Therapist self-disclosure in teletherapy early in the COVID-19 pandemic: Associations with real relationship and traumatic distress.

The usefulness of therapists' self-disclosure (TSD) in psychotherapy remains controversial, and little is known regarding the potential risks and benefits of TSD in times of global crisis such as the COVID-19 pandemic and in teletherapy. We examined two independent samples of therapists (N = 1705; Study 1) and patients (N = 772; Study 2) on their perceptions of increases in TSD during the transition to teletherapy early in the COVID-19 pandemic (spring 2020). Approximately 20% of therapists and 14% of patients reported perceptions of definite increases in TSD. Therapists' top reasons for increased TSD were therapists' heightened distress and an effort to connect with patients in teletherapy. Importantly, therapist perceptions of their increased TSD were positively related to subjective vicarious trauma, real relationship, psychodynamic theoretical orientation and negatively with humanistic orientation, but not with age, race/ethnicity, length of clinical experience, working alliance, or professional self-doubt. Patients' perceptions of increased TSD were positively related with patient pandemic-related traumatic distress and their own self-disclosure, but not with patient-reported therapeutic relationship variables. Longitudinally, patients' perceptions of TSD increases predicted higher pandemic-related traumatic distress at 3-month follow-up, after controlling for their baseline traumatic distress and other variables. These results highlighted that increased TSD in teletherapy may be a potential marker for heightened distress in both patients and therapists during a global crisis and a transition to teletherapy. The findings also contrasted the literature and emphasized that therapists, but perhaps not patients, may have considered increased TSD as a reflection of genuine therapeutic connection.

Heterogeneity in trajectories of traumatic distress at the start of the COVID-19 pandemic.

OBJECTIVE: The COVID-19 outbreak has led to an increase in posttraumatic stress symptoms (PTSSs; Prout et al., 2020) for some individuals, whereas others appeared to be more resilient. It remains relatively unclear what characterizes these potentially different response trajectories ( Chen & Bonanno, 2020). This study sought to (a) assess individuals' PTSS levels at the start of the pandemic and at two subsequent timepoints 3 and 6 months later, (b) identify different trajectories of PTSSs over time, and (c) describe which individual characteristics influenced the likelihood of each of these different trajectories to occur. METHOD: A community sample (n = 317) responded to an online survey during the first weeks of the pandemic, 3 and 6 months later. RESULTS: Among those who reported acute levels of PTSSs, latent class growth analyses identified three different resilience trajectories-resilient (low baseline PTSSs and a slight decrease over time), chronic (severe PTSSs at baseline and no change over time), and recovered (severe PTSSs at baseline but a sharp improvement over time). Baseline childhood adversity, depression, anxiety, defensive functioning, and somatization predicted trajectories. Demographics (age, gender, preexisting chronic illness) and COVID-related factors (knowing someone diagnosed with or who died of COVID-19) were unrelated to trajectories. CONCLUSIONS: Results suggest that although high PTSS levels decreased over time on average, heterogenous change trajectories can be identified based on baseline psychological characteristics. This implies that mental health, including past and present experiences, as well as adaptational mechanisms may shape individuals' experiences with pandemic-related ongoing stress. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Adjusting to a new reality: Consensual qualitative research on therapists' experiences with teletherapy.

