Psychotherapy process research: Identifying productive in-session processes to enhance treatment outcomes and therapist responsiveness.

This paper provides an overview of my research programme for the past 37 years. The focus of my work has been on identifying productive in-session processes to enhance treatment outcomes and therapist responsiveness. Two foci will be reviewed, first, my research on client and therapist interpersonal process and second, productive processing in psychotherapy in three different therapeutic approaches including EFT, CBT and CCT. Given that many competing theoretical perspectives are effective, I was curious about change processes that are common and unique to each. In my work, I employed a variety of research methodologies drawing on frameworks with alternative epistemological and ontological assumptions to capture specific in-session change processes in an attempt to reveal the richness and complexity of the phenomena being studied and illuminate the process of change.

Examining the role of therapists' empathy and clients' attachment styles on changes in clients' affect regulation and outcome in the treatment of depression.

Objective: The purpose of this study was to test whether changes in clients' affect regulation capacity (AR) mediated the impact of therapists' empathy on outcome and whether this relationship was stronger for more insecurely than securely attached clients. Method: The data set included 66 clients, who had participated in 16 weeks of either CBT or EFT for depression. Clients' AR was assessed using an observer and a self-report measure. Results: Changes in AR significantly mediated the relationship between therapists' empathy and outcome for depression, dysfunctional attitudes and self-esteem but not interpersonal problems, and changes in AR were moderated by clients' insecure attachment styles. Conclusions: The findings provide support for therapists' empathy as an active ingredient of change contributing to changes in clients' affect regulation capacities and emphasize the importance of assessing clients' attachment styles so that therapists can be more responsive and effectively tailor their treatments to fit the needs of individual clients.

A quest for self-soothing: A systematic case study into emotion-focused therapy with an emotionally avoidant client who committed sexual offenses.

OBJECTIVE: The current study is part of a multiple case study that investigated the emotional change in individuals who have committed sexual offenses (ISOs). This case study highlights how one client used sex as a maladaptive coping strategy to suppress negative emotions. METHOD: A mixed-methods design was used to track changes in the client's affect regulation (AR) during four phases, including a baseline (Phase A), treatment as usual (Phase B), treatment with an emotion-focused therapy (EFT) component added (Phase C), and follow up (Phase A). RESULTS: The qualitative description with verbatim clinical vignettes, revealed deeper insight into some important steps and hindrances and the impact of specific EFT-interventions. Quantitative analysis of self-report and observational measures showed a significant improvement in the client's AR across different phases of treatment. CONCLUSIONS: The study improves our knowledge of the emotional change in ISOs during treatment and illustrates some key interventions, steps, and hindrances.

The effect of preoperative cognitive impairment and type of vascular surgery procedure on postoperative delirium with associated cost implications.

