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Kleinbub, J. R., Talia, A., & Palmieri, A. (2020). Physiological synchronization in the clinical process: A research primer. Journal of Counseling Psychology, 67(4), 420–437.

When two people interact, their hearts tend to beat at a coordinated rate and breathing rhythms become similar. In addition, people tend to engage in nonverbal behavior synchronization (harmonized facial expression, body posture, vocal tone, etc.). Due to technological developments in video software and in physiological measurement devices, research into synchronization between psychotherapists and patients may soon become common and may begin to inform clinical practice. In this article, Kleinbub and colleagues review the existing research on physiological synchronization and its implications for research and psychotherapy practice. One important finding in the field is that physiological synchronization is related to positive qualities of the therapist, like empathy. That is, therapists whose skin conductance levels (an index of physiological arousal) matched those of their patients, were perceived by their patients as more empathic. In other studies, physiological synchronization between patient and therapist was associated with higher levels of the therapeutic alliance. There is also interesting research showing that therapists with higher attachment security showed greater physiological synchronization in simulated role-plays of clinical interviews. That is, a greater experience of attachment security and a capacity to mentalize appeared to translate into therapists’ capacity to synchronize with their patients at a physiological level. Although one might expect that more physiological synchronization between patients and therapists is better, various studies point to a more nuanced view. Research in romantic couples and with mother-infant dyads suggest that there is an optimal balance between moments of rupture and synchronization. Reporting on their own research, Kelenbub and colleagues suggested that changes in topic and expressions of disagreement between patient and therapist (an indication of a therapeutic alliance rupture) were associated with lower physiological synchronization. Although not yet formally tested, the authors speculated that when therapists and patients repair alliance ruptures, they might return to a heightened state of physiological synchronization.

Practice Implications

Research and interest in patient-therapist synchronization has been around since the late 1950s. However, with recent technological advances, researchers now have the capacity to unobtrusively and inexpensively assess physiological markers in patients and therapists on a moment to moment basis and correlate these with psychotherapy processes. There are no direct practice implications yet from this research. However, the research does point to the need for therapists to improve their capacity to mentalize (i.e., capacity to understand one’s own and others’ mental states) and to empathize, and to acquire skills to develop a therapeutic alliance and repair alliance ruptures when they occur.

Luyten, P., Campbell, C., Allisons, E., & Fonagy, P. (2020). The mentalizing approach to psychopathology: State of the art and future directions. Annual Review of Clinical Psychology, 16, 297-325.

Mentalizing (or reflective functioning) is important to the human ability to understand one’s self and others in terms of mental states like feelings, desires, wishes, attitudes, and goals. Without mentalizing we would not be able to adapt to complex situations including relationships that require high levels of collaboration and cooperation. Mentalizing underlies the capacity for empathy and improves functions like emotion regulation. Parental capacity to mentalize and to provide a secure attachment environment are requirements for children to develop mentalizing capacity. Without that capacity, children and adults are not able to trust that others are reliable sources of social information, which in turn fosters resilience to adversity. In this wide-ranging article, Luyten and colleagues review the research indicating that deficits in mentalizing underlies many mental health problems. For example, non-reflective assumptions about the self and others leads to problems with emotion regulation often seen in those who experienced childhood adversity. For these individuals, caretakers who were hostile and untrustworthy led the child to develop hypervigilant expectations of others as hurtful, critical, and threatening. This hypervigilant stance might have been useful early-on during the adversity, but hypervigilence represents a barrier to psychological and emotional development. Luyten and colleagues also argue that psychological interventions are forms of social learning that increase a patient’s trust in the self and others as sources of knowledge, improve the patient’s capacity to mentalize partly through the therapist’s modeling of mentalizing, and allow the patient to engage in their environment in more adaptive ways. The authors described mentalization-based treatment (MBT) as focused on increasing mentalizing capacity through improving patients’ mental states and emphasizing the active repair of ruptures in the patient-therapist therapeutic alliance. A recent meta-analysis found that MBT is an effective therapy for borderline personality disorder, and recent controlled trials found that patient improvement lasted from 3 years to 8 years post-treatment.

Practice Implications

Therapists who model mentalizing can encourage this capacity in their patients. Therapists can take a curious “not knowing” stance that allows patients to reflect on their own and others’ mental states (intentions, feelings, thoughts). As an important reparative experience, psychotherapists must be able to identify an alliance rupture (a subtle or obvious disagreement on goals or tasks of therapy, or a tension in the affective bond with the patient). Once identified, therapists must act to repair the rupture by renegotiating or re-explaining the goals or tasks of therapy, or discuss how the tension in the therapeutic relationship may represent a pattern of relationship problems for the patient.

