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A model of Psychopathology.
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Objective:
Although the effectiveness of psychotherapy is well documented, little progress has been made in elucidating mechanisms of change. Major impediments to progress are the homogeneity assumptions evident in many psychotherapy studies. Case-specific research strategies avoid treating patients, therapists, and treatments as homogeneous varia...
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... unconscious belief led to psychopathology later in her life including depression, disturbed relationships, and substance abuse. A graphic representation of the control- mastery model of psychopathology is shown in Figure 1. Pathogenic beliefs are internalized cognitive-affec- tive representations of traumatic experiences. ...
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... indicating the therapist's interest in her). Research has shown that when a therapist's response "passes" the patient's test, indicators of therapeutic progress can be observed both immediately following the testing sequence and at post-treatment (Fimiani et al., 2023;Gazzillo et al., 2024;Silberschatz, 2017;Silberschatz & Curtis, 1993). Thus, by testing pathogenic beliefs, the patient's search for corrective experiences -even when operating at an unconscious level -may have a great bearing on how their therapy will turn out. ...
... This approach does not privilege any technique (e.g., interpretation and confrontation), recognizing that pathogenic beliefs can be expressed and responded to in a variety of ways-so long as the therapist's attitude and interventions are basically in accord with the patient's goals for therapy and accurately address the conflicts that inhibit or prevent the patient from pursuing those goals. Research has indicated that patients show immediate and posttreatment improvement when therapists intervene in ways that are compatible with the patient's formulated plan (Fimiani et al., 2023;Gazzillo et al., 2024;Silberschatz, 2017;Silberschatz & Curtis, 1993). Thus, an accurate case formulation, accounting for both the patient's problems and in-session interactions, can contribute to therapeutic progress and potentially avert negative outcomes (Gazzillo et al., 2021). ...
Understanding treatment failures is important for improving therapist responsiveness and mitigating negative outcomes in psychotherapy. One factor that may increase the risk for treatment failure is the therapist’s determination to adhere to a particular treatment model. While therapist adherence has mostly been discussed in reference to manualized treatments, the concept can also be applied to therapies guided by case formulations, in that the formulation can serve as an individualized model of therapy for a given patient. Adherence to an accurate formulation has been shown to have a positive impact on the process and outcome of a therapy. However, failure to test and reevaluate a formulation across the course of a therapy—in light of a patient’s emerging needs and concerns—can result in a failed treatment. Clinical material is presented from a failed 16-session psychotherapy to illustrate the negative effects of a therapist’s rigid formulation adherence, despite communications from the patient signaling potential modifications to the case formulation. By remaining open to new information and reevaluating the case formulation throughout the course of treatment, therapists may improve their responsiveness and decrease the likelihood of negative outcomes in psychotherapy.
... Research into the processes that contribute to psychotherapeutic outcomes has a long history (Timulak & Keogh, 2017), producing a wealth of information that has helped broaden access to funding (Levitt et al., 2016) and inform new and more effective interventions (Elliott & James, 1989) while also highlighting poor training, practice standards, and negative outcomes (Bowie et al., 2016). While it is generally accepted that psychotherapy works (Silberschatz, 2017;Cuijpers et al., 2019), the mechanisms by which it does, and the orientations that may deliver results, are still widely debated (Cooper, 2008;Tzur Bitan & Lazar, 2019). One such debate is between common factors (CF), elements of therapy shared by many modalities), and "empirically supported therapies" (EST) (Roth, 2005, p. 50), which emphasize more orientation-specific techniques (Mulder et al., 2017;Tzur Bitan & Lazar, 2019) aimed at the remediation of any given mental disorder (Laska et al., 2014). ...
Background: While current Somatic Experiencing studies have produced impressive outcomes and
biological rationales for treatment, there is a lack of client-centered research attending to the lived
experience of those attending the therapy. Learning from clients about their therapeutic experience
can illuminate a multitude of factors that help and hinder therapeutic outcomes in order to conceive
of or reform interventions, advance our understanding of therapeutic change, and gain insight into
clients’ hidden processes. These might include unexpressed fear, dissatisfaction, and avoidance, as
well as what they most value about the therapy.
Method: Participants were interviewed using a semi-structured schedule. Interpretive phenomenological analysis (IPA) was used to process the data. The sample size was necessarily small to align with
IPA guidelines.
Findings: Two superordinate themes were abstracted: communication and pacing. Subordinate
themes: Intake assessment, expectation, and psychoeducation are situated under the superordinate
theme of communication.
