Blog

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.

McPherson, S., Wicks, C. & Tercelli, I. (2020). Patient experiences of psychological therapy for depression: A qualitative metasynthesis. BMC Psychiatry, 20, 313. https://doi.org/10.1186/s12888-020-02682-1

Many times, researchers choose what to study in psychotherapy trials without really consulting patients who are receiving the care. For example, researchers are often primarily interested in how well psychotherapies reduce symptoms in patients with a particular disorder, or researchers might be interested in certain constructs that might affect patient outcomes (e.g., therapeutic alliance, therapist empathy). But are these the things that patients are really interested in when they seek psychological therapy? Although many treatment guidelines emphasize patient choice and experience, none of them take research of patient experiences into account to develop the guidelines. When presented with findings from randomized controlled trials of psychotherapy, patients reported that the research was of limited value in helping them make an informed choice about therapy. In this metasynthesis of qualitative studies, McPherson and colleagues aimed to bring together qualitative evidence concerning adult patients’ experiences of psychotherapy for depression. Qualitative research typically involves interviewing patients and systematically categorizing their responses into meaningful themes. The authors found 38 qualitative studies involving patient interviews of their experiences in receiving psychotherapy for depression. Several key themes emerged from the analysis. First, many people who receive remote therapy primarily from a computer program felt dissatisfied because of the lack of or limited contact with a real person therapist. Most patients did not feel connected to the computerized therapy and so their motivation waned quickly. Second, patients found psychological models and techniques to be less relevant than their need for help with their immediate family or social problems that likely triggered their depressive symptoms. This points to the primary importance of quality of life and of the social and cultural context for patients, despite that many psychological therapies tend to focus on symptoms almost exclusively. Third, this metasynthesis pointed to reports of negative effects of therapy, in which some therapeutic techniques like body scans induced flashbacks in some patients. Other patients had mixed or sometimes negative feelings about requirements for homework, which sometimes felt overwhelming, culturally out of step, or irrelevant.

Practice Implications

This metasynthesis of patient experiences in psychotherapy point to the importance of asking patients about their goals, expectations, and preferences in therapy. The findings highlight the importance of some common factors across therapies (e.g., therapist warmth and humanness, collaborative agreement on tasks and goals, and patient factors like culture and individual differences). Patients prefer human connection with therapists, and they tend to place less value on techniques of therapy. Patients also tend to value outcomes related to quality of life, social connection, and they want therapy consistent with their cultural values. Patients should be fully involved in a collaborative discussion about which therapy you offer them, how you provide the therapy, and what they want to achieve in therapy.

Janis, R.A., Burlingame, G.M., Svien, H., Jensen, J. & Lundgreen, R. (2020): Group therapy for mood disorders: A meta-analysis, Psychotherapy Research, DOI: 10.1080/10503307.2020.1817603

Mood disorders are common mental health problems, with a 12-month prevalence of 7% in the population for major depressive disorder (MDD). Researchers have tested group therapy as a treatment for MDD and bipolar disorder. Recently, the American Psychological Association added group therapy as a specialty, attesting to the empirical evidence of group therapy’s efficacy and also the need for specialized education and training. Despite this, some treatment guidelines do not list group therapy as a first line therapy for major depression. Over the past 10 years, an international group of researchers have conducted a number of meta-analyses on the efficacy of group therapy for many disorders. In this particular meta-analysis, Janis and colleagues assessed the efficacy of group therapy to treat mood disorders by looking at randomized controlled trials of group therapy compared to waitlist controls, treatment as usual, and anti-depressant medications. They identified 42 randomized controlled trials of group therapy for mood disorders that included almost 3,000 patients. Treatment orientations included CBT, DBT, psychodynamic, and interpersonal therapies. For primary outcome measures of depressive symptoms at post treatment, the effect of group therapy versus waitlist controls was large and significant (g = .86, 95% CI [.66, 1.06], p < .001, k = 9), and those receiving group treatment were 6.81 times more likely to recover compared to those waiting for treatment (95% CI [3.70, 12.55]). Group therapy also resulted in better outcomes than treatment as usual on primary outcome measures of depression at post treatment with a medium sized effect (g = 0.46, 95% CI [0.22, 0.87], p < .001, k = 11), and those receiving group therapy were 2.75 times more likely to recover than those receiving treatment as usual (95% CI [1.59, 4.72]). Finally, there was no significant difference between group therapy and medications on rate of change in depressive symptoms or on rates of recovery.

Practice Implications

Overall, group therapy was more effective than no treatment and treatment as usual for major depression symptoms. Group therapy was as effective as anti-depressant medications. Group therapy is likely more cost effective because it is a multi-person treatment. Many patients do not respond to medications or they struggle with medication adherence because of unpleasant side effects. And most patients prefer psychotherapy to medications if given the choice. And so, group therapy provides a cost-effective alternative and should be considered as a first line treatment for depression. As indicated by the American Psychological Association’s recognition of group therapy as a specialty, providing group therapy requires specialized education and training in order to offer effective care. Continuing education opportunities exist with the Society of Group Psychology and Group Psychotherapy and with the American Group Psychotherapy Association.

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.