OBJECTIVE: Postoperative delirium (POD) has a high prevalence among vascular surgery patients, increasing morbidity, mortality, and length of stay. We prospectively studied preoperative risk factors for delirium that can be assessed by the surgical team to identify high-risk patients and assessed its impact on hospital costs. METHODS: There were 173 elective vascular surgery patients assessed preoperatively for cognitive function using the Montreal Cognitive Assessment (MoCA) and the Confusion Assessment Method for POD, which was verified by chart and clinical review. Demographic information, medications, and a history of substance abuse, psychiatric disorders, and previous delirium were prospectively recorded. An accompanying retrospective chart review of an additional 434 (elective and emergency) vascular surgery patients provided supplemental cost information related to sitter use and prolonged hospitalization secondary to three factors: delirium alone, dementia alone, and delirium and dementia. RESULTS: Prospective screening of 173 patients (73.4% male; age, 69.9 ± 10.97 years) identified that 119 (68.8%) had MoCA scores <24, indicating cognitive impairment, with 7.5% having severe impairment (dementia). Patients who underwent amputation had significantly (P < .000) lower MoCA scores (17 of 30) compared with open surgery and endovascular aneurysm repair patients (23.7 of 30). The incidence of delirium was 11.6% in the elective cohort. Regression analysis identified predictors of delirium to be type of surgical procedure, including lower limb amputation (odds ratio [OR], 16.67; 95% confidence interval [CI], 3.41-71.54; P < .000) and open aortic repair (OR, 5.33; 95% CI, 1.91-14.89; P < .000); cognitive variables (dementia: OR, 5.63; 95% CI, 2.08-15.01; P < .001); MoCA scores ≤15, indicating moderate to severe impairment (OR, 6.13; 95% CI, 1.56-24.02; P = .02); and previous delirium (OR, 2.98; 95% CI, 1.11-7.96; P = .03). Retrospective review (N = 434) identified differences in sitter needs for patients with both delirium and dementia (mean, 13.6 days), delirium alone (mean, 3.9 days), or dementia alone (mean, <1 day [17.7 hours]). Fifteen patients required >200 hours (8.3 days), accounting for 69.7% of sitter costs for the surgical unit; 43.7% of costs were accounted for by patients with pre-existing cognitive impairment. CONCLUSIONS: POD is predicted by type of vascular surgery procedure, impaired cognition (MoCA), and previous delirium. Costs and morbidity related to delirium are greatest for those with impaired cognitive burden. Preoperative MoCA screening can identify those at highest risk, allowing procedure modification and informed care.

Therapist empathy and client outcome: An updated meta-analysis.

Put simply, empathy refers to understanding what another person is experiencing or trying to express. Therapist empathy has a long history as a hypothesized key change process in psychotherapy. We begin by discussing definitional issues and presenting an integrative definition. We then review measures of therapist empathy, including the conceptual problem of separating empathy from other relationship variables. We follow this with clinical examples illustrating different forms of therapist empathy and empathic response modes. The core of our review is a meta-analysis of research on the relation between therapist empathy and client outcome. Results indicated that empathy is a moderately strong predictor of therapy outcome: mean weighted r = .28 (p < .001; 95% confidence interval [.23, .33]; equivalent of d = .58) for 82 independent samples and 6,138 clients. In general, the empathy-outcome relation held for different theoretical orientations and client presenting problems; however, there was considerable heterogeneity in the effects. Client, observer, and therapist perception measures predicted client outcome better than empathic accuracy measures. We then consider the limitations of the current data. We conclude with diversity considerations and practice recommendations, including endorsing the different forms that empathy may take in therapy. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Mapping patterns of change in emotion-focused psychotherapy: Implications for theory, research, practice, and training.

An important objective in humanistic-experiential psychotherapies and particularly emotion-focused psychotherapy (EFT) is to map patterns of change. Effective mapping of the processes and pathways of change requires that in-session processes be linked to in-session resolutions, immediate post-session changes, intermediate outcome, final therapy outcome, and longer-term change. This is a challenging and long-term endeavour. Fine-grained descriptions of in-session processes that lead to resolution of specific interpersonal and intrapersonal issues linked with longer-term outcomes are the foundation of EFT, the process-experiential approach. In this paper, evidence in support of EFT as a treatment approach will be reviewed along with research on two mechanisms of change, viewed as central to EFT, clients' emotional processing and the therapeutic relationship conditions. The implications for psychotherapy research are discussed. Given the methodological constraints, there is a need for more innovative methodologies and strategies to investigate specific psychotherapy processes within and across different approaches to map patterns and mechanisms of change to enhance theory, research, practice, and training.

Alexithymia and emotional processing: a longitudinal mixed methods research.

