Chairwork in individual psychotherapy: Meta-analyses of intervention effects.

The present study examines (a) the unique effects of chairwork on emotional process and intervention outcomes across treatments in the context of individual psychotherapy and (b) how these effects compare to other treatment interventions. Based on the appropriateness of the data available, meta-analyses with estimated effect sizes and narrative syntheses were conducted for psychotherapy process as well as symptom outcomes. Single-session chairwork was found to be more effective in deepening client experiencing than empathic responding (d = .90), although it may have an effectiveness similar to other interventions for facilitating emotional arousal or shifting the credibility of core beliefs. A single session of chairwork also has noteworthy pre-to-post symptom change (d = 1.73), although these improvements may be comparable to other methods of intervention (d = .02). However, when chairwork was used multiple times over the course of a treatment, it accumulated a meaningful effect (d = .40) compared to treatments that did not use chairwork. Therapeutic orientation emerged as a potential moderator. Incorporating chairwork into treatments may bolster process and intervention outcomes. We conclude the article with training implications and therapeutic practices. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Disordered eating is related to deficits in emotional processing: A correlational study with a subclinical sample.

BACKGROUND: Both clinical and non-clinical levels of disordered eating behaviours have been associated with deficits in emotional processing. METHODS: Through a correlational design, the present study examined the relationship between different types of disordered eating behaviours and various forms of emotional processing. N = 209 female undergraduate participants completed self-report measures of disordered eating behaviours, perceived emotion intensity, emotion regulation skills, and self-compassion. Four groups of participants were identified based on self-reported disordered eating behaviours: a healthy control group (n = 90), dieting group (n = 22), binging group (n = 59), and binging/purging group (n = 38). RESULTS: Greater severity of disordered eating was associated with greater emotional processing deficits including greater perceived emotion intensity, greater emotion regulation difficulties, and diminished self-compassion. Emotion regulation skills mediated the relationship between emotion intensity and disordered eating behaviours. A continuum of emotional processing deficits was observed wherein the healthy control group exhibited the fewest emotional processing deficits, and these deficits became increasingly severe among the dieting group, binging group, and binging/purging group, respectively. Each disordered eating type was associated with a specific profile of emotional processing difficulties. LIMITATIONS: This study examined a subclinical sample of only female participants. CONCLUSIONS: Findings bear clinical importance for the prevention, treatment, and understanding of disordered eating behaviours.

Depth of experiencing and therapeutic alliance: What predicts outcome for whom in emotion-focused therapy for trauma?

OBJECTIVE: The purpose of this study was to determine the extent to which therapeutic processes - working alliance and depth of experiencing - contributed to outcome. METHOD: Individual differences in these processes were examined at the early and working phases to determine their impact on symptom reduction. An archival data set of N = 42 individuals who underwent emotion-focused therapy for trauma for childhood maltreatment was used to examine the differential quality of client processes throughout treatment. RESULTS: For those who had difficulty forming an alliance early in therapy, alliance scores during the working phase were the best predictor of outcome (ß = -.42). This was complemented by a process change of improvement in alliance from the early to working phases (d = 1.0). In contrast, for those who had difficulty engaging in deepened experiencing early in therapy, depth of experiencing in the working phase was the best predictor of outcome (ß = -.36). This was complemented by an improvement in depth of experiencing from the early to working phases (d = .69). CONCLUSIONS: The findings of this study suggest that focusing on the process that clients have trouble with early in therapy contributes to the best treatment outcome. PRACTITIONER POINTS: Sometimes early treatment sessions reveal an abundance of one kind of processing but limitations to another, which poses a puzzle for treatment planning. Our findings suggest that within the first four sessions, therapists could develop tailored treatments based on the relative presence or absence of critical therapeutic changes processes. When it becomes evident that therapy is progressing with a weaker alliance between client and therapist, therapists should redouble their efforts in alliance-building. However, when therapy is developing in a fashion that lacks deep emotional experiencing on the part of the client, treatment efforts should aim to facilitate a richer exploration of moment-by-moment experience. As such, our findings suggest relying on the existing processing strengths within a dyad (e.g., emphasis on an already strong relationships, or augmenting an existing aptitude for deeper experiencing) while shortcomings exist in another kind of process is not optimal responding. Therapists should focus their work on the process that clients have trouble with early in therapy to facilitate the best treatment outcome.

