Dana Atzil-Slonim

Emotional experience and alliance contribute to therapeutic change in psychodynamic therapy.

Accumulating evidence suggests that the therapeutic alliance and clients contact with emotions during therapy sessions can be effective in reducing their suffering outside of sessions. However, the complex associations among these determinants are not yet clear. Using data collected in therapy on a session-by-session basis, this study explored (a) the temporal associations between emotional experience and the therapeutic alliance; (b) the temporal associations between emotional experience and clients level of functioning; and (c) the direct and indirect associations among emotional experience, the therapeutic alliance, and functioning. Clients (N = 101) undergoing psychodynamic therapy completed a functioning and distress measure prior to each session, and reported on their emotional experience and perceived alliance strength following each session. Longitudinal multilevel models indicated that higher therapeutic alliance scores at the end of 1 session predicted a greater emotional experience in the next session but that emotional experience did not predict subsequent levels of alliance. The results provided evidence of reciprocal prediction in which a previous emotional experience predicted a subsequent change in functioning and vice versa. Finally, the alliance predicted emotional experience, which, in turn, predicted functioning; hence, alliance strength indirectly predicted clients level of functioning. Findings indicate that emotional experience and the therapeutic alliance are important determinants of the therapeutic process, which contribute to predict clients improvement in functioning within psychodynamic treatment.

Therapeutic bond judgments: Congruence and incongruence

OBJECTIVEnThe present study had 2 aims: (a) to implement West and Kennys (2011) Truth-and-Bias model to simultaneously assess the temporal congruence and directional discrepancy between clients and therapists ratings of the bond facet of the therapeutic alliance, as they cofluctuate from session to session; and (b) to examine whether symptom severity and a personality disorder (PD) diagnosis moderate congruence and/or discrepancy.nnnMETHODnParticipants included 213 clients treated by 49 therapists. At pretreatment, clients were assessed for a PD diagnosis and completed symptom measures. Symptom severity was also assessed at the beginning of each session, using client self-reports. Both clients and therapists rated the therapeutic bond at the end of each session.nnnRESULTSnTherapists and clients exhibited substantial temporal congruence in their session-by-session bond ratings, but therapists ratings tended to be lower than their clients across sessions. Additionally, therapeutic dyads whose session-by-session ratings were more congruent also tended to have a larger directional discrepancy (clients ratings being higher). Pretreatment symptom severity and PD diagnosis did not moderate either temporal congruence or discrepancy at the dyad level; however, during sessions when clients were more symptomatic, therapist and client ratings were both farther apart and tracked each other less closely.nnnCONCLUSIONSnOur findings are consistent with a better safe than sorry pattern, which suggests that therapists are motivated to take a vigilant approach that may lead both to underestimation and to attunement to fluctuations in the therapeutic bond.

Internal Representations of the Therapeutic Relationship Among Adolescents in Psychodynamic Psychotherapy.

UNLABELLEDnThis study examined changes in adolescents internal representations of their relationship with their therapist and the extent to which these changes were related to changes in their representations of their relationship with their parents and to treatment outcomes.nnnMETHODnThirty adolescents (aged 15-18u2009years, 70% women) undergoing psychodynamic psychotherapy participated in relationship anecdote paradigms interviews based on the core conflictual relationship theme method and completed outcome measures at the beginning of treatment and a year later.nnnRESULTSnAdolescents positive representations of their therapists increased throughout the year of treatment, whereas their negative representations did not change. There was an association between the development of the therapeutic relationship and improvement in the perception of the relationship with parents over the course of therapy. Increases in the level of positive representations and decreases in the level of negative representations of the therapist were associated with greater satisfaction with treatment but not with the other outcome measures. These results support the centrality of the therapeutic relationship in the process of change during adolescents psychodynamic psychotherapy.nnnKEY PRACTITIONER MESSAGEnThe finding that positive representations of the therapist increased throughout treatment but that negative representations remained steady suggests that therapists who treat adolescents should expect and be able to hear adolescent clients positive and negative internal representations of themselves. Therapists need to realize that although adolescents often experience negative emotions and perceptions in therapy as in other significant relationships, this does not necessarily block the development of positive emotions. The finding that changes in the representations of the therapist are associated with changes in the representations of parents is in line with psychodynamic theory, which posits that psychotherapy facilitates new interpersonal experiences and new insights through the exploration of the therapeutic relationship. Working in the here and now may eventually impact the nature of other significant relationships, particularly with parents in the case of adolescents.

Relationship representations and change in adolescents and emerging adults during psychodynamic psychotherapy

Abstract Objective: Two groups of clients at sequential developmental stages, adolescents and emerging adults, were compared regarding their presenting problems, psychological distress, and relationship representations over one year of psychotherapy. Method: Thirty adolescents aged 14–18 years and 30 emerging adults aged 22–28 years, with similar demographic background, completed outcome measures and interviews according to the Core Conflictual Relationship Theme (CCRT) method. Results: The groups differed significantly in the presenting problems but did not differ in their initial levels of distress; their symptoms improved to a similar extent after one year of psychotherapy; differences between the groups in the representations of others were consistent with age-specific developmental challenges; levels of representations were associated with levels of symptoms at the end-point of treatment. Conclusion: Clinicians need to be attuned to the specific difficulties and challenges of these continuous yet distinct developmental stages.

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

Abstract 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.

Emotional congruence between clients and therapists and its effect on treatment outcome.

