aims: In this paper, we use observer-rated measures to explore in depth how patients with different attachment classifications experience closeness and distance from the therapist in different phases of therapy. Method: Three patients' and their therapists' narratives about the therapeutic relationship at three time points during therapy were extracted and analyzed with two transcript-based observational measures: The Patient Attachment Coding System (PACS), which classifies patients' attachment according to their discourse behavior, and the therapeutic-Distance Scale-Observer version (TDS-O), which assesses the therapeutic relationship in terms of closeness, distance, autonomy and engagement. Cases were chosen from a larger research project due to their different prototypical attachment classification on the PACS. The narratives were obtained from Relationship Anecdote Paradigm (RAP) interviews in which the patients and their therapists narrated separately about meaningful interactions with each other, at early, middle and late phases of therapy. In addition, we followed patients self-report of the alliance and symptoms (OQ-45). Results: Although all patients reported experiencing discomfort with feeling distant from the therapist the therapeutic distance, the secure patient was able to reflect on his feelings and, in the therapist's recollection, was able to share them with the therapist. This allowed the therapist to harness these feelings for the benefit of the therapy. The avoidant and the preoccupied patients both experienced the therapist as distant, but the avoidant patient prevented closeness by a minimal expression of feelings, and the preoccupied described strong frustration with the therapist in a one-sided manner that prevented collaborative processing and left the therapist confused. Discussion: It appears that patient discourse is a stable (trait-like) component of attachment, while the therapeutic-distance is a process (state-like) component that may change along therapy. The discourse of insecure patients may hinder therapists' ability to adjust the therapeutic-distance to patients' needs. Therapists' knowledge about the ways patients with different attachment classifications communicate their proximity wishes may improve their attunement.

Changes in clients' relational patterns with parents and therapist during psychodynamic psychotherapy: Their association and relation to treatment outcome.

OBJECTIVE: The study aimed to explore how changes in clients' relational patterns during psychodynamic psychotherapy relate to treatment outcomes and therapy effectiveness. METHOD: Seventy clients receiving psychodynamic psychotherapy in a university counseling center were interviewed three times and filled out the OQ-45 questionnaire five times during therapy. We used the Core Conflictual Relationship Theme (CCRT) to study clients' relational patterns. Mixed models were used to assess the interaction between clients' CCRT intensity toward their parents and toward their therapists, treatment effectiveness, and treatment outcome. RESULTS: First, we found that clients' relational patterns with their parents correlated with relational patterns with their therapists across several time points in therapy. Then, we found significant interactions, indicating that treatment effectiveness moderates the relationship between clients' CCRT intensity and treatment outcomes. CONCLUSIONS: The findings suggest that the transference phenomenon is related to therapy outcomes differently in effective and less-effective therapies, depending on the transference intensity. Further research is needed to expand knowledge about the intensity of transference and its possible impact on treatment choice and management.

Countertransference types and their relation to rupture and repair in the alliance.

Background Ruptures in the alliance are co-constructed by clients and therapists, reflecting an interaction between their respective personality configurations [Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational treatment guide. Guilford Press]. In order to work effectively with ruptures, therapists should be aware of their own feeling states, acknowledging the subjectivity of their perceptions [Safran, J. D. (2002). Brief relational psychoanalytic treatment. Psychoanalytic Dialogues, 12(2), 171-195. https://doi.org/10.1080/10481881209348661]. Lack of such awareness may be a product of countertransference (CT), which has been shown to be inversely related to outcome. However, when effectively managed, CT contributes to positive outcome [Hayes, J. A., Gelso, C. J., Goldberg, S., & Kivlighan, D. M. (2018). Countertransference management and effective psychotherapy: Meta-analytic findings. Psychotherapy, 55(4), 496-507. https://doi.org/10.1037/pst0000189]. Objectives: The present study examined the associations between types of CT and therapists' reports of ruptures and resolutions. Method: Data were collected from 27 therapists, who treated 67 clients in yearlong psychodynamic psychotherapy. CT patterns were assessed based on therapists' Core Conflictual Relationship Themes with their parents, which were repeated in narratives about their clients [Tishby, O., & Wiseman, H. (2014). Types of countertransference dynamics and their impact on the client-therapist relationship. Psychotherapy Research, 24(3), 360-375. https://doi.org/10.1080/10503307.2014.893068]. Results: Negative CT patterns were associated with more ruptures and less resolution. Positive patterns predicted resolution when the therapists repeated positive patterns with parents, but predicted ruptures when they tried to "repair" negative patterns with the parents. These results point to the importance of therapists' awareness of their CT in order to deal effectively with ruptures and facilitate resolution.