Stefana, A., Bulgari, V., Youngstrom, E.A., Dakanalis, A., Bordin, C., & Hopwood, C. (2020). Patient personality and psychotherapist reactions in individual psychotherapy setting: A systematic review. Clinical Psychology and Psychotherapy.

Countertransference is one of the oldest concepts in psychotherapy. An over-inclusive definition refers to all of the therapist’s emotional reactions to a patient that is evoked by the patient’s behaviors, thoughts, or feelings in the therapy. However, a more contemporary and integrated definition defines countertransference as a subset of therapist reactions. In this view, countertransference is the internal and external reactions of a psychotherapist evoked by the patient, such that patient behaviors interact with unresolved issues of the therapist. In a previous meta-analysis, countertransference reactions of the therapist was associated with poorer patient outcomes, and therapists’ successful management of countertransference was associated with improved patient outcomes. The clinical literature often reports that patients with a personality disorder often evoke troublesome emotional reactions in therapists. In this systematic review, Stefana and colleagues provide a comprehensive evaluation of the relationship between patient personality problems and psychotherapists’ emotional, cognitive, and behavioral reactions in individual therapy. Seven studies were included in their review. Fifty-three percent of therapists were psychodynamically-oriented, most therapists had more than 3 years of experience, and all patients had a personality disorder or were assessed for problematic personality traits. Overall, the authors found that patients with Cluster A personality traits (paranoid, schizoid, schizotypal) tended to evoke therapist responses of feeling criticized, unappreciated, dismissed, or devalued by the patient. Patients with Cluster B personality traits (borderline, histrionic, narcissistic) tended to evoke therapist responses of feeling overwhelmed, helpless/inadequate, sexualized (experiences of sexual tension), and disengaged toward the patient. Patients with Cluster C personality traits (avoidant, dependent, obsessive-compulsive) tended to evoke parental/protective responses in the therapist. Looking at specific personality traits: paranoid personality traits evoked therapists feeling criticized, schizoid personality traits evoked therapists feeling inadequate, schizotypal or obsessive compulsive or narcissistic personality traits evoked therapists feeling disengaged, antisocial personality traits evoked therapists feeling devalued, borderline personality traits evoked therapists feeling overinvolved, avoidant or dependent personality traits evoked therapists feeling parental.

Practice Implications

The research appears to show that patients with certain personality traits, and thus certain ways of thinking, feeling, and reacting tend to evoke specific reactions in therapists. Therapists patterns of reactions appeared to be independent of theoretical orientation, suggesting that all therapists tend to have emotional reactions that may affect the therapeutic relationship and patient outcomes. Therapists can manage countertransference by remaining vigilant to their internal reactions, using self-awareness during sessions, consulting with colleagues and supervisors, and engaging in personal therapy.

Davis, D. E., DeBlaere, C., Owen, J., Hook, J. N., Rivera, D. P., Choe, E., Van Tongeren, D. R., Worthington, E. L., Jr., & Placeres, V. (2018). The multicultural orientation framework: A narrative review. Psychotherapy, 55(1), 89–100.

Studies have shown that many therapists have better outcomes with White clients than with racial and ethnic minority (REM) clients. Also the prevalence of racial/ethnic microaggressions in therapy is high, with as many as 81% of REM clients reporting at least one experience in which a therapist said or did something that was insensitive or offensive. Microaggressions can be understood as instances of therapeutic alliance ruptures that if unrepaired could lead to poor client outcomes. In this practice review of the existing research, Davis and colleagues consider the multicultural orientation framework to help therapists to be more sensitive and effective when working with REM clients. A key feature of the multicultural orientation framework is cultural humility, which refers to a therapist’s interpersonal stance that is open in relation to aspects of cultural identity that are important to the client. Another important concept is cultural opportunities, or the events in therapy in which the client’s cultural beliefs, values, and identity can be explored. Finally, cultural comfort refers to the therapist’s thoughts and feelings that emerge as a result of conversations about the client’s cultural identity. The review found two large and well-designed studies that looked at the association between a multicultural orientation and client outcomes. Therapist cultural humility predicted better therapy outcomes, and lower therapist cultural comfort resulted in client premature termination from therapy. In separate studies, cultural humility was associated with higher therapeutic alliance and fewer microaggressions by therapists. Finally, missed opportunities to discuss cultural identity was associated with more negative therapy outcomes for clients.

Practice Implications

Repairing alliance ruptures caused by microaggressions involves therapists: identifying the event, validating the client’s perspective, discussing the microaggression with appropriate humility, taking responsibility and making amends, and asking the client to inform the therapist about the best way forward. One study showed that the therapeutic alliance improved substantially after therapists and clients discussed and repaired a microaggression. A multicultural orientation involves therapists creating a culturally inclusive setting by overtly discussing the importance of culture and what might cause ruptures.