Conclusion: Hidden processes illuminated in qualitative research of this kind can greatly benefit Somatic Experiencing Practitioners (SEPs) in better understanding how their therapeutic approach is
experienced by their clients.
... Moreover, stationarity requires a constant variance, so any change in variance indicates nonstationarity. Processes are not only often trending, their variances also change over time as shown and discussed, for example, in psychotherapy research (e.g., Heinzel et al., 2014;Schiepek et al., 2020;Silberschatz, 2017). The resulting time series may show increasing or decreasing variance. ...
... A visual comparison suggests that the time series reflect somewhat different psychological processes. This observation aligns with the view that individuals are not homogeneous (Silberschatz, 2017). While some processes appear stationary, others seem to exhibit nonstationary. ...
... Assuming a similar proportion of this type of nonstationarity (i.e., 30%) exists in the full sample, this finding suggests not only that the model may have been misspecified, potentially threatening validity, but also that an opportunity to further explore individual differences in nonstationarity was missed. Heterogeneity across individuals is the rule rather than the exception (Bryan, Tipton, & Yeager, 2021;Silberschatz, 2017; see also Zitzmann et al., 2023), and investigating this heterogeneity could offer valuable insights into how changes in variance varies across individuals and under what conditions these changes are more or less pronounced. As demonstrated, the proposed screening procedure is a valuable tool for detecting such changes in variance. ...
Researchers working with intensive longitudinal designs often encounter the challenge of determining whether to relax the assumption of stationarity in their models. Given that these designs typically involve data from a large number of subjects (N ≫ 1), visual screening all time series can quickly become tedious. Even when conducted by experts, such screenings can lack accuracy. In this article, we propose a nonvisual procedure that enables fast and accurate screening. This procedure has potential to become a widely adopted approach for detecting nonstationarity and guiding model building in psychology and related fields, where intensive longitudinal designs are used and time series data are collected.
... A patient's plan is similar to a "roadmap" that guides the clinician to understand what needs to be understood in a specific case and, thus, to deliver "case-specific" treatments (Gazzillo, Curtis, & Silberschatz, 2022). Several studies show that this plan can be reliably formulated by different raters following a specific procedure and support the hypothesis that when a therapist acts in accord with a patient's plan, the outcome of therapy will be positive (see Silberschatz, 2017;Silberschatz et al., 1986). ...
... Furthermore, higher plan compatibility scores of the therapist's interventions corresponded to greater improvement in dyadic adjustment (as measured by the Dyadic Adjustment Scale) and individual partners' well-being (as measured by the Outcome Questionnaire-45.2), leading us to think that previous results from studies on individual psychotherapy will be confirmed also in couple therapy (Silberschatz, 2017). ...
This article aims to highlight how chronic couple conflictuality can be read from the control-mastery theory perspective. Some empirically grounded couple conflictuality models are reviewed and discussed, particularly regarding researchers’ tendency to focus on specific ways of dealing with conflicts, and the presence of a specific relational pattern, the demand/withdraw style, which seems to be particularly present among high-conflict couples. The article further presents an overview of the psychodynamic and systemic literature on couple conflictuality, in which three basic ways of reading conflict emerge: as an outcome of projective identification mechanisms; as a consequence of deficits in mentalization and affective regulation; and as a breakdown of dysfunctional communication strategies. The main control-mastery theory concepts also are presented, with a particular focus on its application to couple conflicts. According to this perspective, chronic couple conflictuality results from the repetition of vicious relational circles—that is, mutually failed tests by partners that give rise to negative escalations and couple dissatisfaction. A sample of clinical material from couple therapy is presented to exemplify this idea.
... This plan includes having their tests passed by their therapists--supporting their mastery of pathogenic beliefs and traumas--and understanding themselves and their problems from a more positive perspective. A specific procedure known as the Plan Formulation Method has been developed and empirically validated to formulate the patient's plan after the first 2 to 10 sessions, and several research projects have shown that therapists' interventions that support the patient in carrying out their plan are associated with patients' immediate and long-term improvement in therapy (Silberschatz, 2017). Being "pro-plan" is thus a measure of therapist responsiveness. ...