Resolving Coparenting Dissatisfaction In Couples: A Preliminary Task Analysis Study.

This study explored the change that unfolded when parents resolved their coparenting dissatisfaction during an Integrative Brief Systemic Intervention (IBSI) for parent couples. We conducted a task analysis (Greenberg, 2007) to build a model of resolving coparenting dissatisfaction. We compared a postulated model of change (rational model) based on theoretical and clinical assumptions to the observations of the actual change process that couples experienced in an IBSI (empirical analysis). The empirical analysis was conducted on six IBSI therapy cases (three exhibiting positive development and three exhibiting no development). We defined positive development in IBSI as moving from coparenting dissatisfaction to coparenting satisfaction. The final rational-empirical model included six steps that facilitated the resolution of coparenting dissatisfaction. This study contributes to deepening the knowledge of how coparenting may change during marital therapy.

Self-Contempt, the Working Alliance and Outcome in Treatments for Borderline Personality Disorder: An Exploratory Study.

Objective. We examined the role of expressed self-contempt in therapy for borderline personality disorder (BPD). Based on previous literature on BPD, we assumed an association between the self-contempt and the core symptoms of BPD. We also studied the progression of expressed self-contempt during the treatment and its effect on the alliance and the outcomes of treatment.Method. We rated the expressed self-contempt in 148 tape-recorded sessions with patients with BPD (N = 50), during a brief psychiatric treatment. We rated self-contempt at three time-points, using an observer-rate scale. Self-reported questionnaires were used to assess symptoms and the working alliance.Results. There are some associations between self-contempt and BPD symptoms. Expressed self-contempt did not change during the treatment. One measure of self-contempt was associated with a weaker alliance rated by the patients and with a stronger alliance rated by the therapists. The expression of high self-contempt was not predictive of outcomes when the initial level of problems was controlled for.Conclusions. The results highlight the importance to examine the complex effects of self-contempt in BPD undergoing treatment in a differentiated manner and suggest to clinicians and researchers to be attentive to this specific emotional state, and change therein, in psychotherapy.Keywords: Self-contempt; Borderline Personality Disorder; Brief Treatment; Therapeutic Alliance; EmotionTrial registration: ClinicalTrials.gov identifier: NCT01896024.

Working with emotion predicts sudden gains during experiential therapy for depression.

Objective: This study involves the first attempt to identify sudden gains in a sample of clients undergoing experiential therapy for depression while also investigating client and therapist change processes related to sudden gains.Method: Pre- and post-session Beck Depression Inventory, short form (BDI-SF) questionnaires were used to identify sudden gains and differentiate between in-session and between-session symptom changes in thirty-six client-therapist dyads. Archival videotape data of a sub-sample were coded using the Experiencing Scale, Classification of Affective Meaning States, and the Coding System for Therapist Focus.Results: The study revealed that 63.9% of clients experienced a sudden gain and the bulk of the total mean symptom decrease (74.9%) was found to occur within the session preceding the sudden gain. During this critical session, clients were more likely to display deepened experiencing (p < .01, η2 = .34), clients were more likely to express "primary adaptive emotions" (p < .05, r = .38), and therapists were found to be more likely to focus on unmet client needs (p < .01, d = .75).Conclusion: The majority of the sudden gain change occurs within session in experiential therapy, and primary adaptive emotions as well as addressing unmet needs are possible processes of sudden gains.

How Personality Disorders Change in Psychotherapy: a Concise Review of Process.

PURPOSE OF REVIEW: The present review summarizes the current state of the art in psychotherapy processes during treatments for clients with personality disorders. We outline some methodological challenges in the discipline of process research, give a brief historical account on process research, and then focus on specific processes studied from an empirical perspective. RECENT FINDINGS: The current review acknowledges the centrality of the therapeutic relationship, in particular the therapeutic alliance, therapist empathy, and responsiveness in explaining outcome across treatment modalities for personality disorders. The review describes evidence from three overall and overlapping lines of inquiry that have garnered scientific interest in the past years. For emotional change (regulation, awareness, and transformation), socio-cognitive change (mentalizing, meta-cognition, and interpersonal patterns), and increase in insight and change in defense mechanisms, evidence is moderate to strong for these processes to contribute to healthy change in treatments for personality disorders, in particular borderline personality disorder. Avenues of future studies are outlined.

