Observing and interpreting clinical process: Methods and findings from 'Layered analysis' of parent-infant psychotherapy.

This paper describes a method for investigating clinical process, Layered Analysis, which combines therapist countertransference reports and multi-faceted microanalytic research approaches. Findings from the application of Layered Analysis to video-recorded micro-events of rupture and repair in four psychoanalytic parent-infant psychotherapy sessions are presented. Layered analysis showed that countertransference and observation are complementary perspectives, which enable concomitant study of interactive events, conscious internal experiences, as well as nonconscious and unconscious elements of therapeutic interaction. Interactional rupture and repair were found to constitute co-constructed micro-events that occurred fleetingly and often implicitly, and differed in the structure, coherence and flow of interactions and in the relationship between verbal and nonverbal communication. Furthermore, interactional ruptures were found to sometimes 'get into' the therapist and transiently disrupt their self-organization, such that the therapist became a locus of disruption for the patient(s), actively contributing to the rupture, which thus became embedded in the therapeutic system. Interactive repair was found to be most often initiated by the therapist and to be underpinned by the therapist re-establishing self-regulation, through metabolizing embodied and verbal aspects of the rupture. Studying such processes can enhance our understanding of clinical process, inform therapist training and clinical supervision, and contribute to clinical outcomes.

Este ensayo describe un método para investigar un proceso clínico, Análisis en Capas, el cual combina los reportes de contratransferencia del terapeuta y los acercamientos investigativos micro analíticos multifacéticos. Se presentan los resultados de aplicar Análisis en Capas a micro eventos, grabados en video, de ruptura y reparación en cuatro sesiones de sicoterapia sicoanalítica de progenitor e infante. Los Análisis en capas mostraron que la contratransferencia y la observación son perspectivas complementarias que, en combinación, permiten el estudio concomitante de eventos interactivos, experiencias internas conscientes, así como elementos no conscientes de la interacción terapéutica. Adicionalmente, los resultados mostraron que la ruptura y la reparación constituyen micro eventos co-construidos que ocurren muy fugazmente y a menudo implícitamente, y que difieren en la estructura, coherencia, flujo de interacciones y en la relación entre la comunicación verbal y no verbal. Es más, rupturas interaccionales pueden 'meterse en' el terapeuta y transitoriamente interrumpir su autoorganización, de manera que el terapeuta se convierte en un punto de interrupción para el paciente y la ruptura pasa a ser parte del sistema terapéutico. La reparación interactiva está sostenida por, y depende de, la metabolización del terapeuta de los aspectos incorporados y verbales de la ruptura. Estudiar tales procesos puede mejorar nuestra comprensión del proceso clínico y ser usado en entrenamiento y supervisión de terapeutas.

Cet article décrit une méthode d'investigation du processus clinique d'Analyse Multidimensionnelle en Couches, qui combine des rapports de contre-transfert du thérapeute et des approches de recherche micro-analytique à facettes multiples. Les résultats de l'application de l'analyse multidimensionnelle en couches à des micro-événements enregistrés à la vidéo de rupture et de réparation dans quatre séances de psychothérapie psychanalytiques parent bébé sont présentés. L'analyse multidimensionnelle en couches a montré que le contre-transfert et l'observation sont des perspectives complémentaires qui, combinés l'un avec l'autre, permettent une étude concomitante d'événements interactifs, d'expériences internes conscientes et d'éléments non-conscients de l'interaction thérapeutique. De plus, les résultats ont montré que la rupture et la réparation constituent des micro-événements co-construits, qui se passent très fugacement et souvent implicitement et diffèrent en structure, cohérence et flux des interactions et dans la relation entre la communication verbale et non verbale. Enfin les ruptures interactionnelles peuvent 'entrer' dans le thérapeute et perturber de façon transitoire leur auto-organisation, de telle manière que le thérapeute devient le locus de la perturbation pour le/la/les patient(e/s) et la rupture s'encastre dans le système thérapeutique. La réparation interactive est étayée par, et elle en dépend également, la métabolisation d'aspects verbaux et incarnés de la rupture du thérapeute. L'étude de tels processus peut améliorer notre compréhension du processus clinique et être utilisée dans la formation et la supervision des thérapeutes.