Flückiger, C., Rubel, J., Del Re, A. C., Horvath, A. O., Wampold, B. E., Crits-Christoph, P., Atzil-Slonim, D., . . . Barber, J. P. (2020). The reciprocal relationship between alliance and early treatment symptoms: A two-stage individual participant data meta-analysis. Journal of Consulting and Clinical Psychology, 88(9), 829–843.

The therapeutic alliance (patient and therapist agreement on tasks and goals of therapy and their emotional bond) is the most researched concept in psychotherapy. The research clearly indicates that a positive alliance reliably predicts patient outcomes in terms of reduced symptoms. However, researchers still debate whether the alliance is at all necessary. That is, some argue that the alliance is the result of patients feeling better early in therapy, and so the alliance is only an outcome of early symptom reduction. If that is the case, then the alliance is an artifact of symptom reduction, and clinicians need not pay much attention to it. In this meta-analysis, Fluckiger and colleagues collected 17 studies representing over 5000 patients that evaluated whether alliance in a previous session predicted outcomes in a subsequent therapy session, and vice versa. In other words, they looked at all studies that evaluated if change in alliance preceded change in symptoms and if change in symptoms preceded change in the alliance. What is unique about this meta-analysis is that they gathered patient-level data from the original studies. That allowed them to test the therapeutic alliance theory for each individual patient on a session by session basis for the first 7 sessions of therapy. (For the stats geeks out there, the authors analysed within-person [between-session] effects using multilevel time-lagged models). Their analyses found that high alliance at a preceding session was related to lower symptoms at the subsequent session (B adjusted = -.065 (95% CI [-.092, -.038]; p < .0001)), and higher symptoms at the start of a session was related to lower post session alliance (B adjusted = -.148 (95% CI [-.215, -.081]; p < .0001). They also found that patients who generally reported high alliance scores showed a stronger alliance – outcome relationship, and those with greater symptoms had a weaker alliance - outcome relationship.

Practice Implications

This meta-analysis is another indication of the importance of therapists and patients coming to a collaborative agreement on the tasks of therapy (what is done during sessions) and the goals of therapy (what issues to work on), and of their relational bond. The alliance is not always easy to establish – especially with regard to agreeing on goals. Also, the alliance should not be forgotten once established – alliance ruptures or tensions occur frequently and can have a negative effect on patients’ mental health outcomes. Patients of psychotherapists who repair alliance tensions generally have better mental health outcomes.

Hiebler-Rager, M., Nausner, L., Blaha, A., Grimmer, K., Korlath, S., Mernyi, M., & Unterrainer, H.F. (2020). The supervisory relationship from an attachment perspective: Connections to burnout and sense of coherence in health professionals. Clinical Psychology and Psychotherapy, Online First Publication: https://doi.org/10.1002/cpp.2494.

Health professionals including psychotherapists are susceptible to burnout due to the emotional challenges of the work. There is some research indicating that with good supervision trainees and experienced therapists might be less susceptible to burnout (i.e., exhaustion, inefficiency, cynicism) and might gain a greater sense of personal coherence (i.e., that stressful events encountered in life are predictable and manageable, and that managing these events is personally meaningful). Supervision involves a senior qualified practitioner providing an intensive relationship-based education and training focused on supporting, guiding, and teaching a trainee or colleague. One can argue that the supervisory relationship provides the supervisee with a secure base from which to learn and grow as a professional. This secure base functions similar to an attachment relationship, which means that the bond, trust, agreement, and clarity of supervisory goals are key. That is, when a critical incident occurs in the therapy, the supervisee experiences stressful emotions and seeks support and security from the supervisor. One factor that may affect this process is the pre-existing level of attachment insecurity in the trainee (i.e., being too preoccupied with relationships or being too dismissing of relationships). Greater attachment insecurity may make it more difficult for supervisees to experience supervision as a safe environment. In this study, Hiebler-Rager and colleagues assessed if the quality of the supervisory relationship reported by supervisees predicted their level of burnout and of cohesion, and also if supervisees’ level of attachment insecurity also predicted these outcomes over and above the effects of supervision. The sample included 346 supervisees with a wide range of experience (0 to 50 years), ages (23 to 80 years), and professions who completed questionnaires about the supervisory relationship, attachment, burnout, and cohesion. Even after controlling for number of supervision sessions and supervisees’ clinical experience, lower quality of the supervisory relationship was related higher levels of burnout (β = −.31) and a lower sense of coherence (β = .31; both p < .01) in the supervisee. Higher levels of insecure attachment of the supervisee also predicted higher burnout (attachment anxiety: β = .30, p < .01) and lower coherence (attachment anxiety: β = −.40, p < .01; attachment avoidance:β = −.17, p < .01), even after controlling for the effects of number of supervisions sessions, experience, and the quality of the supervisory relationship. Adding attachment insecurity was associated with a medium to large incremental effect over and above the quality of the supervisory experience (R-square change = 0.13 for burnout, and 0.24 for coherence).

Practice Implications

Supervision is a key manner in which psychotherapists are trained, and in which many participate in continuing education. A good quality supervisory relationship (secure and supportive) can help professionals mitigate the risk of burnout and to have a greater sense of personal coherence. However, some of the utility of supervision may depend to some extent on the supervisee’s own level of attachment insecurity. If a supervisee experiences an insecure attachment generally, they may require personal therapy to work on their sense of security in relationships and their ability to manage theirs and others’ emotions.