Emotional processing of trauma narratives is a predictor of outcome in emotion-focused therapy for complex trauma.

This study tested a model of emotional processes over the course of emotion-focused therapy for trauma. The model of emotional processing (Pascual-Leone & Greenberg, 2007) proposes a sequential order of shifting from "early expressions of distress" to "primary adaptive emotion" that aid in adaptive functioning. Thirty-eight participants were taken from a randomized clinical trial to examine in-session process from video recordings of treatment. The sample had an average age (M = 44.3 years) and the majority was female (55.3%) and of European descent (89.5%). The Classification of Affective Meaning States was used to examine changes in emotional processes during trauma narratives in both early and late sessions. Processes were related to treatment outcome as measured by the Impact of Event Scale and the Resolution Scale. Sessions later in treatment showed a higher frequency of primary adaptive emotions compared with early sessions (p < .001, r = .76). Primary adaptive emotions were also more frequent in good-outcome cases (p = .017). Using emotional processes as predictors correctly classified 67% of poor-outcome cases and 80% of good-outcome cases. Increases in primary adaptive emotions from early to late treatment sessions more than doubled the odds (2.2) of having a good treatment outcome. The order of emotion was concordant with the sequential model in early sessions and partially concordant in late sessions. Findings have implications for guiding therapeutic process in a productive manner that leads to trauma recovery. Changes in discrete emotions were related to good treatment outcome. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Change in Emotional and Theory of Mind Processing in Borderline Personality Disorder: A Pilot Study.

Changes in emotional processing (EP) and in theory of mind (TOM) are central across treatment approaches for patients with borderline personality disorder (BPD). Although the assessment of EP relies on the observation of a patient's self-criticism in a two-chair dialogue, an individual's TOM assessments is made based on responses to humorous stimuli based on false beliefs. For this pilot study, we assessed eight patients with BPD before and after a 3-month-long psychiatric treatment, using functional magnetic resonance imaging and behavioral tasks. We observed arousal increase within the session of the two-chair dialogue (d = 0.36), paralleled by arousal decrease between sessions (d = 0.80). We found treatment-associated trends for neural activity reduction in brain areas central for EP and TOM. Our exploratory findings using an integrative assessment procedure of changes in EP and TOM point toward evidence for treatment effects at the brain systems level related to behavioral modulation.

Emotional processing in an expressive writing task on trauma.

BACKGROUND: The current study examined expressive writing by investigating two aspects of emotional processing: depth of experiencing and order of emotional processing. MATERIALS AND METHODS: A sample of 110 undergraduates, who suffered traumas, were instructed to write based on differing theories of emotional processing. Participant narratives were coded for depth of emotional processing and the presence of key emotions. To assess outcome, anxiety was measured at baseline and two weeks following writing. RESULTS: Depth of emotional processing differed as a function of condition and writing session. Moreover, a significant negative relationship was found between changes in the depth of emotional processing and anxiety symptoms (r = -.209, p < .05), such that an increase in experiencing corresponded to a decrease in overall anxiety. CONCLUSION: The results suggest that writing instructions might differentially promote emotional processing over time and that promoting deepened emotional processing might facilitate reductions in anxiety.

Self-Knowledge in Personality Disorders: An Emotion-Focused Perspective.

Emotional knowledge about one's own and others' emotional experience are central features of mental health and may be characteristic of therapeutic processes leading to good outcome. Clients with personality disorders (PDs) often lack in their ability to access and accept emotional experiences, or to reflect on emotion and use it in adaptive ways. The present theoretical and clinical review discusses self-knowledge, and lack thereof, in personality disorders, from an emotion-focused perspective. A first section differentiates between two fundamental types of meaning construction processing. The second section describes, from an integrative therapy perspective, how self-knowledge may be facilitated in psychotherapy by the client-therapist interaction. A subsequent section discusses lack of awareness of one's own emotions in the construction of meaning associated with PDs. The final section describes initial studies that demonstrate change occurring in constructing emotional self-knowledge as a correlate of treatment. The concepts of the review are illustrated throughout with three clinical cases of PD.

