Blog

Johnson, S.M, Burgess Moser, M., Beckes, L., Smith, A., Dalgliesh… Coan, J.A. (2013). Soothing the threatened brain: Leveraging contact comfort with emotionally focused therapy. PLoS ONE 8(11): e79314. doi:10.1371/journal.pone.0079314.

Attachment theory argues that a felt sense of connection to others provides a secure base and safe haven, thus increasing one’s tolerance for uncertainty and threat. Improved access to and experience of social resources likely help us regulate negative emotions thus reducing our perception of threat. In a previous study, women in a couple were confronted with a threat (the possibility of a shock to the ankle) while their brain was scanned by functional magnetic resonance imaging (fMRI). These women were either holding the hand of their spouse or the hand of a stranger. Women with the highest quality relationships showed lower threat response in the brain especially while they held the hand of their spouse. Holding the hand of a spouse with whom they had a loving relationship reduced the fear response in these women measured directly in the brain by fMRI. In the study by Johnson and colleagues (2013) the authors wanted to see if improving attachment relationship between couples following Emotionally Focused Couples Therapy (EFT) would result reduced responses to threat measured in the brain. Twenty-three couples completed a course of EFT (23 sessions on average) with experienced therapists. EFT is an evidence based couples treatment that conceptualizes couple distress as caused by unmet attachment needs. When feeling emotionally disconnected, partners in a couple may be anxiously blaming or withdrawing, and this pattern exacerbates relationship distress and threat. EFT focuses on repairing attachment bonds between spouses. In this trial, EFT significantly improved couples’ self reported distress from pre to post therapy. The brain of the female member of the couple was scanned in an fMRI before and after EFT. An electrode was fixed to her ankle, and she was threatened with a mild shock. This procedure took place while she was on her own and while she held her partner’s hand. Threat response was measured by activity in the prefrontal cortex and dorsal anterior cingulate cortex, both of which are associated with processing threat cues and negative affect. EFT resulted in a decrease activity in these areas of the brain from pre to post couples treatment, and these results were especially prominent during hand holding with the partner.

Practice Implications

There is emerging evidence that the effects of psychotherapy like EFT for couples, has a direct impact on the brain that correlates with patients’ self report. In addition, EFT appears to increase the attachment bond between couples and this helps them to regulate their emotions and to moderate their reactions to threat. This study by Johnson and colleagues (2013) also supports some fundamental tenets of attachment theory – that increasing attachment security is possible with psychotherapy and doing so improves affect regulation as measured in the brain. This has broad implications because strong social and attachment bonds help us live longer and enjoy better health.

Author email: jcoan@virginia.edu

Colli, A., Tanzilli, A., Dimaggio, G., & Lingiardi, V. (2013). Patient personality and therapist response: An empirical investigation. American Journal of Psychiatry.

Therapist emotional responses to patients may refer to emotional reactions or to countertransference. Emotional responses can inform therapeutic interventions if therapists view their responses as informative about the patient’s feelings, perspectives, and relationship patterns. Clinicians have an intuitive sense that specific patient characteristics tend to evoke distinct emotional reactions (i.e., countertransferences) in the therapist. However, there are very few studies that examine the association between patient personality features and therapist emotional responses. A study Colli and colleagues examined this issue. They sampled 203 therapists from two theoretical orientations (psychodynamic = 103; cognitive-behavioral = 100). Among the therapists, 58% were women, mean age was 43 years, average experience was 10 years, average time spent providing psychotherapy was 16 hours per week, and 78% were in private practice. Each therapist was asked to randomly select a patient in their caseload, and complete a validated personality assessment questionnaire about the patient. Three weeks later, and immediately following a therapy session with the patient, the therapist completed a validated therapist emotional response questionnaire. Half of the patients were women (53%), mean age was 34 years, average length of treatment was 5 months (once per week), and 72% were diagnosed with a personality disorder (either comorbid or as a primary diagnosis). Patient paranoid and antisocial features were associated with therapists feeling criticized/mistreated. Patient borderline personality features were associated with therapists feeling helpless/inadequate, overwhelmed/disorganized, and special/overinvolved. Patient narcissistic features were associated with therapists feeling disengaged. Patient dependent personality features were associated with therapists feeling both parental/protective and special/overinvolved. The results were not affected by clinicians’ theoretical orientation. That is, psychodynamic and cognitive-behavioral therapists showed similar emotional responses to each patient personality pattern.

Practice Implications

The results do not appear to be an artifact of therapist theoretical orientation, and so the authors argue that patient interpersonal patterns are quite robust in evoking specific therapist countertransference. A therapist’s emotional responses that are not primarily related to the therapist’s own issues could be an important source of information about the patient’s emotional and interpersonal patterns. Therapist emotional responses can also impede the therapist’s work if the responses are not well understood. Therapists who treat those with borderline personality features may avoid their own experience of negative thoughts and feelings during a session and this may unwittingly manifest as a sudden confrontation of the patient. With patients who have narcissistic features, therapists may feel disengaged, unempathic, and emotionally mis-attuned, which could lead to an impasse or premature termination. Therapists who treat patients with dependent features may be overprotective and may avoid exploring the patient’s painful feelings.