Insight as a dual-perspective construct: Convergence between patients' and professional evaluators' perspective on baseline level of insight and on changes in insight.

Insight gained by patients during treatment has been theorized to be a central mechanism of change in psychotherapy, but empirical studies examining the association between patients' insight and psychopathological symptoms have produced mixed results. The present study addresses these inconsistencies by investigating convergence between the perspectives of patient and professional evaluator on insight and disentangling two potentially distinct components of insight: pretreatment individual differences and changes in insight during treatment. A sample of 393 patients receiving psychodynamic psychotherapy completed pre- and posttreatment measures on symptoms and insight. Professional evaluators evaluated patients' insight based on clinical interviews pre- and posttreatment. Polynomial regression and response surface analyses were used to examine congruence. The results indicate that when there was agreement between the patient and the evaluator on insight, both baseline level of insight and the changes in insight during treatment were found to be related to symptomatic change, although showing different patterns of association. Lower baseline levels of insight were significantly associated with greater symptomatic improvement than were higher levels of insight. At the same time, greater increase in insight during treatment was moderately significantly associated with greater reduction in symptoms, as long as the changes in insight were not minimal. The findings underscore the importance of assessing the congruence between patients' and professional observers' perspectives on patient insight and the potentially distinct roles of between-patients baseline differences and within-patient changes in insight during treatment. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Therapeutic distance in client-therapist narratives: client attachment, therapist attachment, and dyadic effects.

Based on the attachment framework, therapeutic distance conceptualization focuses on closeness-distance dynamics in the therapeutic relationship. We aimed to evaluate the psychometric properties of the Therapeutic-Distance-Scale, Observer-version (TDS-O) and apply a dyadic approach to examine associations between attachment characteristics and therapeutic distance experiences of clients, therapists, and mutual effects. Sixty-six clients and their 29 therapists completed the ECR and relational narratives collected in RAP interviews at early, mid, and late psychodynamic-therapy were rated on TDS-O scales: too close, too distant, autonomy, and engagement. The TDS-O showed good IRR, internal reliability and content validity. Client anxiety was not associated with therapeutic distance but associated with autonomy. Client avoidance associated with clients' experiencing therapist as too close, and lower engagement only at early therapy, but was not associated with therapists' experience. Therapist anxiety was not related to closeness-distance at early therapy but related to gaps between client and therapist experiences at mid and late therapy. Therapist avoidance related to clients experiencing therapists as too close and granting less autonomy at early and mid-therapy, and to therapist experience of distance at late therapy. The findings underscore the importance of therapists' regulating therapeutic distance through attunement to client's interpersonal needs and therapy phase.

Changes in clients and therapists experiences of therapeutic distance during psychodynamic therapy.

Attachment theory provides a framework for examining closeness-distance experiences in the development of the therapeutic relationship. OBJECTIVE: To examine changes in clients' and therapists' experiences of therapeutic distance along with psychodynamic therapy. HYPOTHESES: Clients' and therapists' comfort with closeness and distance will increase, and the client's autonomy and engagement will increase with time. METHOD: A total of 67 clients and their 27 therapists underwent Relationship Paradigm interviews in which they told narratives about their experience with each other, three times during therapy. The narratives were rated on the Therapeutic Distance Scale-Observer (TDS-O) version. RESULTS: Growth curve analysis of the TDS-O ratings showed that clients decrease in perceiving therapists as too distant and increase in engagement. Therapists showed a decrease in perceiving clients as too close and an increase in granting autonomy and engagement. A clinical illustration depicts these experiences in a client-therapist dyad. CONCLUSIONS: Therapists' awareness of clients' changing needs of closeness and autonomy may enhance attunement.

Therapist effects in yearlong psychodynamic therapy: An exploratory study.

