Better social reversal learning is associated with a more social approach across time.

Flexibly updating behaviors towards others is crucial for adaptive social functioning. Previous studies have found that difficulties in flexibly updating behaviors are associated with social anxiety (SA). However, it is unclear whether such difficulties relate to actual social behaviors. The current study investigated the relationships between negative-to-positive social reversal learning, social approach behavior, and SA across time. Participants (MTurk, Time 1 = 275, Time 2 = 126, 16 weeks later) completed a performance-based social reversal-learning task. In the initial phase, participants learned that interactions with certain individuals are associated with negative outcomes, whereas interactions with other individuals are associated with positive outcomes. In the reversal phase, these associations were reversed, requiring participants to update their behaviors. The relationships between the performance in the task, SA severity, and social approach behavior reported by participants were assessed cross-sectionally and longitudinally. We found that negative-to-positive updating was negatively associated with SA severity. Furthermore, negative-to-positive updating was positively correlated with social approach behavior, both cross-sectionally and prospectively. Hence, individuals with better negative-to-positive updating at Time 1 reported significantly more social approach behaviors across time. The results support the role of negative-to-positive updating as a mechanism associated with SA and social approach, advancing and refining interpersonal and cognitive theories of SA.

Mentalizing in and out of awareness: A meta-analytic review of implicit and explicit mentalizing.

BACKGROUND: Mentalizing, making sense of mental states, is hypothesized to have a central role in self-organization and social learning. Findings support this notion, but the extent of the association between mentalizing and various correlates has not been meta-analyzed. Furthermore, mentalizing presumably occurs with (explicit) and without (implicit) awareness but few studies have attempted to disentangle these aspects. We conducted a meta-analysis of implicit and explicit mentalizing in relation to the domains of attachment security, personality, affect, psychopathology, and functioning. METHODS: We searched for studies of adult mentalizing in PsycINFO and in related reviews. Overall, 511 studies (N = 78,733) met criteria and were analyzed using multi-level meta-analysis. RESULTS: Implicit (r = 0.19-0.29) and explicit (r = 0.26-0.40) mentalizing were moderately correlated with psychopathology, functioning, personality, affect, and attachment security. The correlations of implicit mentalizing were stronger with more objectively measured correlates (b = 0.02, p < .001) while the correlations of explicit mentalizing were not (b = -0.07, p = .21). CONCLUSIONS: Mentalizing is associated with better intra- and interpersonal functioning. Implicit mentalizing is more strongly associated with objectively measured correlates. These findings underscore the importance of an integrative approach considering both implicit and explicit mentalizing.

Transdiagnostic effects of therapist self-disclosure on diverse emotional experiences of clients with emotional disorders and schizophrenia.

OBJECTIVE: Despite the clinical significance of emotional diversity, also known as emodiversity, there has been limited investigation into the therapeutic interventions that influence this construct. In the current study we examined the association between immediate therapist self-disclosure (TSD) and emodiversity among two diagnostic groups who tend to experience emotional difficulties: people with schizophrenia and people with emotional disorders (i.e., depression and/or anxiety). METHOD: The sample comprised 74 clients (37 diagnosed with schizophrenia and 37 with emotional disorders) treated by 45 therapists in a university clinic setting. Following each session, clients self-reported their emotions, and therapists completed a measure of frequency and centrality of their immediate TSD during the session. RESULTS: Longitudinal multilevel models indicated that immediate TSD was positively associated with clients' global emodiversity, both at the within- and the between-client levels, as well as with clients' negative emodiversity at the between-client level. Moreover, clients with emotional disorders and clients with schizophrenia did not differ in the association between immediate TSD and emodiversity. In addition, across groups, clients treated by therapists who used more immediate TSD on average showed greater increases in global emodiversity during treatment. CONCLUSIONS: immediate TSD is associated with clients' ability to experience rich and diverse emotional experiences across different disorders. The theoretical and clinical implications of these findings are discussed.