Stoll, J., Muller, J.A., Trachsel, M. (2020). Ethical issues in online psychotherapy: A narrative review. Frontiers in Psychiatry, 10, 993. doi: 10.3389/fpsyt.2019.00993

There is emerging evidence that videoconference delivered psychotherapy is as effective as face to face therapy. Providing psychotherapy by telecommunication technologies might be synchronous (real time) or asynchronous (email, chat, internet-based) in nature. During the current COVID-19 pandemic, many psychotherapists have moved to telehealth methods due to necessity rather than by choice. Based on previous survey findings, psychotherapists’ attitudes, and legal-ethical barriers have hampered a wider use of video conferencing methods for delivering psychological interventions. In this narrative review, Stoll and colleagues conduct a broad-based summary of 249 studies touching on the main ethical arguments for and against the provision of online psychotherapy. The top five ethical arguments in favor of online psychotherapy include the following. (1) Increased access and availability: online psychotherapy can improve access to health care services for those living in rural and remote areas. (2) Enhanced communication: online therapy is as effective as face to face therapy and allows for creative approaches to delivering therapy including integrating online materials, websites, and videos into therapy sessions. (3) Client characteristics: some clients who have problems with agoraphobia and severe anxiety may find online therapy a useful first step in treatment. (4) Convenience: research indicates that both patients and therapists judge online therapy to be convenient and comfortable. (5) Economic advantages: online therapy might be more cost-efficient due to reduced overhead and travel costs for therapists and clients. The top five ethical arguments against online psychotherapy include the following. (1) Privacy and confidentiality: related to the use of unsecured websites or unencrypted communication tools. (2) Therapist competence: some therapists may not have technology related competencies including specific ethical and legal requirements. (3) Communication issues: the absence of non-verbal cues may reduce the information that therapists have to work with in a session. (4) Research gaps: there is insufficient research to support online therapy, including no knowledge about which clients can benefit, and the impact on therapeutic processes. (5) Emergency issues: ethical issues may arise as to how to manage emergencies or crises of patients who are in different locations.

Practice Implications

The practice of videoconference delivered psychotherapy is here to stay and will be more widespread even after the pandemic. Therapists can take comfort in the many ethical reasons to provide such services, including reaching patients who might not otherwise have access to therapy or who might not be comfortable seeking out face to face therapy. Nevertheless, there are a number of ethical concenrs about the use of online therapy, not the least of which includes questions about privacy and confidentiality and therapist competence. Psychotherapists should follow practice guidelines of their regulatory colleges when considering online therapy.

Muir, H. J., Coyne, A. E., Morrison, N. R., Boswell, J. F., & Constantino, M. J. (2019). Ethical implications of routine outcomes monitoring for patients, psychotherapists, and mental health care systems. Psychotherapy, 56(4), 459–469.

On average, psychotherapy is effective for a variety of disorders, however about two thirds of patients in regular clinical practice do not improve or recover. Even more problematic is the 5% to 10% of patients who get worse during psychotherapy. Research has repeatedly demonstrated that psychotherapists are not capable of identifying patients who get worse, and therapists regularly over-estimate their effectiveness. This is not surprising because the information therapists need to make these determinations about patients is complex. Therapists, like most humans, have a difficult time integrating complex information to make nuanced decisions about how to act. Therapists need help in the form of reliable and accurate information to make complex clinical decisions. One approach to addressing these concerns is to use routine outcome monitoring (ROM), which involves assessing patient progress by reliable means as patients progress through therapy. ROM also involves feeding that information back to therapists on a regular basis so that they can make the best determinations. In this narrative review, Muir and colleagues discuss the ethical implications of the use of ROM given the research support. The research indicates that ROM feedback leads better outcomes for patients than treatment as usual, and most importantly ROM feedback to therapists reduces patient deterioration in half. Qualitative research also finds that patients generally view ROM feedback as valuable, and patients prefer to use it. Given these findings, implementing ROM represents one way to help therapists to meet ethical aspirations of beneficence, and to fulfill ethical obligations of forestalling harm. The research also indicates that therapists differ in their outcomes. One large study in clinical practices indicated that above average therapists were two times more effective than other clinicians. Individual psychotherapists may not be aware of their effectiveness and so do not know if they need more training or need to focus on certain types of patients for whom they are particularly effective. Ethically, ROM may be one means by which therapists can assess the boundaries of and areas competence, and those areas for which they may need more training and supervision.

Practice Implications

ROM may be a means for psychotherapists to practice ethically by knowing their patients better and by knowing themselves better. Basing one’s perception of one’s own competence fulfills the ethical requirement to ground clinical practice within the scientific knowledge of the field. Consistent and reliable information may allow therapists to know their own general effectiveness, and also to know for which patients they are more or less effective. This might result in therapists focusing their practices on those patient problems for which they are effective, or to seek further training and supervision in those areas in which they can improve.