OBJECTIVE: In the wake of the COVID-19 pandemic, the use of teletherapy has become more pervasive than ever. Many therapists faced this move to a remote setting with little experience or training. We aimed to qualitatively examine therapists' subjective experience of providing teletherapy, including changes in technique, the therapeutic relationship, and the therapeutic process. METHODS: Thirty-one psychotherapists participated in semistructured interviews. Interviews were recorded, then transcribed and analyzed using the Consensual Qualitative Research method. RESULTS: Therapists typically reported a change in the therapeutic relationship in terms of an increased sense of disconnection as well as shifts in various aspects of the relational dynamics, and they also typically experienced differences in the therapy process due to changes in patient and therapist engagement in the therapeutic work. Additionally, some therapists also reported that they became more active and directive in sessions, took a more informal, personal, or relaxed approach to interacting with patients, and while the emotional connection changed and they missed the energy and intimacy of in-person sessions, the relationship in telesessions felt more authentic and human for some, and teletherapy also provided a way to discuss new dimensions in the process. CONCLUSION: Overall, these results suggest great variability in therapists' subjective experiences with teletherapy, and present teletherapy as a distinct therapy format in many aspects. Further process-level research and subsequent training is needed to better equip therapists to navigate teletherapy's challenges and harness its unique opportunities.

Defense mechanisms are associated with mental health symptoms across six countries.

Defense mechanisms are adaptative processes that are related to mental health and psychological functioning and may play an important role in adaptation to distress, as well as in mental health interventions. The present study aimed to compare the use of defense mechanisms and their relationship to mental health symptoms across six countries. In a large-scale descriptive study, we collected data from community- based individuals (N=19,860) in the United States, Australia, Canada, Germany, Italy, and the United Kingdom about the use of defense mechanisms and experienced mental health symptoms during the early phase of the pandemic. We found that the use of defense mechanism categories was similar across countries. Moreover, lower defensive functioning, specifically, neurotic and immature defenses were related to experiencing higher distress across countries, whereas mature defenses were generally inversely related to symptoms. Furthermore, these findings were relatively similar across the six countries. Cross-cultural research on defense mechanisms and mental health has important clinical implications. Our results are consistent with the goal of promoting more adaptive defensive functioning to increase psychological well-being and mitigate the detrimental impact of situational stress.

Practicing Online During COVID-19: Psychodynamic and Psychoanalytic Therapists' Experiences.

During the Covid-19 pandemic, psychotherapists quickly transitioned to provide online therapy, while facing many challenges. This study aimed to explore psychodynamic and psychoanalytically oriented therapists' (N = 1450) experiences with online therapy during the first weeks of the pandemic and two months later. Results showed that therapists had little pre-pandemic experience with providing online therapy and even less training in it, and that younger therapists reported more challenges in the transition to online therapy. During the first weeks of the pandemic, most therapists thought that online therapy was less effective than in-person therapy, and they reported a wide range of relational and technical challenges, feeling more tired, less confident and competent, and less connected and authentic in online sessions, compared to previous in-person sessions. At follow-up, therapists viewed online therapy as more comparable to in-person therapy; the majority felt connected and authentic as they had during the initial weeks of the pandemic, or more so, but were still as tired as before. The most challenging aspect of online therapy was distraction in sessions, which increased over time. This study demonstrates the professional adaptability of therapists and highlights the need for more training and professional support for clinicians providing remote psychotherapy.

Defense-Oriented Psychoanalytic Psychotherapy as a Tailored Treatment for Boys: Neurobiological Underpinnings to Male-Specific Response Tested in Regulation-Focused Psychotherapy for Children.

This paper presents defense-oriented psychoanalytic psychotherapy as a tailored treatment for boys through a neurophysiological hypothesis. Male central nervous system development is reviewed, with a focus on the development of the emotion regulation system. The organizational effects of pre- and post-natal androgens delay central nervous system development in males relative to females, following a caudal to rostral phylogenetic framework. Ventromedial prefrontal structures mature at an earlier developmental age than dorsolateral prefrontal structures, creating less of a gender gap in the available underlying neural architecture for responsivity to targeted therapeutic intervention. The hypothesized operation of defense analysis upon ventromedial prefrontal cortical structures and corticolimbic connectivity therefore positions boys to benefit from psychotherapy equally as girls. In this study, we explored gender differences in presentation and response to a short-term, manualized defense-oriented psychoanalytic psychotherapy named regulation-focused psychotherapy for children. In a sample size of 43 school-aged children, consisting of 32 boys and 11 girls, with oppositional defiant disorder, we found no statistically significant differences in participant characteristics upon entry nor in treatment response, as measured by changes in scores on the Oppositional Defiant Disorder Rating Scale, the oppositional defiant problems subscale of the Child Behavior Checklist, the suppression and reappraisal subscales of the Emotion Regulation Questionnaire for Children and Adolescents, and the lability and negativity subscale of the Emotion Regulation Checklist. The findings were comparable with the gendered findings of preexisting studies of play therapy, where boys and girls improve equally, but not of behaviorally predominant psychotherapy, where girls appear to have superior responses. Our findings suggest that the treatment as a general play therapy, but with a focus on the implicit emotion regulation system, was successful in meeting boys' gendered treatment needs. Conclusions are drawn with implications for further study.

