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.

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).

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.

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.

Arousal and affective differences between student gamblers and non-gamblers during a card game.

The current study examined the differences in arousal (physiologically and subjectively) between gamblers and non-gamblers. Thirty students from a mid-sized university took part in the study for a chance to win money in a gambling task. Nearly half of the participants identified themselves as non-gamblers and slightly more than half of the participants considered themselves gamblers. Findings indicated that gamblers experienced a significantly higher increase in physiological arousal (heart rate) compared to non-gamblers during the gambling experience. The results suggests the possibility that physiological arousal may play a role in the appeal of gambling to certain types of people. Furthermore, when gamblers suffered a loss at the end of the game, they reported feeling worse as compared to the non-gamblers and relative to their state before playing. Moreover, this affective change explained 28.6% of the variance in gambling behavior according to self-reports. Findings suggest that gamblers in our study may have been more personally invested in the gambling tasks, such that losing was more disappointing to the habitual gamblers than the non-gamblers.

Electromyographic activity in the immobilized shoulder girdle musculature during contralateral upper limb movements.

The purpose of this study was to quantify electromyographic (EMG) activity in the immobilized shoulder girdle musculature at rest and during a battery of contralateral upper limb activities. Six asymptomatic men, aged 22 to 33 years, volunteered to participate. Fine-wire (supraspinatus, infraspinatus) and surface (deltoids, trapezii, biceps, serratus anterior) electrodes recorded the mean peak normalized (percent maximal voluntary contraction [%MVC]) EMG activity from each immobilized muscle at rest and during slow, fast, and incrementally resisted contralateral upper limb motions (5, 15, and 25 lb). EMG activity in all muscles was low during quiet immobilized standing (<1.5% maximal voluntary contraction [MVC]). During slow contralateral upper limb motions, activity ranged from 0.7% to 51.6% MVC (highest in trapezii) and was less than 15% MVC in the supraspinatus, infraspinatus, and anterior deltoid. Bimanual jar opening increased biceps activity from 7.8% to 16.1% MVC. During fast contralateral upper limb motions, peak infraspinatus activity increased to 56.7% during a fast straightforward reach. Supraspinatus activity was relatively high during all resisted backward-pulling motions (25.2%-32.1% MVC), whereas resisted forward reaching produced relatively little activity in the anterior deltoid, supraspinatus, infraspinatus, or biceps. Several slow and fast motions produced high trapezius activity (>45% MVC) with low supraspinatus, biceps, and anterior deltoid activities (<10% MVC). Our findings suggest that (1) immobilized shoulder girdle muscle EMG activity during quiet standing is negligible in asymptomatic individuals; (2) contralateral upper limb motions at self-selected speeds are not likely to be harmful to healing tissues; (3) during early healing periods, patients with biceps-labral injury should minimize bimanual activities, those with supraspinatus injury should avoid backward-pulling motions, and those with infraspinatus injury should avoid fast straightforward reaches; and (4) cross-body, straightforward, or downward reaches at either a slow or fast speed may be appropriately prescribed as rehabilitative exercises that can be initiated while the shoulder remains immobilized.

Rhomboid muscle electromyography activity during 3 different manual muscle tests.

OBJECTIVE: To determine which of 3 previously published rhomboid manual muscle tests (MMTs) elicits the maximal rhomboid electromyographic activity in an asymptomatic population. DESIGN: Criterion standard. SETTING: Motion analysis laboratory at tertiary care medical center. PARTICIPANTS: Eleven male volunteers (age range, 24-40y) without shoulder or neck pain. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Peak 1-second normalized electromyographic activity in the rhomboid muscle during 8 different MMT positions, including 3 different rhomboid MMT positions (Kendall, Kendall-Alternative, Hislop-Montgomery). RESULTS: The Kendall MMT (78% maximal voluntary contraction [MVC]) produced higher rhomboid electromyographic activity than the Kendall-Alternative (71% MVC) or the Hislop-Montgomery MMT (52% MVC), but the differences were not statistically significant. The posterior deltoid MMT generated the greatest rhomboid electromyographic activity of all MMTs, and 4% to 30% greater rhomboid electromyographic activity than the 3 rhomboid MMTs (P=.0001; posterior deltoid > Hislop-Montgomery). Electromyographic profiles of the Kendall and Kendall-Alternative MMTs were similar, whereas the Hislop-Montgomery MMT produced less upper trapezius activity (P=.0001 vs Kendall and Kendall-Alternative) and more latissimus dorsi activity (P=.0001 vs Kendall-Alternative). The standard MMT positions for the middle trapezius, levator scapula, posterior deltoid, and latissimus dorsi produced the maximal electromyographic activity for their respective target muscles. CONCLUSIONS: The posterior deltoid MMT position should be used to produce maximal rhomboid electromyographic activity for normalization purposes during kinesiologic studies. The Kendall and Kendall-Alternative rhomboid MMT are likely to be clinically indistinct. It is unlikely that clinicians can use standard MMT positions to distinguish rhomboid strength from synergists, such as the levator scapula and middle trapezius muscle, for diagnostic purposes.

Acute hemodynamic effects of abdominal exercise with and without breath holding.

OBJECTIVES: To compare the magnitudes of change in heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure, and rate-pressure product (RPP) during 3 abdominal exercises: straight partial sit-up (SPSU), oblique partial sit-up (OPSU), and the AbSculptor(R) sit-up; and to examine the effect of breath holding on these parameters. DESIGN: Prospective, repeated measures. SETTING: Autonomic research laboratory in a major medical center. PARTICIPANTS: Fourteen normal male and female volunteers (age range, 24-37y; mean, 30.4y). INTERVENTIONS: Hemodynamic parameters were recorded during each abdominal exercise performed with and without breath holding. Mean peak values were calculated for 1 minute before exercise, during exercise, and for 10 minutes after exercise. MAIN OUTCOME MEASURES: Statistical analysis examined for differences in the hemodynamic changes among the 3 exercises under both conditions (with and without breath holding). RESULTS: Heart rate, SBP, DBP, mean blood pressure, and RPP increased during all 3 exercises. The mean peak heart rate and RPP increases were greater for the OPSU than the AbSculptor (heart-rate increase, 21.1+/-6.6bpm vs 17.6+/-5.7bpm, P=.03; RPP increase, 36.9+/-15.5bpm.mmHg vs 29.4+/-10.1bpm.mmHg, P=.05). For all 3 exercises, breath holding significantly increased the hemodynamic parameter elevations during exercise, with the exception of heart rate (SBP, P<.001; DBP, P<.001; mean blood pressure, P<.001; RPP, P=.02). Quantitatively, breath holding during the OPSU resulted in the largest exercise-associated increases in heart rate (21.0+/-8.1bpm), mean blood pressure (22.2+/-16.4mmHg), and RPP (44.9+/-22.3bpm.mmHg). Postexercise, all hemodynamic parameters generally returned to baseline within several minutes. CONCLUSION: When performing the OPSU, SPSU, or the AbSculptor exercises as used in this investigation, normal individuals exercising at low intensities may experience peak heart rate and mean blood pressure increases of 30bpm and 50mmHg, respectively. Voluntary breath holding significantly increased the peak blood pressure elevations and RPP for all 3 exercises, but particularly for the OPSU.