Empathic accuracy of romantic partner negative affect is influenced by borderline personality symptoms.

The present study sought to examine the relation between borderline personality disorder (BPD) symptoms and empathic accuracy while improving on prior methodologies by using daily affect assessment in romantic partners. BPD symptoms were assessed in both members of 81 community couples who also reported on their own and their partner's negative and positive affect daily for 3 weeks. Data were analyzed using the Truth and Bias Model of Judgment, which allows the source of empathic accuracy to be parsed into partner affect (truth) and own affect (bias). Results provided evidence that individuals with higher BPD symptoms exhibited increased empathic accuracy for a partner's negative affect, particularly when partners also had higher BPD symptoms. The source of this accuracy stemmed more from bias forces than truth forces, indicating that participants' own affective states lead to more accurate judgments of partner affective state. The results suggest that this bias reduced the general tendency among participants to underestimate partner negative affect, thus leading to higher empathic accuracy. Overall, our results extend and provide support for previous research indicating that BPD symptoms are associated with heightened, not diminished, empathic accuracy. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

A dyadic session-by-session assessment of therapeutic alliance and short-term outcome among clients with schizophrenia in comparison with clients with emotional disorders.

OBJECTIVE: Although the clinical significance of the therapeutic alliance (TA) is well documented, the literature regarding the establishment of TA and the relation between client-therapist agreement on it to short-term outcome among various diagnostic groups-and specifically among clients diagnosed with serious mental illness (SMI)-is sparse. The aim of the present study was to examine the effect of client diagnosis on the abovementioned TA characteristics. METHOD: Dyadic analyses of session-by-session (SBS) data were used to compare clients diagnosed with schizophrenia and clients diagnosed with emotional disorders (based on a clinical interview) in their TA characteristics. RESULTS: TA as initially rated by clients was stronger in the emotional disorders group than in the schizophrenia group. Higher TA ratings, regardless of whether these were provided by the therapist or the client, predicted better subsequent functioning in the emotional disorders group, whereas in the schizophrenia group, this association was observed only among good-outcome cases. CONCLUSIONS: Establishing TA, having client-therapist agreement on it, and having clients derive therapeutic benefit from it might be more challenging with clients with schizophrenia than with clients with emotional disorders. Special attention should be given to specific challenges and needs regarding clients' diagnosis in order to enhance favourable therapy outcomes.

Examining the associations between difficulties in emotion regulation and symptomatic outcome measures among individuals with different mental disorders.

Background: Difficulties in emotion regulation (ER) abilities have been found to play a central role in different psychiatric disorders. However, researchers rarely compare ER across different diagnostic groups. In the current study, we examined ER and its relation to functional and symptomatic outcome among three distinct diagnostic groups: people with schizophrenia (SCZ), people with emotional disorders (EDs; i.e., depression and/or anxiety), and individuals without any psychiatric diagnosis (controls). Methods: Participants in this study comprised 108 adults who requested psychotherapy at a community clinic in the year 2015 and between 2017 and 2019. Clients were interviewed and filled out questionnaires measuring depression, distress, and difficulties in ER abilities. Results: Results showed that individuals with psychiatric diagnoses reported higher levels of difficulties in ER abilities than did controls. Moreover, there were very few differences in levels of ER difficulty between SCZ and EDs. Further, the associations between maladaptive ER and psychological outcomes were significant in each diagnostic group, and especially for SCZ. Conclusion: Our study indicates that difficulties in ER abilities partially have a transdiagnostic nature, and that these difficulties are associated with psychological outcomes among both clinical populations and controls. There were very few differences in levels of ER ability difficulties between SCZ and EDs, suggesting that the two groups share difficulties in relating and responding to emotional distress. The associations between difficulties in ER abilities and outcome were more robust and stronger among SCZ than the other groups, highlighting the potential contribution of targeting ER abilities in the treatment of schizophrenia.

Affective and cognitive impact of social overinclusion: a meta-analytic review of cyberball studies.