A large body of research indicates that therapists can have a strong impact on treatment outcome, but little is known about the relationship between therapist effects and treatment phase. Our objective was to examine the interactive effect of therapist effectiveness and treatment phase on the outcome of 1 year of dynamic therapy. Therapists' effectiveness scores were defined as the extent of change for each therapist on the OQ-45 scores across their clients at five time points. The sample included 24 therapists who conducted psychodynamic therapy with 65 clients in a naturalistic setting. A three-level hierarchical linear model was applied. In accordance with the hypotheses, a significant main effect was found for effectiveness (estimate = 1.69, p < .05), for the two-way interactions between effectiveness and time (estimate = 1.36, p < .01), and for effectiveness and initial severity of symptoms (estimate = -0.02, p < .05). Simple slope analysis was conducted showing that among the less effective therapists, no significant change in outcome was found as time progressed; among the more effective therapists, outcome improved as time progressed. In addition, therapists were more influential in the treatments of clients with low initial severity. Our findings lend some support to the notion that therapist effects become increasingly influential as therapy progresses. The findings highlight the need for further research into changes in the magnitude of therapists' effect in various phases of therapy. Furthermore, the severity level of the initial symptoms of the client should be taken into account.

Women's narratives of crisis and change: Transitioning from infertility to pregnancy.

This study explores ways women, who endured prolonged fertility difficulties, after which they eventually conceived, integrate the two phases within their life stories. A total of 12 women were interviewed during their first pregnancy after having experienced 2-6 years of infertility. Three types of narratives were identified: (1) the infertility overshadows the pregnancy and approaching motherhood, (2) the pregnancy leads to a dissociation concerning the infertile period, and (3) the two states coexist together along an integrated continuum. We suggested that the different narrative types may occur in diverse circumstances that entail integrating a crisis or prolonged illness into a constructive and meaningful life story.

Therapists' honesty, humor styles, playfulness, and creativity as outcome predictors: A retrospective study of the therapist effect.

OBJECTIVE: This study examined whether therapists' honesty, humor style, playfulness, and creativity would retrospectively predict the outcomes of therapies ended five years earlier. METHOD: In the Jerusalem-Haifa study, 29 therapists treated 70 clients in dynamic psychotherapy for 1 year. The Outcome Questionnaire 45 scores were collected at five time points. Five years later, the therapists were contacted via email and asked to fill out honesty, humor styles, playfulness, and creativity self-report questionnaires. Five were excluded since they had only one client in the study each. The remaining 24 therapists treated 65 clients out of whom 20 therapists with 54 clients completed the questionnaires. RESULTS: Therapists' Aggressive Humor Style (AHS) was a significant negative predictor of clients' symptom change over time. The therapists' honesty scores were positively correlated with symptom change. That is, higher AHS therapists were more effective, while higher honesty therapists were less effective. CONCLUSIONS: Therapists' inferred traits of Honesty-Humility and AHS may influence the effectiveness of their treatments.

Sense of Coherence and Parenting Representation among Parents of Adolescents with Type 1 Diabetes.

INTRODUCTION: This study examines the association between parental sense of coherence (SOC) and maternal and paternal representations of parents of adolescents diagnosed with type 1 diabetes (IDDM). METHOD: Seventy five mothers and fathers of adolescents (age 13-18) diagnosed with IDDM, were recruited. Data were gathered from a demographic and SOC questionnaires, and the Parenting Representations Interview (PRI-A). RESULTS: A significant association was found between mothers' and fathers' SOC and a more balanced description of parenting, and positive correlations between mothers' and fathers' SOC and their representations of the self as parent, representations of the adolescent, and relationships representations. Furthermore, a negative correlation was found between parents' SOC and less differentiated relationships. CONCLUSIONS: SOC may promote well-being in spite of exposure to challenging circumstances as parenting an adolescent with IDDM. It appears that fathers and mothers need to and can be addressed as significant caregivers in any treatment or clinical intervention, as they have a relative involvement in taking care of children and therefore sharing the caregiving responsibilities and functioning as co-primary caregivers.

Applying relationship anecdotes paradigm interviews to study client-therapist relationship narratives: Core conflictual relationship theme analyses.