The present study aimed to (a) explore 2 indices of emotional congruence—temporal similarity and directional discrepancy—between clients’ and therapists’ ratings of their emotions as they cofluctuate session-by-session; and (b) examine whether client/therapist emotional congruence predicts clients’ symptom relief and improved functioning. The sample comprised 109 clients treated by 62 therapists in a university setting. Clients and therapists self-reported their negative (NE) and positive emotions (PE) after each session. Symptom severity and functioning level were assessed at the beginning of each session using the clients’ self-reports. To assess emotional congruence, an adaptation of West and Kenny’s (2011) Truth and Bias model was applied. To examine the consequences of emotional congruence, polynomial regression, and response surface analyses were conducted (Edwards & Parry, 1993). Clients and therapists were temporally similar in both PE and NE. Therapists experienced less intense PE on average, but did not experience more or less intense NE than their clients. Those therapists who experienced more intense NE than their clients were more temporally similar in their emotions to their clients. Therapist/client incongruence in both PE and NE predicted poorer next-session symptomatology; incongruence in PE was also associated with lower client next-session functioning. Session-level symptoms were better when therapists experienced more intense emotions (both PE and NE) than their clients. The findings highlight the importance of recognizing the dynamic nature of emotions in client-therapist interactions and the contribution of session-by-session emotional dynamics to outcomes.

Congruence of Therapeutic Bond Perceptions and Its Relation to Treatment Outcome: Within- and Between-Dyad Effects.

Objective: The present study investigates the association between congruence of patients’ and therapists’ perceptions of the therapeutic bond and symptom improvement. Method: Bond congruence-outcome associations were examined on the within- and between-dyad level for 580 patients (mainly depression and anxiety) receiving cognitive–behavioral therapy. Symptom change was assessed on a session-to-session level as well as from pre- to posttreatment. For the between-dyad analyses, the truth and bias model was applied. For the within-dyad analyses, polynomial regression and response surface analysis were conducted. Results: On the between-dyad level, higher temporal congruence between patients’ and therapists’ bond ratings (i.e., their correlation) was associated with better treatment outcomes. Additionally, the average discrepancy between therapists’ and patients’ bond ratings showed a significant quadratic association with treatment outcome. A tendency for therapists to moderately rate the bond lower than their patients’ showed lowest posttreatment symptom scores. On the within-dyad level, we found that when patients’ and therapists’ ratings were in “agreement,” higher bond scores were associated with fewer next-session symptoms. For “disagreement,” the results showed that if therapists rated the bond as weak, whereas their patients rated it as strong, higher subsequent symptom distress was observed than if patients rated the bond as weak and their therapists rated it as strong. Conclusions: The present study highlights the importance of therapists being vigilant to session-to-session changes in the therapeutic bond to adjust their interventions accordingly.

The MATRIX, a novel tool exploring dynamic psychotherapy: Preliminary psychometric properties

Most measures in the field of psychodynamic psychotherapy are bound to a specific theory, and usually focus only on patient processes or therapist interventions. The MATRIX is a newly developed research tool that focuses on events within both the patient and the therapist individually, as well as on dyadic events, and provides the simple and meaningful coding of content for therapy session transcripts in psychotherapy. The present study describes the inter-rater reliability and construct validity of the MATRIX. Reliability of the MATRIX was assessed by applying it to 805 fragments of psychodynamic-oriented psychotherapy sessions. Three independent experts coded fragments, and the tool was examined for reliability. Validity in identifying the theoretical inclinations was assessed by applying the MATRIX to 30 segments (containing 1309 fragments) of sessions that reflect different theoretical orientations. Findings evinced high inter-rater reliability for all dimensions. The MATRIX was found to have high degree of validity for differentiating the theoretical inclinations of segments of sessions. The MATRIX is a reliable and valid measure that may enable moment-to-moment, quantitative, analysis of psychodynamic psychotherapy.

The association between patient–therapist MATRIX congruence and treatment outcome

Abstract Objective: The present study aimed to examine the association between patient–therapist micro-level congruence/incongruence ratio and psychotherapeutic outcome. Method: Nine good- and nine poor-outcome psychodynamic treatments (segregated by comparing pre- and post-treatment BDI-II) were analyzed (Nu2009=u200918) moment by moment using the MATRIX (total number of MATRIX codes analyzedu2009=u200911,125). MATRIX congruence was defined as similar adjacent MATRIX codes. Results: the congruence/incongruence ratio tended to increase as the treatment progressed only in good-outcome treatments. Conclusion: Progression of MATRIX codes’ congruence/incongruence ratio is associated with good outcome of psychotherapy.

Moderators of congruent alliance between therapists and clients: A realistic accuracy model.

Congruence between therapists’ and their clients’ alliance ratings was found to be beneficial to therapeutic processes and outcomes. To date, however, less is known about the possible moderators of such congruence. The current study adapted Funder’s (1995) realistic accuracy model to identify a judge characteristic (therapists’ affiliative tendencies), a target characteristic (clients’ affiliative tendencies), information (time elapsed in therapy), and traits (bond vs. task/goal aspects of the alliance) that may moderate this congruence. These were examined using the innovative truth-and-bias model (West & Kenny, 2011), which allows the simultaneous estimation of two different congruence indices within repeatedly measured data: therapist/client temporal congruence (i.e., the correlation over time between therapists’ and their clients’ alliance ratings) and directional discrepancy (i.e., the average difference between therapists’ and their clients’ alliance ratings across sessions). Clients (n = 109) and therapists (n = 62) at a university-based clinic rated their affiliation tendencies at the beginning of treatment and rated their alliance perception after each session. Time elapsed in therapy, as well as therapists’ (but not clients’) affiliative tendencies were linked to higher therapist/client temporal congruence and to lower therapist directional discrepancy. In addition, congruence was higher for the bond aspect of the therapeutic alliance than for goals/tasks. Consistent with Funder’s model, multiple factors (including judge, information, and trait) were associated with therapist/client congruence in alliance.