Belongingness is a central biopsychosocial system. Challenges to belongingness (i.e. exclusion/ostracism) engender robust negative effects on affect and cognitions. Whether overinclusion - getting more than one's fair share of social attention - favourably impacts affect and cognitions remains an open question. This pre-registered meta-analysis includes twenty-two studies (N = 2757) examining overinclusion in the context of the Cyberball task. We found that the estimated overall effect size of overinclusion on positive affect was small but robust, and the effect on fundamental needs cognitions (belongingness, self-esteem, meaningful existence and control) was moderate in size and positive in direction. Notably, the effect sizes of overinclusion were smaller than the corresponding effects of exclusion. Finally, the effects of overinclusion on positive affect were greater for high, as compared to low, socially anxious individuals. Exploring the sequelae of the full range of inclusion experiences - from exclusion to overinclusion - may enrich our understanding of the functioning of the belongingness system as well as its interaction with another central biosocial system - the social status system.

Intranasal Oxytocin as Add-On Treatment for Inpatients with Severe Mental Illness: A Randomized Clinical Trial.

INTRODUCTION: In recent years, several studies were conducted to explore the potential augmenting effect of oxytocin for the treatment of individuals with severe mental illness. Nonetheless, studies exploring its effects in routine inpatient settings using high-quality randomized controlled trials are scarce. The current study assessed the effect of oxytocin administration on treatment process and outcome among psychiatric inpatients, while employing a rigorous experimental methodology. METHODS: A double-blind, placebo-controlled, randomized trial was conducted at a public psychiatric hospital in Israel. Patients (N = 87, 71.3% female participants) were administered intranasal oxytocin/placebo twice daily for 4 weeks, as add-on to usual care. Patients were assessed for severity of anxiety and depression symptoms and their working alliance with their therapist after each therapy session, and treatment outcome was assessed weekly. Multilevel modeling was performed to assess the linear change from pre- to post-treatment. RESULTS: Patients receiving OT demonstrated significantly larger symptomatic improvements (B = -0.01, t [437] = -2.36, p = 0.01). Larger gains were also observed for depression (B = -0.14, p < 0.001 in the OT group, B = -0.06, p = 0.02 in the placebo group) and general distress (B = -0.57, p < 0.001 in the OT group, B = -0.29, p = 0.02 in the placebo group). No significant effect was observed for anxiety, the working alliance, or attachment. DISCUSSION: Oxytocin has the potential to improve treatment outcome among inpatients. Nonetheless, additional controlled research is needed to further assess its effects on therapy process, as well as to account for therapeutic, pharmacological, and neuronal intervening factors.

Client-therapist temporal congruence in perceiving immediate therapist self-disclosure and its association with treatment outcome.

Objective: Immediate therapist self-disclosure (Im-TSD) can be a powerful intervention. When engaged in judiciously, it can provide clients with a unique opportunity to explore their interpersonal relationship in real time. Relational theories suggest that for Im-TSD to be effective, both client and therapist must have temporally congruent perceptions of its occurrence. The present study examined (a) whether clients and therapists are temporally congruent in their session-by-session ratings of Im-TSD; and (b) whether this congruence is associated with therapy outcomes. Method: After each session, clients (n = 102) and therapists (n = 60) at a university-based clinic indicated whether Im-TSD was present during the session. Before each session, clients self-reported their functioning. They rated session quality after each session. Results: Therapists' ratings of their Im-TSD tended to be temporally congruent with their clients' Im-TSD ratings. Greater temporal congruvdence was associated with greater improvement over time in clients' experience of the session as helpful, but not with changes in clients' functioning. Conclusion: The findings highlight the importance of establishing a stronger temporal congruence of Im-TSD ratings between therapists and clients to further improve clients' experiences in treatment. The findings' implications are discussed as well as situations in which temporal congruence may not be beneficial.

Agreement in patient-therapist alliance ratings and its relation to dropout and outcome in a large sample of cognitive behavioral therapy for panic disorder.