Psychometric Properties of the Defense Mechanisms Rating Scales-Self-Report-30 (DMRS-SR-30): Internal Consistency, Validity and Factor Structure.

Assessment of defense mechanisms has a longstanding history within the clinical psychology and psychopathology literature. Despite their centrality to clinical practice, there are few self-report measures that assess defenses and, those that do exist, have limitations in addressing individual defenses and levels of defensive functioning. To address this need, we investigated the psychometric properties of the Defense Mechanisms Rating Scale - Self-Report - 30 item (DMRS-SR-30) with a global, community sample of 1,539 participants who responded to an online survey about distress and coping. Exploratory factor analysis found a three-factor model for the DMRS-SR-30 - mature, mental inhibition and avoidance, and immature-depressive. Internal consistency was high for the Overall Defensive Functioning (ODF) and the three extracted factors with coefficient alphas ranging from .75 to .90. Examination of concurrent validity with a commonly used measure of defensive functioning found significant relationships in the predicted directions. The group of immature defenses had the strongest concurrent validity (r = .50). Finally, correlations with external criteria - including psychological distress and adverse childhood experiences - supported the convergent and discriminant validity of the DMRS-SR-30. The three factor structure of the DMRS-SR-30 has good psychometric properties. Limitations and directions for future research, as well as clinical implications, are described.

Randomized controlled trial of Regulation Focused Psychotherapy for children: A manualized psychodynamic treatment for externalizing behaviors.

OBJECTIVE: This article examines outcomes of the first randomized controlled trial of Regulation Focused Psychotherapy for Children (RFP-C), a manualized, short-term, psychodynamic intervention for decreasing symptoms of the oppositional defiant disorder (ODD) in school-aged children. METHOD: Participants (n = 43) were school-aged children who were randomly assigned to RFP-C or a waitlist control group. Symptoms of ODD and explicit emotion regulation capacities were assessed at baseline, end of waitlist, and end of treatment. Multilevel modeling was used to account for patient and therapist factors in outcomes. RESULTS: At the end of treatment, parents reported significant reductions in children's ODD symptoms on the primary outcome measure. There were no observed changes in explicit emotion regulation. Reliable change index scores indicated that 79.4% of children were recovered or improved after 10 weeks of treatment. There were no identifiable patient or therapist effects. Treatment adherence and completion was high. CONCLUSION: This study is the first randomized controlled trial of a manualized psychodynamic intervention for children with ODD. Participants demonstrated significant reductions in symptoms of ODD after 10 weeks of treatment. Further investigation is needed to compare RFP-C relative to active treatment, assess changes in implicit emotion, and to determine long-term maintenance of symptom improvement.Clinical trial registration information: Evaluation of Regulation Focused Psychotherapy for Children (RFP-C); https://clinicaltrials.gov/ct2/show/NCT03594253.

Therapists' resilience and posttraumatic growth during the COVID-19 pandemic.