The interplay between therapeutic relationship and therapeutic technique: The whole is more than the sum of its parts.

The interplay between the therapeutic relationship and experiential techniques is powerful. The whole is more than the sum of its parts. Therapeutic relationship predicts therapy outcomes, especially when this involves shared goals, agreed methods, and a strong interpersonal bond. When patients feel safely held in a therapeutic relationship, they feel more confident and willing to participate in experiential techniques. Conversely, the therapist's careful, purposeful implementation of techniques can help strengthen the therapeutic relationship. While the interplay between relationship and technique can be complicated, resulting in rupture, carefully repairing ruptures can both strengthen the relationship and increase willingness to engage with techniques. We comment on five case studies from this issue of the Journal of Clinical Psychology: In Session. We review the literature regarding this interplay between relationship and technique, summarize the case studies and lessons learned, consolidate the findings into a framework, and propose avenues for future therapy consideration and research.

Building the alliance and using experiential techniques in the early phases of psychotherapy for avoidant personality disorder.

Individuals experiencing avoidant personality disorder (AvPD) tend to make sense of social interactions via maladaptive self-and other attributions. They also experience difficulties in recognizing emotions. A further feature of AvPD psychopathology is the tendency to resort to maladaptive coping strategies, such as behavioral avoidance and perfectionism. Despite its impact, psychological treatments for AvPD remains poorly investigated. Herein, we describe the first five sessions of Metacognitive Interpersonal Therapy with a 28-year-old woman, whose treatment goal was to reduce social avoidance. We describe how this goal was achieved through a combination of working through the therapeutic relationship, alongside experiential techniques such as guided imagery, rescripting, and bodily work. Through this treatment configuration, the patient was able to increase self-awareness of her own emotions, enabling her to realize that she was guided by rigid schemas; specifically seeing herself as inadequate and others as judgmental. Finally, implications for the treatment of AvPD are discussed.

Alliance rupture and repair in early sessions of dialectical behavior therapy: The case of Rachel.

Emotional and interpersonal instability are core features of borderline personality disorder (BPD) and can pose a challenge for the therapeutic relationship. In dialectical behavior therapy (DBT) for BPD, ruptures in the therapeutic alliance are considered through a behavioral lens that examines the client's relational learning history, the function and context of the rupture, as well as the patterns of emotional processing difficulties that underlie interpersonal conflict. In this article, we use the case of Rachel to illustrate how alliance-focused approach can be integrated with DBT case formulation to enhance treatment planning and the successful negotiation of alliance ruptures.

The adenoviral protein E4orf4: a probing tool to decipher mechanical stress-induced nuclear envelope remodeling in tumor cells.

The human adenovirus (Ad) type 2/5 early region 4 (E4) ORF4 protein (E4orf4) exerts a remarkable tumor cell-selective killing activity in mammalian cells. This indicates that E4orf4 can target tumor cell-defining features and is a unique tool to probe cancer cell vulnerabilities. Recently, we found that E4orf4, through an interaction with the polarity protein PAR3, subverts nuclear envelope (NE) remodeling processes in a tumor cell-selective manner. In this Perspective, we outline mechanical signals that modify nuclear dynamics and tumor cell behavior to highlight potential mechanisms for E4orf4's tumoricidal activity. Through an analysis of E4orf4's cellular targets, we define a protein subnetwork that comprises phosphatase systems interconnected to polarity protein hubs, which could contribute to enhanced NE plasticity. We infer that elucidating E4orf4's protein network at a functional level could uncover key mechanisms of NE remodeling that define the tumor cell phenotype.

Ruptures and repairs of group therapy alliance. An untold story in psychotherapy research.