OBJECTIVE: We describe client-therapist relational narratives collected in relationship anecdotes paradigm (RAP) interviews during psychotherapy and the application of the core conflictual relationship theme (CCRT) method. Changes in clients' and therapists' CCRT in relation to each other are examined and associations between their CCRTs and self-reported ruptures and repairs are explored. METHOD: Sixty-seven clients and 27 therapists underwent RAP interviews and completed self-report rupture and repair items at early, middle, and late psychodynamic psychotherapy. Client-therapist relationship narratives were rated on the CCRT and the relational interplay within dyads was explored qualitatively. RESULTS: CCRT changes from early to late therapy showed that with time clients perceived the therapist (RO) and the self (RS) more positively, and the therapist perceived the self (RS) less negatively. Some associations were found between tension in the session and clients' and therapists' negative RO and RS. Therapists' reports of alliance repairs were associated with positive RO and RS. CONCLUSIONS: Relational narratives that clients and therapists tell in RAP interviews about meaningful interactions between them, enhance our understanding of clients' and therapists' inner experiences during interpersonal dances in the therapeutic relationship. Limitations and directions for future research are discussed, and implications for training are suggested.

Pseudosecure vs. individuated-secure client attachment to therapist: Implications for therapy process and outcome.

OBJECTIVE: We differentiated two hypothesized client subtypes: (a) Pseudosecure clients have high Client Attachment to Therapist Scale (CATS) Secure and high CATS Preoccupied scores, tend to idealize their therapist, and exhibit maladaptive dependency; (b) Individuated-secure clients combine high Secure with low Preoccupied scores and function more autonomously. Clients who, despite insecure attachment to others, "earn" individuated-secure attachment to their therapist benefit most from therapy. METHOD: We examined regression suppressor effects by reanalyzing raw data from four published studies. If pseudosecure attachment is present, when covariance between CATS Secure and Preoccupied scores is removed, residual Secure scores should be significantly better predictors of process/outcome indicators than raw Secure scores. RESULTS: Suppressor effects were observed in eight of nine analyses. Two were statistically significant. Earned individuated-secure attachment predicted improvement in interpersonal relationship symptoms, but only for clients with Avoidant pre-therapy attachment patterns. Finally, significant meta-analytic effect size estimates were obtained for CATS subscales, Secure r = .274 (95% CI = .177, .366), Avoidant, r = -.296 (95% CI = -.392, -193), and Preoccupied, r = -.192 (95% CI = -.289, -.092). CONCLUSIONS: Clients with pre-therapy Avoidant attachment who nevertheless "earn" individuated-secure attachment to their therapist appear to benefit more from therapy.

Relational Patterns and the Development of the Alliance: A Systematic Comparison of two Cases.

A systematic case study approach was taken to explore the impact of client and therapist relational patterns on the development of the therapeutic alliance and symptom reduction in two cases of psychodynamic psychotherapy treated by the same therapist. The cases were selected from a larger sample and represent two distinct trajectories of alliance development: improvement versus deterioration. The comparison was based on participants' ongoing narratives about each other and about significant others, using the Relationship Anecdote Paradigm (RAP) interview. The qualitative findings were triangulated with process and outcome measures assessed at four time points during the year of treatment. We hypothesized that different therapeutic processes, including different handling by the therapist of interpersonal difficulties as they arose in treatment, could explain the two distinct trajectories of alliance development and symptom change within the caseload of one therapist. Results indicate two linked elements that may explain a steady increase in alliance and decrease in symptoms in one case, compared with the second case that started with an increase in alliance and symptom improvement, but gradually reached an impasse and a setback in symptoms. One element was the extent to which client's and therapist's relational patterns clashed, impacting each other negatively. The second was the extent to which differences and disagreements were stated openly and negotiated so that the therapist could flexibly adapt to meet the client's relational patterns in one case versus inability to do so in the other. Implications for training and other psychotherapy orientations are discussed. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: The interaction of client and therapist relational patterns may be a key factor in the development of the therapeutic alliance and might potentially impact client outcome. Therapeutic practice will likely be improved if therapists are more aware of their own relational patterns and the ways these interact with their clients' relational patterns. Striving for this awareness should probably be a main focal point for therapists throughout their careers, in their training, supervisions and personal therapies.

The quest for connection in interpersonal and therapeutic relationships.