OBJECTIVE: This study aimed to examine therapists' unfolding response to the challenges of vicarious traumatization and transitioning to online therapy in the wake of the pandemic. This is the first study to empirically examine therapists' experience of resilience and posttraumatic growth during COVID-19. METHOD: This longitudinal study reports on the self-reported resilience and posttraumatic growth of 185 psychotherapists (mostly White, female and North American) across 4 time points during the COVID-19 pandemic. Therapist-reported working alliance, vicarious traumatization, and acceptance of online therapy at baseline were examined as potential predictors of professional self-doubt at baseline as well as potential predictors of subsequent resilience (e.g., reduction of professional self-doubt) and posttraumatic growth. RESULTS: Therapists experienced moderate levels of professional self-doubt, more than outside pandemic times, and this self-doubt decreased over time, thus showing a resilient trajectory. Professional self-doubt at baseline was predicted by higher vicarious trauma and weaker working alliance, less clinical experience, and less acceptance of online therapy technology. Higher levels of resilience over time were predicted by less acceptance of online therapy. Moreover, therapists reported relatively low levels of posttraumatic growth, and this remained consistent during the subsequent 12 weeks. Posttraumatic growth was predicted by high levels of vicarious trauma, and acceptance of online therapy technology. CONCLUSIONS: Therapists in our study reported resilience during the initial months of COVID-19. Those who were relatively more traumatized and more comfortable in their online work during the pandemic experienced more posttraumatic growth. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The development of a self-report scale to assess therapists' acceptance of telepsychotherapy.

OBJECTIVE: We aimed to develop a self-report measure of therapist acceptance of telepsychotherapy based on the Unified Theory of Acceptance and Use of Technology (UTAUT) framework. METHODS: Using a cross-sectional survey design, 1265 therapists completed the UTAUT-T, as well as additional questions. RESULTS: Confirmatory analysis indicated that the original UTAUT model did not fit the therapist context well. Exploratory factor analysis specified a better-fitting five-factor model, which showed good internal validity fit (χ2 = 17,753.36, RMSEA = 0.063, TLI = 0.886, SRMSR = 0.04). The five UTAUT-T subscales showed high internal consistency (Cronbach's α = 0.86) and together predicted the intention to use online therapy in the future (R2 = 0.42, F(5, 1259) = 181.9, p < 0.001). CONCLUSION: The 21-item UTAUT-T offers a promising self-report measure of therapist acceptance of telepsychotherapy and intention towards using it in the future. Future studies on the convergent and predictive validity of the UTAUT-T are warranted.

Psychotherapists' acceptance of telepsychotherapy during the COVID-19 pandemic: A machine learning approach.

OBJECTIVE: This study aimed to develop predictive models of three aspects of psychotherapists' acceptance of telepsychotherapy (TPT) during the COVID-19 pandemic, attitudes towards TPT technology, concerns about using TPT technology and intention to use TPT technology in the future. METHOD: Therapists (n = 795) responded to a survey about their TPT experiences during the pandemic, including quality of the therapeutic relationship, professional self-doubt, vicarious trauma and TPT acceptance. Regression decision tree machine learning analyses were used to build prediction models for each of three aspects of TPT acceptance in a training subset of the data and subsequently tested in the remaining subset of the total sample. RESULTS: Attitudes towards TPT were most positive for therapists who reported a neutral or strong online working alliance with their patients, especially if they experienced little professional self-doubt and were younger than 40 years old. Therapists who were most concerned about TPT were those who reported higher levels of professional self-doubt, particularly if they also reported vicarious trauma experiences. Therapists who reported low working alliance with their patients were least likely to use TPT in the future. Performance metrics for the decision trees indicated that these three models held up well in an out-of-sample dataset. CONCLUSIONS: Therapists' professional self-doubt and the quality of their working alliance with their online patients appear to be the most pertinent factors associated with therapists' acceptance of TPT technology during COVID-19 and should be addressed in future training and research.

Psychotherapists' Challenges With Online Therapy During COVID-19: Concerns About Connectedness Predict Therapists' Negative View of Online Therapy and Its Perceived Efficacy Over Time.