Although previous studies investigated the characteristics of therapeutic alliance in group treatments, there is still a dearth of research on group alliance ruptures and repairs. The model by Safran and Muran was originally developed to address therapeutic alliance in individual therapies, and the usefulness of this approach to group intervention needs to be demonstrated. Alliance ruptures are possible at member to therapist, member to member, member to group levels. Moreover, repairs of ruptures in group are quite complex, i.e., because other group members have to process the rupture even if not directly involved. The aim of the current study is to review the empirical research on group alliance, and to examine whether the rupture repair model can be a suitable framework for clinical understanding and research of the complexity of therapeutic alliance in group treatments. We provide clinical vignettes and commentary to illustrate theoretical and research aspects of therapeutic alliance rupture and repair in groups. Our colleague Jeremy Safran made a substantial contribution to research on therapeutic alliance, and the current paper illustrates the enduring legacy of this work and its potential application to the group therapy context.

Therapists' recognition of alliance ruptures as a moderator of change in alliance and symptoms.

Therapists' awareness of ruptures in the alliance may determine whether such ruptures will prove beneficial or obstructive to the therapy process. OBJECTIVE: This study investigated the associations between therapists' recognition of these ruptures, and changes in clients' alliance ratings and symptom reports, using time-series data in a naturalistic treatment setting. METHOD: Eighty-four clients treated by 56 therapists completed alliance measures after each session, and the clients also completed symptom measures at the beginning of each session. RESULTS: Therapists' recognition of alliance rupture in non-rupture sessions was positively associated with clients' alliance ratings in the next session and this effect was significantly higher when rupture did occur. There was also a significant interaction effect for functioning ratings: Therapists' recognition of alliance ruptures abolished the negative effect of ruptures on clients' symptom ratings in the following session. CONCLUSION: These results highlight the importance of therapists' recognition of deterioration in the alliance for a repair process to take place that may eventually lead to an improved relationship and outcome.

Alliance rupture and repair processes and therapeutic change in youth with borderline personality disorder.

OBJECTIVES: This study aimed to investigate alliance rupture and repair processes in psychotherapy for youth with borderline personality disorder. It sought to examine whether alliance processes differ between treatments, across the phases of therapy, and what associations these processes might have with therapeutic outcomes. DESIGN: The study involves repeated measurement of both process and outcome measures. Hypotheses were addressed using within- and between-subjects analyses. METHODS: Forty-four people, aged 15-24, with a diagnosis of BPD were randomized to receive either 16 sessions of Cognitive Analytic Therapy (CAT) or a supportive treatment known as Befriending. In addition to pre-post outcome assessments, alliance processes were rated using the observer-based Rupture Resolution Rating Scale. RESULTS: Results indicated that CAT and Befriending did not differ in terms of number of ruptures, although CAT was associated with more stages of rupture resolution. Examination of alliance processes across time pointed to increasing ruptures, more frequent confrontation ruptures and increasing rupture resolution, suggesting increased volatility, directness and productivity in the therapeutic process across time. Contrary to hypotheses, there was no consistent link between alliance processes and outcome. However, two specific phases were significant. Early treatment ruptures were associated with poor outcome whereas greater late treatment resolution was associated with better outcomes. CONCLUSIONS: This study suggests that alliance processes can differ across treatments and the phases of therapy in psychotherapy for youth with BPD. Alliance ruptures are more likely to be problematic early in therapy but later in therapy, they appear to be opportunities for therapeutic growth. PRACTITIONER POINTS: Alliance ruptures are more likely than not to occur in any given session with a young person with Borderline Personality Disorder. Early in therapy, withdrawal type ruptures are more frequent, whereas late in therapy, confrontation ruptures are more frequent. Late in therapy, alliance ruptures should be viewed as opportunities for therapeutic change, rather than barriers to good outcomes.

The working alliance: Where have we been, where are we going?