Guilt and shame are emotions that, albeit subjectively negative, help humans adapt to their social environment. However, in some cases, there are pathogenic beliefs, shaped over the lifespan that sustain them and make them a source of psychopathological suffering. In this paper we will first briefly show how Control-Mastery Theory (CMT) considers several types of pathogenic beliefs shaped by traumatic experiences that underly chronic feelings of guilt and shame. We then focus on a clinical case of Livia, a 28 year-old woman with relational and academic problems suffering mainly from two such types of pathogenic beliefs: burdening guilt and disloyalty guilt. We describe how a) Livia was driven by adverse and traumatic experiences to form some of these pathogenic beliefs, b) how she tested the therapist in order to discover whether he would dis-confirm these beliefs, and c) how the therapist was able to successfully pass these tests and provide her with new and healthier interpersonal experiences. The case of Livia will highlight therapists' ability to accurately formulate patients' goals, pathogenic beliefs-including types of guilt-and shame-related beliefs-and traumas. Moreover, the case will illustrate how therapists can pass patients' tests and J Clin Psychol. 2024;1-13. wileyonlinelibrary.com/journal/jclp | 1 This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
... This plan specifies which healthy goals patients want to pursue in their therapy, which pathogenic beliefs they need to disprove, which traumas are at the basis of these pathogenic beliefs and need to be better mastered, and what patients may want to understand about themselves. A procedure for reliably elaborating this plan, the plan Notes on some non-psychotic hypochondriacal states 5 formulation method (PFM; Curtis & Silberschatz, 2022), has been developed, and several research studies have shown that therapists' interventions that support patients' plans correlate with both immediate and long-term improvements in psychotherapy (Silberschatz, 2017;Silberschatz et al., 1986). ...
The aim of this paper is to propose a psychodynamic hypothesis based on control-mastery theory (CMT) about the self-punishment function of some non-psychotic hypochondriacal states. After a review of several major psychoanalytic hypotheses about hypochondria, we will show the main concepts of CMT, an integrative, relational, cognitive-dynamic theory of mental functioning, psychopathology, and therapeutic process that is the theoretical framework that has helped us understand and treat these states in our patients. We will then describe two clinical cases to show how some hypochondriacal states can be interpreted as self-punishments connected to three main kinds of guilt hypothesized byCMT: survivor guilt, burdening guilt, and separation/disloyalty guilt. Finally, we will discuss the implications of these hypotheses
... In turn, Kramer et al. (2016) drew on Leiman and Stiles, (2001) and Pascual-Leone (2009) to define appropriate TR as the dynamic adjustments between the therapist's interventions and the client's emotional processes, revealed by the therapist's constant sensitivity to the client's degree of openness to change. Snyder and Silberschatz (2017), Silberschatz (2017) and Penedo et al. (2020) focused mainly on the therapist responsiveness and included considerations on the therapist's capacity to be attuned to the client's current state (attuned responsiveness; Snyder & Silberschatz, 2017); the compatibility of the therapist's interventions with an intervention plan that effectively addressed the client's problems Silberschatz (2017); and the importance of the therapist's adjustments to the client's behavior and needs, ...
... In turn, Kramer et al. (2016) drew on Leiman and Stiles, (2001) and Pascual-Leone (2009) to define appropriate TR as the dynamic adjustments between the therapist's interventions and the client's emotional processes, revealed by the therapist's constant sensitivity to the client's degree of openness to change. Snyder and Silberschatz (2017), Silberschatz (2017) and Penedo et al. (2020) focused mainly on the therapist responsiveness and included considerations on the therapist's capacity to be attuned to the client's current state (attuned responsiveness; Snyder & Silberschatz, 2017); the compatibility of the therapist's interventions with an intervention plan that effectively addressed the client's problems Silberschatz (2017); and the importance of the therapist's adjustments to the client's behavior and needs, ...
... Hardy et al. (1998) used the Sheffield Psychotherapy Rating Scale (SPRS) to assess therapist interventions related to treatment adherence. Silberschatz (2017) employed an observational coding system to assess therapist responsiveness in addressing client problems and the compatibility of interventions with the client's therapeutic plan. Kramer et al. (2017) studied the responsiveness effect in General Psychiatric Management (GPM) treatment for borderline clients using the Motive-Oriented Therapeutic Relationship idiographic case formulation (MOTR; Caspar, 2007) and the Coping Action Patterns Rating Scale (CAPRS; Kramer & Drapeau, 2011) to evaluate client coping strategies. ...