Therapists' forced transition to provide psychotherapy remotely during the COVID-19 pandemic offers a unique opportunity to examine therapists' views and challenges with online therapy. This study aimed to investigate the main challenges experienced by therapists during the transition from in-person to online therapy at the beginning of the pandemic and 3 months later, and the association between these challenges and therapists' perception of the quality of the relationship with their online patients, and therapists' attitudes and views about online therapy and its efficacy at these two timepoints. As part of a large-scale international longitudinal survey, we collected data from 1,257 therapists at two timepoints: at the start of COVID-19, when many therapists switched from providing in-person therapy to online therapy, as well as 3 months later, when they had had the opportunity to adjust to the online therapy format. At both timepoints, therapists reported on perceived challenges, quality of working alliance and real relationship, attitudes toward online therapy, and their views on online therapy's efficacy compared to in-person therapy. Factor analysis of individual survey items at both timepoints identified four different types of challenges among this therapist sample: Emotional connection (feeling connected with patients, reading emotions, express or feel empathy), Distraction during sessions (therapist or patient), Patients' privacy (private space, confidentiality), and Therapists' boundaries (professional space, boundary setting). Older and more experienced therapists perceived fewer challenges in their online sessions. At baseline, all four types of challenges were associated with lower perceived quality of the therapeutic relationship (working alliance and real relationship), and more negative attitudes toward online therapy and its efficacy. After 3 months, perceived challenges with three domains - Emotional connection, Patients' privacy, and Therapists' boundaries significantly decreased - whereas challenges in the fourth domain - Distraction - increased. In our study, therapists' concerns about being able to connect with patients online appeared to be the most impactful, in that it predicted negative attitudes toward online therapy and its perceived efficacy 3 months later, above and beyond the effect of therapists' age and clinical experience. Clinical and training implications are discussed.

What Do Therapist Defense Mechanisms Have to Do With Their Experience of Professional Self-Doubt and Vicarious Trauma During the COVID-19 Pandemic?

This is the first study to examine psychotherapists' levels of defense mechanisms, their concurrent relationship with professional work-related stress (professional self-doubt and vicarious trauma), and how their levels of defense mechanisms predict the changes in these professional stresses over the course of 3 months since the start of the COVID-19 pandemic. Data from two online studies (Study 1; N = 105 and Study 2; N = 336), using two self-report measures of therapists' defense mechanisms (Defense Style Questionnaire-40 in Study 1 and Defense Mechanism Rating Scales Self-Report-30 in Study 2), are presented. Therapists reported higher levels of mature defense mechanisms, and lower levels of immature defense mechanisms, compared to published community and clinical populations assessed before and during the pandemic. Therapists' lower level of mature defense mechanisms and higher levels of neurotic and immature defense mechanisms were related to higher concurrent levels of vicarious trauma and professional doubt. Therapists who reported higher levels of mature defense mechanisms at 3-month follow-up showed less vicarious trauma and professional self-doubt at follow-up, after controlling for these professional stressors at baseline. Implications for clinical supervision and training are discussed. The context and professional challenges during the pandemic are unique and future replications of the results outside the pandemic context are warranted.

Stress, Burnout, and Resilience among Healthcare Workers during the COVID-19 Emergency: The Role of Defense Mechanisms.

The experience of working on the frontlines of the COVID-19 healthcare crisis has presented a cumulative traumatic experience that affects healthcare professionals' well-being. Psychological resources such as resilience and adaptive defense mechanisms are essential in protecting individuals from severe stress and burnout. During September 2020, 233 healthcare workers responded to an online survey to test the impact of demographic variables, COVID-19 exposure, and psychological resources in determining stress and burnout during the COVID-19 emergency. Frontline workers reported higher scores for stress, emotional exhaustion, and depersonalization (p < 0.001) as compared to colleagues working in units not directly serving patients with COVID-19. Mature defensive functioning was associated with resilience and personal accomplishment (r = 0.320; p < 0.001), while neurotic and immature defenses were related to perceived stress and burnout. Stress and burnout were predicted by lower age, female gender, greater exposure to COVID-19, lower resilience, and immature defensive functioning among healthcare professionals (R2 = 463; p < 0.001). Working on the frontlines of the COVID-19 pandemic appears to provoke greater stress and burnout. On the other hand, resilience and adaptive defense mechanisms predicted better adjustment. Future reaction plans should promote effective programs offering support for healthcare workers who provide direct care to patients with COVID-19.