OBJECTIVE: This paper reviews the construct of the working alliance, beginning with its historical development and moving into its modern pantheoretical conceptualization. METHOD: Major research efforts on the topic are reviewed. The review includes both theoretical and empirical literature on the working alliance and related constructs, such as alliance ruptures and repair, and therapeutic negotiation. Existing measures of the working alliance are also reviewed. RESULTS: The working alliance is critiqued on both theoretical and empirical grounds, including the strengths and limitations of current approaches and assessments. Recent theoretical developments are reviewed, among them work on alliance rupture and repair and the reconceptualization of the alliance as a process of therapeutic negotiation. Emerging applications of advanced statistical techniques to measure the working alliance are also considered. CONCLUSION: The review concludes by supporting recent efforts that have attempted to increase the sophistication of measurement tools and statistical approaches, and encouraging future research in these areas.

Enhancement of Achilles tendon repair mediated by matrix metalloproteinase inhibition via systemic administration of doxycycline.

Collagenases or matrix metalloproteinases (MMPs) have been shown to play an important role in the matrix degradation cascade associated with Achilles tendon rupture and disease. The goal of this study was to examine the effects of daily administration of doxycycline (Doxy) through oral gavage on MMP activity and on the repair quality of Achilles tendons in vivo. Our findings indicate that Achilles tendon transection resulted in increasing MMP-8 activity from 2 to 6 weeks post-injury, with peak increases in activity occurring at 4 weeks post-injury. Doxy adiministration at clinically relevant serum concentrations was found to significantly inhibit MMP activity after continuous treatment for 4 weeks, but not for continuous administration for shorter durations (96 h or 2 weeks). Extended doxy administration was also associated with improved collagen fibril organization, and enhanced biomechanical properties (stiffness, ultimate tensile strength, maximum load to failure, and elastic toughness). Our findings indicate that a temporal delay exists between Achilles tendon transection and associated increases in MMP-8 activity in situ. Our findings suggest that inhibition of MMP-8 at its peak activity levels ameliorates fibrosis development and improves biomechanical properties of the Achilles tendon.

Cantata a cinco voces: una experiencia de supervisión relacional / Cantata for five voices: an experience in relational supervision

El trabajo está dividido en tres partes. La primera hace un breve recorrido histórico de la supervisión. La segunda parte relata la experiencia personal de supervisión de 4 profesionales y su supervisora abordando algunas diferencias con su aprendizaje previo basado en un modelo neo-kleiniano. Las vivencias personales recorren las expectativas, dudas y angustias producidas por cada modelo y dan vida a través del relato a conceptos centrales del modelo relacional tales como: la emergencia de significado, la co-construcción, momentos de ruptura y reparación, el enactment y la develación además de la importancia del timing y el sostén por parte de la supervisora cuando existe un impasse en la díada de la supervisión. En la tercera parte se describe una situación de impasse entre la supervisora y una de las profesionales. Como sucede en la terapia analítica, dicho impasse ha sido transmitido por vías no verbales y ha involucrado a ambas, supervisora y supervisada. Vemos que en la resolución de dicho impasse, ha sido necesario tener cuidado de mantener el sostén necesario hasta el momento adecuado para poder abordarlo. Se finaliza con algunos comentarios que insertan la experiencia en un contexto de cambio social.

The experience of supervising and being supervised in a relational model setting is described by four psychologists and their supervisor, and compared to their previous training based on a neo-kleinian model. Their journey covers the expectations, doubts and anxieties produced in each period of their learning process and gives life to key concepts in the relational model such as: co-construction of meaning, rupture and repair, enactment and disclosure, as well as the importance of timing and holding during moments of impasse. The paper is divided into three parts. The first is a brief history of supervision. The second describes the experience of the supervisees and the supervisor past and present. The third analyzes a year long impasse involving one of the supervisees and the supervisor, in which timing and holding have been necessary until a better moment is found to disclose verbally what has been experienced in the body and through non verbal means. Concluding comments insert the experience of this supervision in a context of social change.