Alexithymia has been associated with poor outcomes in psychotherapy. This association has been attributed to a difficulty in patients processing emotions and engaging in emotional tasks. The possibility of alexithymia being modified by psychotherapy remains a topic of great debate but with little empirical research. In this study a mixed methods longitudinal design was used to better understand alexithymia, emotional processing and change process in psychotherapy. Twelve clients, five with alexithymia, were studied considering the development of alexithymia, emotional awareness, differentiation, regulation and severity of symptoms. The reliable change index was used to interpret the evolution of those emotional variables' scores for each case and thematic analysis was used to analyze individual interviews. Thematic analysis generated several themes, organized in two broad domains: i) perception of emotions and ii) description of change. The three alexithymic patients that changed in alexithymia also changed in at least one of the emotional variables - lack of emotional awareness, emotion differentiation or emotion regulation. Generally, alexithymic patients were able to accomplish change in psychotherapy although they had a tendency to focus on physical complaints, describe changes in a more rational rather than emotional way and present vaguer descriptions of their problems. These results point that alexithymia may change through therapy and reinforces that those changes are associated with improved emotional processing.

Alexithymia and therapeutic alliance: a multiple case study comparing good and poor outcome cases.

Alexithymia has been associated with poor outcomes in psychotherapy. This association has been attributed to a difficulty in patients expressing emotions, engaging in emotional tasks and also poor therapeutic alliances. This study aims to better understand alexithymic patients in psychotherapy. A multiple case study design was used. Cases were selected from a larger research project considering their alexithymia level and outcome status, based on the reliable change index and the client perspective on change. Four cases are presented: with and without alexithymia with good and poor outcome. The therapeutic alliance was included as a process measure, evaluated from both client and therapist. At the end a semi structured interview was conducted with both participants, individually. The analysis concerned the integration and triangulation of the therapist and client experience for each case. Each patient was briefly presented and then a focus was made regarding the perception of both participants on the therapeutic alliance and the emotional processing and change process of the client. Both alexithymic cases and the non-alexithymic poor outcome case showed difficulties in the therapeutic alliance, especially from the perspective of the therapist. In these cases, emotional impairments may have contributed to a poor therapeutic alliance, impacting on the outcome. We suggest that a great focus on the therapeutic alliance with alexithymic patients may increase the quality of treatment and it may be more useful for case conceptualization to consider each feature of the alexithymia construct individual.

Alexithymia and Emotional Processing: A Mediation Model.

OBJECTIVE: Although alexithymia has been associated with difficulties in emotional regulation, both constructs are complex and this association remains unclear. This research attempts to study the relation between both constructs to identify better ways to guide clinical intervention. METHOD: Emotion awareness, differentiation, and regulation were tested as mediators of the associations between alexithymia and severity of symptoms. The model was tested in a clinical (121 participants) and a nonclinical sample (188 participants). RESULTS: Mediation effects were found in both samples with respect to different alexithymia factors, with the effects being higher in the clinical sample. CONCLUSION: Emotional awareness and emotional differentiation mediate the relationship between alexithymia and emotion regulation. The similarities between samples suggest that emotional processing may be better thought of as being on a continuum. Being aware of the differential effect each alexithymia factor has on emotional processing may be helpful to guide intervention.

Humanistic psychotherapy research 1990-2015: from methodological innovation to evidence-supported treatment outcomes and beyond.

OBJECTIVE: Over the past 25 years, humanistic psychotherapy (HP) researchers have actively contributed to the development and implementation of innovative practice-informed research measures and coding systems. METHOD: Qualitative and quantitative research findings, including meta-analyses, support the identification of HP approaches as evidence-based treatments for a variety of psychological conditions. RESULTS: Implications for future psychotherapy research, training, and practice are discussed in terms of addressing the persistent disjunction between significant HP research productivity and relatively low support for HP approaches in university-based clinical training programs, funding agencies, and government-supported clinical guidelines. CONCLUSION: Finally, specific recommendations are provided to further enhance and expand the impact of HP research for clinical training programs and the development of treatment guidelines.

The role of empathy in promoting change.