How clients "change emotion with emotion": A programme of research on emotional processing.

This paper reviews a body of research that has examined Pascual-Leone and Greenberg's sequential model of emotional processing or used its accompanying measure (the Classification of Affective Meaning States). Research from 24 studies using a plurality of methods examined process-outcome relationships from micro to macro levels of observation and builds support for emotional transformation as a possible causal mechanism of change in psychotherapy. A pooled sample of 310 clinical and 130 sub-clinical cases have been studied, reflecting the process of 7 different treatment approaches in addressing over 5 different presenting clinical problems (including depression, anxiety, relational trauma, and personality disorders). The initial findings on this model support the hypothesis that emotional transformation occurs in specific canonical sequences and these show large effects in the prediction of positive treatment outcomes. This model is the first in the field of psychotherapy to show how non-linear temporal patterns of moment-by-moment process relate to the unfolding of increasingly larger changes to create good psychotherapy treatment outcomes. Finally, clinical application of the model is also considered as a template for case formulations focused on emotion. Clinical or methodological significance of this article: This review article examines research on a specific model of emotional processing. (i) Experiencing certain key emotions during psychotherapy seems to predict good treatment outcomes, at both the session and treatment levels. (ii) There is also evidence to suggest that these productive emotional experiences unfold in an ordered pattern. Moreover, (iii) support for this way of understanding emotional processing comes from a number of very different treatment approaches and for several kinds of major disorders.

Neurophysiological traces of interpersonal pain: How emotional autobiographical memories affect event-related potentials.

The automatic, involuntary reactivation of disturbing emotional memories, for example, of interpersonal pain, causes psychological discomfort and is central to many psychopathologies. This study aimed at elucidating the automatic brain processes underlying emotional autobiographical memories by investigating the neurophysiological dynamics within the first second after memory reactivation. Pictures of different individualized familiar faces served as cues for different specific emotional autobiographical memories, for example, for memories of interpersonal pain and grievances or for memories of appreciation in interpersonal relationships. Nineteen subjects participated in a passive face-viewing task while multichannel electroencephalogram was recorded. Analyses of event-related potentials demonstrated that emotional memories elicited an early posterior negativity and a stronger late positive potential, which tended to be particularly enhanced for painful memories. Source estimations attributed this stronger activation to networks including the posterior cingulate and ventrolateral prefrontal cortices. The findings suggest that the reactivation of emotional autobiographical memories involves privileged automatic attention at perceptual processing stages, and an enhanced recruitment of neural network activity at a postperceptual stage sensitive to emotional-motivational processing. (PsycINFO Database Record

The role of shame and self-compassion in psychotherapy for narcissistic personality disorder: An exploratory study.

This process-outcome study aims at exploring the role of shame, self-compassion, and specific therapeutic interventions in psychotherapy for patients with narcissistic personality disorder (NPD). This exploratory study included a total of N = 17 patients with NPD undergoing long-term clarification-oriented psychotherapy. Their mean age was 39 years, and 10 were male. On average, treatments were 64 sessions long (range between 45 and 99). Sessions 25 and 36 were rated using the Classification of Affective Meaning States and the Process-Content-Relationship Scale. Outcome was assessed using the Symptom Check List-90 and Beck Depression Inventory-II. Between Sessions 25 and 36, a small decrease in the frequency of shame was found (d = .30). In Session 36, the presence of self-compassion was linked with a set of specific therapist interventions (process-guidance and treatment of behaviour-underlying assumptions; 51% of variance explained and adjusted). This study points to the possible central role of shame in the therapeutic process of patients with NPD. Hypothetically, one way of resolving shame is, for the patient, to access underlying self-compassion.

Leaving Distress Behind: A Randomized Controlled Study on Change in Emotional Processing in Borderline Personality Disorder.