Author email address: antonello.colli@uniurb.it

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, you can read the Handbook table of content and sections of the book on Google Books.

Bohart, A.C. & Wade, A.G. (2013). The client in psychotherapy. In M. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behavior change (6^th ed.), pp. 219-257. Hoboken, NJ: Wiley.

Last month I blogged about the section in Bohart and Wade’s (2013) chapter that focused on client attachment. This month I focus on other factors like severity of distress and comorbidity, and level of motivation. Some authors argue that client factors predict 30% of variance in outcomes. That accounts for more of psychotherapy outcome than therapist effects and therapeutic techniques combined. Severity of symptoms of anxiety and depression and functional impairment caused by this distress leads to poorer client prognosis. Further, individuals with more severe symptoms need more sessions to show improvement. Some research shows that those with greater symptoms change more than those with fewer symptoms. However, even though those with higher levels of distress show the most change, they are less likely to achieve recovery in which they return to a normal level of functioning. In most cases, clients with comorbid problems are less likely to do well. For example, comorbidity for personality disorder or substance abuse negatively impact outcome. Client motivation is also related to psychotherapy outcomes. Motivation can be internal (those that arise from the individual’s intrinsic interests or values) or external (those that arise from external rewards or punishments). Generally, internal motives (i.e., greater readiness to change) are better predictors of sustained behaviour change. The stages of change model describes readiness to change as occurring in progressive stages that include: (1) precontemplation, in which clients are not internally motivated; (2) contemplation in which clients move to the next stage where they recognize a problem but are not ready to take action; and (3) preparation for action in which clients are more internally motivated to change. The next two stages of the model do not speak to motivation but to action and maintenance of change. Norcross looked at clients’ readiness to change prior to therapy and its relationship to outcome. Greater readiness to change was moderately and significantly associated with better treatment outcomes.

Practice Implications

The results on severity and comorbidity suggest that providers and policy makers must consider increasing the number of treatment sessions to take into account clients who have greater initial severity and comorbidities, especially for those with comorbid personality disorders. Results related to motivation indicate that when client motivation to work in therapy comes from within and they show progress in their readiness to change, they are more likely to do well. Therapists need to find ways of mobilizing clients’ internal reasons for change. Motivational interviewing may be one means of doing so.

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content can be viewed on Amazon.

Bohart, A.C. & Wade, A.G. (2013). The client in psychotherapy. In M. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behavior change (6^th ed.), pp. 219-257. Hoboken, NJ: Wiley.

Some authors argue that client factors account for 30% of variance in outcomes. That represents a greater association to psychotherapy outcome than therapist effects and therapeutic techniques combined. In this part of the Handbook chapter on client factors, Bohart and Wade discuss client attachment. Bowlby found that attachment relationships were important and were different from other relationships. Attachment figures confer a sense of security and safety to infants that allow children to explore their environment and experience the self. Attachment patterns that develop in childhood tend to be stable throughout the lifespan, but attachment style can change with positive (i.e., psychotherapy, romantic relationships) and negative (i.e., traumatic events) experiences. Attachment security is associated with adaptive affect regulation, positive view of self and others, and reflective functioning that is related to mentalizing. Attachment anxiety is associated with maladaptive up-regulation of emotions, positive view of others but negative view of self, and reduced reflective functioning likely due to preoccupation with relationships and emotion dysregulation. Attachment avoidance is associated with maladaptive down-regulation of emotions, negative view of others and positive view of self (or negative view of others and negative view of self in the case of fearful avoidant attachment), and limited reflective functioning due to dismissing of emotions and relationships. There are also disorganized attachment states related to traumatic events. Those with attachment avoidance tend to be distrustful and less likely to seek psychotherapy. A meta-analysis by Levy and colleagues (2011) of 19 studies including 1467 clients found that attachment security was associated with good psychotherapy outcomes and attachment anxiety was negatively associated with good outcomes. No relationship was found for attachment avoidance and outcomes. Diener and Monroe (2011) conducted a separate meta analysis on attachment and therapeutic alliance which included 17 studies with 886 clients. They found that clients with secure attachments had better alliances with their therapist and those with insecure attachments (anxious or avoidant) had weaker alliances.

Practice Implications

The research is clear that client attachment style influences how clients enter therapy, engage with the therapist, and experience outcomes. Attachment style likely affects specific therapy behaviors like self-disclosure and amount of exploration. In his book Attachment and Psychotherapy, David Wallin (2007) translates attachment theory into a framework for adult psychotherapy by tailoring interventions to specific attachment styles. For example, clients with greater attachment anxiety may do better in psychotherapy when the therapist: helps with down regulation of client emotional experiences, behaves in a way that does not evoke client fears of abandonment or loss, and helps clients improve reflective functioning by encouraging a thoughtful appraisal of their behaviors. On the other hand clients with greater attachment avoidance may require a therapist who: slowly introduces the client to greater attention to emotional experiences, does not demand too much from the client in terms of closeness in therapy at the outset, and encourages reflective functioning by helping the client understand the association between defensive avoidance of affect and relationship problems.