An examination of parent sessions in regulation-focused psychotherapy for children.

Collateral work with parents is a widely adopted practice within child psychotherapy. Therapeutic process within these parent sessions has not been empirically studied or defined, despite a sizable process-outcome literature in both child and adult individual therapy. This link between research and practice is particularly important among manualized, child-focused treatments, where the proposed therapeutic action and clinical approach to parent work is defined according to distinct theoretical principles. To address this gap in the child treatment literature, the present study used the Psychotherapy Process Q Set to examine the in-session processes of parent sessions from 16 treatments of regulation-focused psychotherapy for children (RFP-C). RFP-C is a manualized, psychodynamic treatment for children with disruptive behaviors that consists of 16 child sessions and four collateral parent sessions. The parent-session process ratings were compared to existing adult therapy prototypes and the RFP-C child session prototype. Results indicated that observer-coded psychotherapy process in RFP-C parent sessions was most similar to a cognitive-behavioral therapy prototype and moderately correlated with both a supportive-expressive psychodynamic psychotherapy and a reflective functioning prototype. Observer-coded parent session process was distinct from the RFP-C child prototype. Limitations and directions for future research and clinical practice are discussed. The findings of this study indicate the need to intentionally examine process in parent sessions, both within RFP-C and across modalities, as these sessions have their own unique mechanisms of therapeutic action that ultimately may be additive with regard to child outcomes. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Psychodynamic Psychotherapy for Children as a Trauma-Informed Intervention.

This article outlines the underpinnings of a psychodynamic approach for the treatment of childhood trauma through strengthening the implicit emotion regulation system. Childhood trauma impairs the functioning of the emotion regulation system, where deficits are common in children with post-traumatic stress disorder (PTSD). Difficulties with emotion regulation arise out of disruptions in the development of neurobiological pathways through the interaction of constitutional determinants with environmental factors, including the child's relationships with caregivers and the broader environment. We propose that a therapeutic focus on traumatized children's defenses can overcome the damaging reverberations of trauma. This approach may bypass the difficulties of high attrition rates, expense, and limited generalizability characteristic of skills training-based modalities. An illustration of an intervention to help children address unbearable emotions in traumatic experiences through defense interpretation is presented. The manualization and study of this approach within a project titled Regulation Focused Psychotherapy for Children (RFP-C) presents a unique opportunity to contribute to the evidence-based canon of treatments for children with histories of trauma.

The Connecting and Reflecting Experience (CARE): theoretical foundation and development of mentalizing-focused parenting groups.

In underserved communities with limited resources and disproportionately high morbidity and mortality rates, attachment-based, short-term, group interventions that are effective yet simple to disseminate can have a profound public health impact. This paper describes the implementation of a mentalizing-focused group parenting intervention. The Connecting and Reflecting Experience (CARE) serves primary caregivers of children from birth to 18 years within a diverse and impoverished community setting. Families living in communities facing health disparities are at heightened risk for intergenerational cycles of trauma which give rise to myriad public health crises at high societal cost. CARE's mission is to facilitate the intergenerational transmission of secure attachment which can profoundly reduce rates of psychiatric illness for future generations. The theoretical and empirical bases for the intervention and the evidence base for existing mentalizing-focused parenting interventions are reviewed. The program's structure and treatment goals are presented in the context of clinical case material.