OBJECTIVE: This paper focuses on the need for connection as a common core theme at the heart of both close relationships and therapeutic relationships and explores ways to connect these two research domains that have evolved as separate fields of study. Bowlby's attachment theory provides a strong conceptual and empirical base for linking human bonds and bonds in psychotherapy. METHOD: The growing body of research intersecting attachment and psychotherapy (1980-2014) is documented, and meta-analytic studies on attachment-outcome and attachment-alliance links are highlighted. RESULTS: Five ways of studying attachment as a variable in psychotherapy are underscored: as moderator, as mediator, as outcome, client-therapist attachment match, and as process. By integrating conceptualizations and methods in studying relational narratives of client-therapist dyads (Core Conflictual Relationship Theme), measures of alliance, and client attachment to therapist during psychotherapy, we may discover unique client-therapist relational dances. CONCLUSIONS: Future fine-grained studies on how to promote core authentic relational relearning are important to clinicians, supervisors and trainers, who all share the common quest to alleviate interpersonal distress and enhance wellbeing. Directions for advancing research on interpersonal and therapeutic relationships are suggested. Learning from each other, both researchers of close relationships and of psychotherapy relationships can gain a deeper and multidimensional understanding of complex relational processes and outcomes.

Parental resolution and the adolescent's health and adjustment: The case of adolescents with type 1 diabetes.

This study examines the association between parents' resolution of their adolescent child's diagnosis of type 1 diabetes and the health and mental adjustment of the adolescents themselves. Parents of 75 adolescents with type 1 diabetes were interviewed using the Reaction to Diagnosis Interview. Parents and adolescents completed questionnaires regarding the child's physical health, self-management of the disease, and behavioral and emotional problems. Physicians reported adolescents' HbA1c levels. Results showed that adolescents whose fathers were resolved with the diagnosis exhibited better diabetes self-management and adolescents whose mothers were resolved with the diagnosis exhibited fewer internalizing and externalizing problems. The findings highlight the different role of mothers and fathers in the treatment of adolescents with diabetes and provide a basis for clinical intervention that focuses not only on adolescent health, but also on parental state of mind regarding the resolution with the disease.

Relationship representations and change in adolescents and emerging adults during psychodynamic psychotherapy.

OBJECTIVE: Two groups of clients at sequential developmental stages, adolescents and emerging adults, were compared regarding their presenting problems, psychological distress, and relationship representations over one year of psychotherapy. METHOD: Thirty adolescents aged 14-18 years and 30 emerging adults aged 22-28 years, with similar demographic background, completed outcome measures and interviews according to the Core Conflictual Relationship Theme (CCRT) method. RESULTS: The groups differed significantly in the presenting problems but did not differ in their initial levels of distress; their symptoms improved to a similar extent after one year of psychotherapy; differences between the groups in the representations of others were consistent with age-specific developmental challenges; levels of representations were associated with levels of symptoms at the end-point of treatment. CONCLUSION: Clinicians need to be attuned to the specific difficulties and challenges of these continuous yet distinct developmental stages.

Client attachment, attachment to the therapist and client-therapist attachment match: how do they relate to change in psychodynamic psychotherapy?

OBJECTIVE: We examined the associations between client attachment, client attachment to the therapist, and symptom change, as well as the effects of client-therapist attachment match on outcome. Clients (n = 67) and their therapists (n = 27) completed the ECR to assess attachment. METHOD: Clients completed also the Client Attachment to Therapist scale three times (early, middle, and late sessions) and the OQ-45 at intake and four times over the course of a year of psychodynamic psychotherapy. RESULTS: Clients characterized by avoidant attachment and by avoidant attachment to their therapist showed the least improvement. A low-avoidant client-therapist attachment match led to a greater decrease in symptom distress than when a low-avoidant therapist treated a high-avoidant client. CONCLUSIONS: These findings suggest the importance of considering client-therapist attachment matching and the need to pay attention to the special challenges involved in treating avoidant clients in order to facilitate progress in psychotherapy.

Types of countertransference dynamics: an exploration of their impact on the client-therapist relationship.

OBJECTIVE: The purpose of this study was to develop a typology of countertransference (CT) based on therapists' narratives about their parents and their clients. METHOD: Data are based on interviews conducted in the early, middle and late phases of ongoing psychodynamic psychotherapy with five therapists who treated 12 clients. Narratives were analyzed using the Core Conflictual Relationship Theme Method (CCRT). CT was defined as repetition of CCRT components from therapists' relationship with their parents in their narratives with their clients. RESULTS: Raters identified five types of CT in the narratives: Wish from parent transferred to client, Projection of the parent Response from Other (RO) to client, Repetition of the Response of Self (RS), Repeating the negative parent RO, and Repair of the parent RO. CONCLUSIONS: A preliminary analysis of two psychodynamic therapies, one with good outcome and one with poor outcome, showed that CT types could be reliably rated.