Objective The therapeutic alliance is related to treatment outcome but less is known about the agreement on alliance between patients and therapists and its relationship to outcomes. We examined the association of patient-therapist congruence of alliance perceptions, early and late in cognitive behavioral therapy for panic disorder in relation to symptom reduction and dropout. Method: Patients (n = 181) and their therapists provided alliance ratings early and late during 11-session treatment. Independent evaluators rated patients' symptomatic levels post-treatment. Polynomial regression and response surface analysis were used to examine congruence as a predictor of outcome. Results: Early in therapy, stronger combined patient-therapist alliances, regardless of agreement, predicted lower symptom severity at the end of therapy and a lower likelihood of dropout. Late in treatment, the outcome was worse when therapist ratings of the alliance were higher than those of the patient. Conclusions: Therapist-patient agreement on the strength of the alliance is important for symptom improvement and dropout. The study highlights the importance of understanding the dyadic nature of the alliance and its impact on therapeutic change.

Patterns of alliance development in cognitive behavioral therapy versus attention bias modification for social anxiety disorder: Sawtooth patterns and sudden gains.

OBJECTIVES: We examined patterns in alliance development in cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) compared to attention bias modification (ABM). We focused on the occurrence of sawtooth patterns (increases within- and decreases between-sessions) and sudden gains and their association with outcome. METHODS: Clients received CBT (n = 33) or ABM (n = 17). Client-rated alliance was measured before and after each session. Self-reported and clinician-rated anxiety were measured weekly and monthly, respectively. RESULTS: The alliance increased in CBT in a sawtooth pattern and did not change in ABM. When examining individual clients, sawtooths were more common in CBT (61% clients) than in ABM (6%) and predicted worse outcome in CBT. Sudden gains were equally frequent (CBT, 18%; ABM, 18%) and did not predict outcome. CONCLUSION: The alliance in CBT is dynamic and important for outcome. Sawtooths are common in CBT and may mark worse outcome.

Patient-therapist congruence and incongruence of process expectations during psychotherapy.

Recent studies suggest that patient-therapist congruence of expectations affects psychotherapy outcome. Nonetheless, most studies assessing expectations in their dyadic context have focused on outcome expectations. This study was aimed to assess whether patients and therapists view expected processes similarly, and whether these beliefs change over time to become more congruent or more dissimilar. Patients (N = 75) were assessed for process expectations at baseline and at 3 months into treatment, and their therapists (N = 17) reported on their general expectations only once, prior to the initiation of treatment. Multilevel models were fitted to assess differences between patients' and therapists' process expectations at baseline and after 3 months and changes in level of congruence. The results indicated that at baseline, therapists perceived the processing of therapist-patient relations as the expected therapeutic process, whereas patients viewed the provision of tools of cognitive control as such. No significant changes in patients' expectations after 3 months of treatment were detected; however, therapists' higher expectations of the provision of tools for cognitive control predicted increases in patients' rankings of this process. These results suggest that patients and therapists are incongruent in their views of the expected therapeutic process, and that therapists' initial views of the therapeutic process affect patients' beliefs. These findings highlight the importance of investigating process expectations in the dyadic context and set the stage for subsequent process-outcome demonstrations, focusing on the effect of patient-therapist congruence of process expectations as a potential predictor or mediator of psychotherapy outcomes. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

In-session reflective functioning in psychotherapies for borderline personality disorder: The emotion regulatory role of reflective functioning.