OBJECTIVE: The marked impulsivity and instability of clients suffering from borderline personality disorder (BPD) greatly challenge therapists' understanding and responsiveness. This may hinder the development of a constructive therapeutic relationship despite it being of particular importance in their treatment. Recent studies have shown that using motive-oriented therapeutic relationship (MOTR), a possible operationalization of appropriate therapist responsiveness, can enhance treatment outcome for BPD. The overall objective of this study is to examine change in emotional processing in BPD clients following the therapist's use of MOTR. METHOD: The present paper focuses on N = 50 cases, n = 25 taken from each of two conditions of a randomized controlled add-on effectiveness design. Clients were either allocated to a manual-based psychiatric-psychodynamic 10-session version of general psychiatric management (GPM), a borderline-specific treatment, or to a 10-session version of GPM augmented with MOTR. Emotional states were assessed using the Classification of Affective-Meaning States (Pascual-Leone & Greenberg, 2005) at intake, midtreatment, and in the penultimate session. RESULTS: Across treatment, early expressions of distress, especially the emotion state of global distress, were shown to significantly decrease (p = .00), and adaptive emotions were found to emerge (p < .05). Between-condition differences of change were found, including a significant increase in emotional variability and stronger outcome predictors in the MOTR condition. CONCLUSIONS: The findings indicate initial emotional change in BPD clients in a relatively short time frame and suggest the addition of MOTR to psychotherapeutic treatments as promising. Clinical implications are discussed.

The client "experiencing" scale as a predictor of treatment outcomes: A meta-analysis on psychotherapy process.

OBJECTIVE: The experiencing scale (EXP) is an often used measure of client's depth of processing and meaning-making in-session. While research suggests that "client experiencing" predicts psychotherapy outcomes, this relationship has never been summarized in a meta-analysis. We examine this specific client factor as an in-session process predictor of good treatment outcomes. METHOD: A meta-analysis quantified the relationship between client experiencing and therapy outcomes using a total of 10 studies and 406 clients. RESULTS: Analysis indicated that client experiencing is a small to medium predictor of standardized symptom improvements at final treatment outcomes with an effect of r = -.19 (95% CI -.10 to -.29), which we consider a "best estimate" for robustly quantifying the association between EXP and self-reported clinical outcomes. However, effects were higher (i.e., r = -.25) when observational measures of outcome were also included: Subgroup analyses indicated that EXP effects were moderated by the modality of outcome measurement (i.e., symptom reports vs. observational measures). On the other hand, statistical index, treatment phase, or treatment approach did not have significant impacts, which addresses some perennial questions in the EXP literature. CONCLUSIONS: Client experiencing is a small to medium predictor of treatment outcomes and a probable common factor.

Developing Emotion-Based Case Formulations: A Research-Informed Method.

OBJECTIVES: New research-informed methods for case conceptualization that cut across traditional therapy approaches are increasingly popular. This paper presents a trans-theoretical approach to case formulation based on the research observations of emotion. METHODS: The sequential model of emotional processing (Pascual-Leone & Greenberg, 2007) is a process research model that provides concrete markers for therapists to observe the emerging emotional development of their clients. We illustrate how this model can be used by clinicians to track change and provides a 'clinical map,' by which therapist may orient themselves in-session and plan treatment interventions. RESULTS: Emotional processing offers as a trans-theoretical framework for therapists who wish to conduct emotion-based case formulations. First, we present criteria for why this research model translates well into practice. Second, two contrasting case studies are presented to demonstrate the method. CONCLUSIONS: The model bridges research with practice by using client emotion as an axis of integration. Key Practitioner Message Process research on emotion can offer a template for therapists to make case formulations while using a range of treatment approaches. The sequential model of emotional processing provides a 'process map' of concrete markers for therapists to (1) observe the emerging emotional development of their clients, and (2) help therapists develop a treatment plan. Copyright © 2016 John Wiley & Sons, Ltd.

Assertive Anger Mediates Effects of Dialectical Behaviour-informed Skills Training for Borderline Personality Disorder: A Randomized Controlled Trial.