Since Rogers identified empathy as an important variable in therapy, it has been found to be a consistent predictor of client change; less clear is how this occurs. The objective in this study was to test a mediation model to determine whether clients' self-reported experience of therapists' empathy contributed to changes in their attachment styles and treatment of self, after 16 weeks of psychotherapy for depression. There was a significant direct relationship between therapists' empathy and outcome and a significant indirect effect, showing that clients' perceptions of therapists' empathy was associated with significant improvement in attachment insecurity and significant decreases in negative self-treatment at the end of therapy as well as reductions on BDI, IIP, DAS and SCL-90-R, GSI, and increases on RSE. The findings suggest that clients' perception of their therapists as empathic is an important mechanism of change in psychotherapy that warrants further investigation.

Treatment failure in humanistic and experiential psychotherapy.

In this article, treatment failure in humanistic experiential psychotherapy is defined and explored. I outline several markers that indicate when treatment is not going well. Factors that contribute to failure include client factors, for example, emotional processing capacities, shame, and impoverished narratives, as well as therapist factors including lack of empathic attunement and inflexibility. Treatment failure is illuminated with a case example drawn from humanistic/experiential psychotherapy, and clinical strategies for dealing with failures are recommended.

Empathy.

After defining empathy, discussing its measurement, and offering an example of empathy in practice, we present the results of an updated meta-analysis of the relation between empathy and psychotherapy outcome. Results indicated that empathy is a moderately strong predictor of therapy outcome: mean weighted r = .31 (p < .001; 95% confidence interval: .28-.34), for 59 independent samples and 3599 clients. Although the empathy-outcome relation held equally for different theoretical orientations, there was considerable nonrandom variability. Client and observer perceptions of therapist empathy predicted outcomes better than therapist perceptions of empathic accuracy measures, and the relation was strongest for less experienced therapists. We conclude with practice recommendations, including endorsing the different forms that empathy may take in therapy.

Intraclass correlation associated with therapists: estimates and applications in planning psychotherapy research.

It is essential that outcome research permit clear conclusions to be drawn about the efficacy of interventions. The common practice of nesting therapists within conditions can pose important methodological challenges that affect interpretation, particularly if the study is not powered to account for the nested design. An obstacle to the optimal design of these studies is the lack of data about the intraclass correlation coefficient (ICC), which measures the statistical dependencies introduced by nesting. To begin the development of a public database of ICC estimates, the authors investigated ICCs for a variety outcomes reported in 20 psychotherapy outcome studies. The magnitude of the 495 ICC estimates varied widely across measures and studies. The authors provide recommendations regarding how to select and aggregate ICC estimates for power calculations and show how researchers can use ICC estimates to choose the number of patients and therapists that will optimize power. Attention to these recommendations will strengthen the validity of inferences drawn from psychotherapy studies that nest therapists within conditions.

An examination of the relationships among clients' affect regulation, in-session emotional processing, the working alliance, and outcome.

The objectives were to examine the relationships among clients' affect regulation capacities, in-session emotional processing, outcome, and the working alliance in 66 clients who received either cognitive-behavioral therapy or process-experiential emotion-focused therapy for depression. Clients' initial level of affect regulation predicted their level of emotional processing during early and working phases of therapy. Clients' peak emotional processing in the working phase of therapy mediated the relationship between their initial level of affect regulation and their level of affect regulation at the end of therapy; and clients' level of affect regulation at the end of therapy mediated the relationship between their peak level of emotional processing in the working phase of therapy and outcome. Clients' affect regulation at the end of therapy predicted outcome independently of the working alliance. The findings suggest that clients' level of affect regulation early in therapy has a significant impact on the quality of their in-session processing and outcome in short-term therapy. Limitations of the study and future directions for research are discussed.

Nurses' educational needs for pain management of post-cardiac surgery patients: a qualitative study.