Therapeutic responsiveness (TR) encompasses the dynamic interaction between therapist and client, reflecting adjustments in behavior and interventions to meet individual needs, characteristics, and preferences. TR influences the therapeutic alliance, client engagement, and treatment outcomes. Despite evolving conceptualizations over time, a unified definition of TR remains elusive, hindering research and practice in psychotherapy. We aimed to explore how TR has been defined and studied in psychotherapy process research, identifying elements incorporated into its conceptualization and methodologies for its assessment. A systematic literature review was conducted across four databases using search terms related to the variables of interest (TR and the psychotherapy process). Thirty empirical studies were identified. The review revealed diverse methodologies and definitions of TR, with an emphasis on quantitative approaches. Four dimensions of TR emerged, highlighting its multidimensional nature: therapist and treatment responsiveness, relational responsiveness, and client responsiveness. Challenges in defining and assessing TR were evident, with studies often focusing on one dimension rather than embracing its complexity fully. A proposal for a ‘gold standard’ definition was presented, based on the different conceptualizations of TR mentioned in the various studies. Consolidating existing measures, developing new tools, and adopting multidimensional assessment approaches are recommended to advance our understanding of this complex construct. Recognizing TR’s multifaceted nature and addressing challenges in its definition and assessment are essential for informing responsive therapeutic interventions, with implications for therapist training and supervision.
... In recent years, dissatisfied with the effectiveness of empirically supported treatments and techniques for specific disorders (regarding their limitations, see Shedler, 2018;Westen, Novotny, & Thompson-Brenner, 2004), many authors have suggested that the effectiveness of psychotherapies could be improved by shifting from disorder-specific treatments to case-specific psychotherapies (Critchfield, Gazzillo, & Kramer, 2022;Kramer, 2019Kramer, , 2020Silberschatz, 2017). For such a shift to occur, clinicians would need to pay greater attention to the idiosyncratic formulations of their patients' cases. ...
... The Plan Formulation Method (PFM; is an empirically validated procedure that clinicians and researchers can use to develop reliable formulations of patient plans during the first 2 to 10 therapy sessions. Numerous empirical studies on psychotherapies with different theoretical orientations have shown that plan formulations developed using this procedure are highly reliable and that therapists' interventions that support patient plans (pro-plan communications) are associated with both short-and long-term improvement in psychotherapy (Silberschatz, 2017;Silberschatz & Curtis, 1986). ...
... We empirically verified that raters with adequate training were able to properly differentiate the different kinds of tests and reliably identify what kind of pathogenic belief a patient was testing in a given moment of a session. As we stated before, being able to reliably differentiate which specific kind of test the patient is posing to the therapist in a given moment of a session, and which specific pathogenic belief is being tested in that moment is crucial to help clinicians understand what kind of responses their patients need, moment by moment, in order to help them disprove their pathogenic beliefs (see Silberschatz, 2017). ...
According to Control-Mastery Theory, patients attend therapy with
an unconscious plan to achieve adaptive goals and disprove their
pathogenic beliefs. One important way patients work to disconfirm
these beliefs is by testing them. Moreover, patients coach their
therapists on what they need at different times during their treatment.
The aim of this study is to expand the results of previous
studies suggesting that therapists’ responses that support patients’
plan predict progress. We investigated whether therapists' ability to
pass patients’ tests correlated with patients' improvement in the
following session and whether their ability to follow patients' coaches
correlated with immediate improvement. Transcriptions of 98
sessions from six brief psychodynamic psychotherapies were
assessed by 12 independent raters. The patients’ plans were formulated,
and tests and coaching communications were identified.
The accuracy of the therapist’s responses to these tests and coaches
was rated, and the impact of the therapist’s interventions on the
patient’s following communication was measured. The results
showed that when a therapist’s intervention passes a patient's
tests, patients show signs of improvement both immediately and
in the following session, and when therapists follow patients’ coaches,
patients show signs of immediate improvement. The clinical
implications and limitations of the findings are discussed.
... jo de la contratransferencia (Hayes et al., 2018), la humildad y la competencia multicultural (Nissen-Lie et al., 2013), la flexibilidad en la adaptación a las características de los pacientes (Silberschatz, 2017), el uso de autorrevelaciones (Hill et al., 2018) y el autocuestionamiento o auto-duda profesional, así como la apertura al feedback de la evolución del proceso psicoterapéutico (Delgadillo et al., 2022;Gimeno-Peón et al., 2018;Nissen-Lie et al., 2017). ...
El terapeuta, junto con el paciente, es uno de los elementos esenciales de la relación terapéutica que conforma cualquier forma de psicoterapia. En la actualidad, el conocimiento acumulado permite identificar algunas de las características de los terapeutas más eficaces facilitando la comprensión de los elementos implicados en el proceso psicoterapéutico y su desenlace efectivo. En el presente artículo se formula una conceptualización sobre la persona del terapeuta que pretende apoyar un marco de comprensión de su rol en el proceso psicoterapéutico. Asimismo, se revisan las investigaciones realizadas sobre el Estilo Personal del Terapeuta en Iberoamérica y se reflexiona sobre los posibles desarrollos del campo.