UNLABELLED: Dialectical behaviour therapy (DBT)-informed skills training for borderline personality disorder (BPD) aims at the development of specific emotion regulation skills in patients, particularly with regard to the regulation of problematic anger. While the effects of dialectical behaviour skills training have been shown, their processes of change are rarely examined. Neacsiu, Rizvi and Linehan (2010) found that patient's self-reported use of emotion regulation skills was a mediator of therapeutic change in these treatments; however, they found no effect for problematic anger. From an integrative perspective on anger (Pascual-Leone & Greenberg, 2007; Pascual-Leone & Paivio, 2013), there are several forms of anger, varying in their degree of therapeutic productivity. The present add-on randomized controlled trial included n = 41 patients with BPD (n = 21 DBT-informed skills training versus n = 20 treatment as usual). The first study examined the outcome of the DBT-informed skills training encompassing basic components of training in mindfulness, distress tolerance, interpersonal effectiveness and emotion regulation. Results showed that symptom reduction was significantly greater in the DBT-informed skills training, compared with the treatment as usual. The second study used process assessment, for which all patient completers underwent a 50-min-long psychological interview both early and late in treatment, which was rated using the Classification of Affective Meaning States. DBT-informed skills training produced increased levels of primary 'assertive' anger, as compared with the treatment as usual, whereas no effect was found for 'rejecting' secondary anger. Most importantly, we showed that changes in assertive anger mediated the reported symptom reduction, in particular in patient's social roles. We discuss these results in the context of underlying mechanisms of change in DBT skills group treatments, in particular towards developing more productive forms of anger in this patient population. Copyright © 2015 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: A 20-session dialectical behaviour therapy (DBT)-informed skills training is a promising adjunct intervention for patients with borderline personality disorder, in particular for reducing problems related to social role. Increases in assertive anger mediate the effects of DBT-informed skills training, whereas rejecting anger remains unchanged over the course of treatment. Short-term objectives for intervention might involve the specific increase of assertive anger in BPD, by using DBT-informed skills training; long-term objectives for intervention might involve a specific decrease of rejecting anger in BPD.

Emotional Processing, Interaction Process, and Outcome in Clarification-Oriented Psychotherapy for Personality Disorders: A Process-Outcome Analysis.

It is important to understand the change processes involved in psychotherapies for patients with personality disorders (PDs). One patient process that promises to be useful in relation to the outcome of psychotherapy is emotional processing. In the present process-outcome analysis, we examine this question by using a sequential model of emotional processing and by additionally taking into account a therapist's appropriate responsiveness to a patient's presentation in clarification-oriented psychotherapy (COP), a humanistic-experiential form of therapy. The present study involved 39 patients with a range of PDs undergoing COP. Session 25 was assessed as part of the working phase of each therapy by external raters in terms of emotional processing using the Classification of Affective-Meaning States (CAMS) and in terms of the overall quality of therapist-patient interaction using the Process-Content-Relationship Scale (BIBS). Treatment outcome was assessed pre- and post-therapy using the Global Severity Index (GSI) of the SCL-90-R and the BDI. Results indicate that the good outcome cases showed more self-compassion, more rejecting anger, and a higher quality of therapist-patient interaction compared to poorer outcome cases. For good outcome cases, emotional processing predicted 18% of symptom change at the end of treatment, which was not found for poor outcome cases. These results are discussed within the framework of an integrative understanding of emotional processing as an underlying mechanism of change in COP, and perhaps in other effective therapy approaches for PDs.

Measuring Subtypes of Emotion Regulation: From Broad Behavioural Skills to Idiosyncratic Meaning-making.

UNLABELLED: The current paper introduces the notion of clinically relevant subtypes of emotion regulation behaviours. A new measure of emotion regulation, the Complexity of Emotional Regulation Scale (CERS), was established as psychometrically sound. It was positively correlated with a measure of emotional awareness (r = 0.28, p < 0.001) and negatively correlated with measures of self-criticism (r = -0.28, p < 0.001) and depression (r = -0.35, p = 0.025), among others. Participants were drawn from two samples: clients from a university counselling centre and a non-clinical student sample. Comparisons were conducted between non-clinical and clinical samples to determine the effects of depression and other symptoms of psychopathology on participant's generation of strategies for emotion regulation. Participants in the clinical sample more often identified an intention to soothe but did not follow through as compared with the non-clinical group, F(1, 198) = 4.662, p < 0.04. Furthermore, individuals in the non-clinical sample were more likely to engage in specific, meaning-making strategies when compared with the clinical group, F(1, 198) = 5.875, p < 0.02. Implications from the current studies suggest the possible applicability of the CERS to clinical settings using an interview rather than questionnaire format. Copyright © 2015 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: Emotion regulation should be thought of as being on a continuum of complexity, where strategies range from general ('one size fits all') action to specific ('personal and idiosyncratic') meaning. The best emotion regulation strategy depends on a client's presenting difficulty and level of distress.