BACKGROUND AND RESEARCH OBJECTIVE: Inadequate knowledge among health care providers is a key barrier to good pain management, and nurses have a major role to provide education to patients. The purpose of this study was to identify nurses' learning needs to prepare patients for managing pain before and after discharge home from cardiac surgery. The overall aim is to develop a pain education intervention for nurses working with cardiac surgical patients. SUBJECT AND METHODS: This was a focus groups study. Participants (N=22) were asked about their perceptions of patients' education needs for pain management after cardiac surgery and approaches to help nurses meet these needs. The Pain Beliefs Scale was used to capture nurses' own misbeliefs about pain that would need clarification in a successful pain education intervention. RESULTS: Nurses identified pain management challenges in the hospital, particularly related to patients' age, patient concerns about the use of opioids, the need to use multiple management strategies, and preparing patients to manage pain at home. Pain Beliefs Scale scores were low related to opioid dosing and adverse effects. Participants identified their most helpful educational approaches being brief in-services, hands-on learning, lunch-and-learn sessions, and designated education days. CONCLUSION: Participants identified the most common pain knowledge gaps for patients before and after discharge after cardiac surgery. These data will be used to develop an education intervention for nurses to help their cardiac surgery patients with more effective pain management strategies before and after discharge home.

Therapist and client perceptions of therapeutic presence: the development of a measure.

The authors developed two versions of a therapeutic presence measure, based on an earlier model of presence (Geller & Greenberg, 2002)-Therapeutic Presence Inventory-therapist (TPI-T) and client (TPI-C) versions-to measure in-session therapeutic presence. They explored their reliability and validity in two studies. In the first, items generated from the previously established model were subjected to analyses and expert ratings. In the second study, therapists and clients rated therapists' presence postsession. Therapists also completed the Relationship Inventory, and clients assessed two additional factors: session outcome, using the Client Task Specific Measure-Revised, and therapeutic alliance, using the Working Alliance Inventory. Findings revealed that both versions of the TPI had good reliability and construct validity. However, TPI-T had low predictive validity and the TPI-C showed good predictive validity. In particular, clients reported positive therapeutic alliance and change following sessions when they felt their therapist was present with them.

Using audience response technology in hospital education programs.

An audience response system (ARS) is an interactive teaching tool that permits an instructor to poll an audience, either anonymously or in a tracked manner, in response to questions. The instructor can then display the responses to the audience. An ARS can be used in hospital-based education programs to assess group learning. The instructor receives immediate feedback that allows review of concepts that were not grasped by the majority of students. This article reviews systems currently on the market and offers tips for choosing an ARS for hospital-based use. Survey data of nurses attending in-service education sessions show that participants overwhelmingly favor the use of an ARS and the nonthreatening learning environment that these systems create. Instructor survey data show positive responses regarding the benefits of ARS use in hospital-based education programs.

An examination of clients' in-session changes and their relationship to the working alliance and outcome.

The objective of the current study was to investigate the psychometric properties of the Client Task Specific Change Measure-Revised (CTSC-R), a measure of clients' in-session changes, and to determine whether the CTSC-R predicted outcome over and above the therapeutic alliance in a study of 66 clients treated with process-experiential psychotherapy or cognitive-behavioural therapy for depression. The measure showed high internal consistency and item-total correlations. Principal-axis factoring, followed by oblique rotation, showed that the measure comprised two factors: (a) behaviour change and (b) awareness and understanding. Clients' CTSC-R scores changed over the course of psychotherapy and predicted change in depression at the end of therapy over and above the therapeutic alliance, explaining an additional 13% of the variance in outcome on the Beck Depression Inventory. Limitations of the study and future directions for research are discussed.

An adjudicated hermeneutic single-case efficacy design study of experiential therapy for panic/phobia.

This article illustrates the application of an adjudicated form of hermeneutic single-case efficacy design, a critical-reflective method for inferring change and therapeutic influence in single therapy cases. The client was a 61-year-old European-American male diagnosed with panic and bridge phobia. He was seen for 23 sessions of individual process-experiential/emotion-focused therapy. In this study, affirmative and skeptic teams of researchers developed opposing arguments regarding whether the client changed over therapy and whether therapy was responsible for these changes. Three judges representing different theoretical orientations then assessed data and arguments, rendering judgments in favor of the affirmative side. The authors discuss clinical implications and recommendations for future interpretive case study research.