OBJECTIVE: The capacity for understanding mental states (reflective functioning; RF) is considered essential for self-growth, social learning, and emotion regulation. Impaired RF is thought to play a central role in borderline personality disorder (BPD). We examined whether asking patients to consider mental states in-session has a down-regulatory effect on emotional arousal in treatments for BPD. METHOD: Early-, middle- and late-phase videotaped sessions from a randomized-controlled trial of transference-focused psychotherapy (TFP; n = 30), dialectical behavior therapy (DBT; n = 29), and supportive psychodynamic therapy (SPT; n = 29) were segmented to therapist and patient talk-turns. Therapist talk-turns were rated as asking patients to consider mental state (bids for RF) or not. Patient talk-turns were rated for RF and acoustically encoded for arousal. RESULTS: Bids were twice as common in TFP compared to DBT and SPT. Across treatments, therapist bids for RF predicted better RF, which, in turn, predicted lower emotional arousal. CONCLUSIONS: Asking patients to consider mental states has a down-regulatory effect on patients' arousal in psychotherapies for BPD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The alliance mediates outcome in cognitive-behavioral therapy for social anxiety disorder, but not in attention bias modification.

Objective: The aim of the current study was to examine changes in the therapeutic alliance and its role as a mediator of treatment outcome in cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) compared to attention bias modification (ABM). Method: Patients were randomized to 16-20 sessions of CBT (n = 33) or 8 sessions of ABM (n = 17). Patient-rated alliance and self-reported social anxiety were measured weekly and evaluator-rated social anxiety was measured monthly. Results: Early alliance predicted greater subsequent anxiety reduction in CBT but not in ABM. The alliance increased and weekly improvements in alliance predicted weekly contemporaneous and subsequent decreases in anxiety only in CBT. Decreases in anxiety did not predict subsequent improvements in alliance. Both treatments were effective in reducing anxiety, but treatment effects were mediated by stronger early alliance and stronger cross-lagged effects of alliance on outcome in CBT compared to ABM. Conclusions: The results highlight the importance of the alliance in CBT for SAD. Further studies should examine the role of alliance alongside additional mediators to better understand differential mechanisms in CBT and ABM.

The role of expressive suppression and cognitive reappraisal in cognitive behavioral therapy for social anxiety disorder: A study of self-report, subjective, and electrocortical measures.

BACKGROUND: Contemporary models of cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) emphasize emotion dysregulation as a core impairment whose reduction may play a causal role in psychotherapy. The current study examined changes in use of emotion regulation strategies as possible mechanisms of change in CBT for SAD. Specifically, we examined changes in expressive suppression and cognitive reappraisal during CBT and whether these changes predict treatment outcome. METHODS: Patients (n = 34; 13 females; Mean age = 28.36 (6.97)) were allocated to 16-20 sessions of CBT. An electrocortical measure of emotion regulation and a clinician-rated measure of SAD were administered monthly. Self-report measures of emotion regulation and social anxiety were administered weekly. Multilevel models were used to examine changes in emotion regulation during treatment and cross-lagged associations between emotion regulation and anxiety. RESULTS: CBT led to decreased suppression frequency, increased reappraisal self-efficacy, and decreased unpleasantness for SAD-related pictures (ps < .05). At post-treatment, patients were equivalent to healthy controls in terms of suppression frequency and subjective reactivity to SAD-related stimuli. Gains were maintained at 3-months follow-up. Decreases in suppression frequency and electrocortical reactivity to SAD-related pictures predicted lower subsequent anxiety but not the other way around (ps < .05). Lower anxiety predicted greater subsequent increases in reappraisal self-efficacy. LIMITATIONS: The lack of a control group precludes conclusions regarding mechanisms specificity. CONCLUSIONS: Decreased frequency of suppression is a potential mechanism of change in CBT for SAD.

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.

Mental pain intensity and tolerance as predictors of psychotherapy process and outcome.

BACKGROUND: The extensive reliance on symptoms for the study of psychotherapy is often criticized. In this study we examined whether the subjective sense of mental pain predicts psychotherapy process and outcome, above and beyond the effect of symptomatic distress. METHODS: Outpatients (n = 53) treated in a psychiatric hospital completed measures of mental pain intensity and tolerance, symptomatic distress, and session climate at pretreatment and posttreatment. Multilevel modeling was utilized to assess the predictive effect of mental pain, while controlling baseline symptomatic distress. RESULTS: Patients with high mental pain at baseline showed significant reductions in distress, while patients with low mental pain showed no significant improvement. Moreover, low mental pain and high mental pain tolerance predicted decreases in session smoothness. CONCLUSIONS: Mental pain can serve as a predictive marker for psychotherapy process and outcome, and complement the reliance on symptomatic distress in psychotherapy research.

The reciprocal relationship between alliance and early treatment symptoms: A two-stage individual participant data meta-analysis.

OBJECTIVE: Even though the early alliance has been shown to robustly predict posttreatment outcomes, the question whether alliance leads to symptom reduction or symptom reduction leads to a better alliance remains unresolved. To better understand the relation between alliance and symptoms early in therapy, we meta-analyzed the lagged session-by-session within-patient effects of alliance and symptoms from Sessions 1 to 7. METHOD: We applied a 2-stage individual participant data meta-analytic approach. Based on the data sets of 17 primary studies from 9 countries that comprised 5,350 participants, we first calculated standardized session-by-session within-patient coefficients. Second, we meta-analyzed these coefficients by using random-effects models to calculate omnibus effects across the studies. RESULTS: In line with previous meta-analyses, we found that early alliance predicted posttreatment outcome. We identified significant reciprocal within-patient effects between alliance and symptoms within the first 7 sessions. Cross-level interactions indicated that higher alliances and lower symptoms positively impacted the relation between alliance and symptoms in the subsequent session. CONCLUSION: The findings provide empirical evidence that in the early phase of therapy, symptoms and alliance were reciprocally related to one other, often resulting in a positive upward spiral of higher alliance/lower symptoms that predicted higher alliances/lower symptoms in the subsequent sessions. Two-stage individual participant data meta-analyses have the potential to move the field forward by generating and interlinking well-replicable process-based knowledge. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The Therapeutic Alliance Over 10 Sessions of Therapy for Borderline Personality Disorder: Agreement and Congruence Analysis and Relation to Outcome.

The authors examined whether alliance dynamics are affected by tailoring the therapeutic relationship to the individual patient in brief psychotherapy of borderline personality disorder. Sixty patients were randomized to 10-session Good Psychiatric Management (GPM-BV) or GPM combined with Motive-Oriented Therapeutic Relationship techniques (MOTR+GPM-BV). Patient- and therapist-rated alliance was assessed weekly. Self-reported symptomatic distress was assessed pre-, mid-, and posttreatment. In MOTR+GPM-BV, stronger therapist-rated alliance predicted lower symptomatic distress in the same timepoint, but not in a lag, whereas symptomatic distress predicted therapist-rated alliance in a lag. Therapist-rated alliance was lower than patient-rated alliance in GPM-BV but not in MOTR+GPM-BV. In MOTR+GPM-BV, higher agreement on strong alliance tended to predict lower symptomatic distress. Patient- and therapist-rated alliances were temporally congruent, but congruence did not predict outcome. Addressing the relationship needs of patients may partly exert its salutary effect by increasing agreement between patients' and therapists' experience of the alliance.

The effect of process and outcome feedback in highly distressed outpatients: A randomized controlled trial.

Objectives: Although process and outcome feedback is considered to be facilitative of psychotherapeutic processes, recent studies have suggested that such feedback may not produce the same effect when applied to highly distressed patients. This study examined the effect of process and outcome feedback in highly distressed patients treated in a public mental health center in Israel.Method: Patients (n = 197) were randomly allocated to receive feedback, or to treatment as usual. Therapists in the feedback condition received weekly reports, whereas therapists in the control group received no feedback. After attrition from study and treatment, a total of 123 cases were analyzed.Results: Feedback had no significant effect on either symptom reduction or on well-being. However, patients in the feedback group showed higher gains in alliance as compared to the treatment as usual group.Conclusion: Process and outcome feedback might have a potential beneficial effect of improving alliance for patients with severe symptomatology, with whom the establishment of an alliance can be challenging. The current findings also stress the need to continue to study the effect of feedback on therapy outcomes in diverse clinical settings. Limitations and directions for future research are discussed.