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Therapist skills associated with client emotional expression in psychodynamic psychotherapy
Psychotherapy Research
Abstract
Objective: We wanted to determine whether four therapist skills were differentially associated with emotional expression. Method: We compared paraphrases (restatements and reflections of feelings) and open questions (focused on thoughts or feelings) in relation to antecedent and subsequent client emotional expression and client attachment style for 36 clients and 22 therapists in psychodynamic psychotherapy. Results: Therapists gave more paraphrases when clients were expressing more emotions, but more open questions when clients were expressing fewer emotions. Regardless of attachment style, subsequent emotional expression was highest when therapists used open questions for feelings, and intermediate when therapists used reflections of feelings or open questions for thoughts. Subsequent client emotional expression was lowest when therapists used restatements with clients who were low in attachment avoidance, and at about the same level as other skills for clients who were high in attachment avoidance. Conclusions: Therapists differentially used the skills based on how much emotion clients were expressing. Clients expressed emotions differentially depending on antecedent client emotional expression, therapist skills used, and client avoidant attachment style.
... For example, Freites et al. (2022) found that clients had more self-referring pronouns and emotion words in response to open questions about feelings, suggesting that open questions facilitate exploration. Relatedly, Anvari et al. (2020) found greater client emotional expression in response to questions when clients had been expressing fewer emotions. They suggested that therapists may use open questions with clients who are "not into their feelings" (p. ...
... Examining the 10th session of psychodynamic therapy in a community clinic, the researchers found that therapists focused more on thoughts than feelings. However, therapists did focus more on affect when clients were already expressing their emotions (in contrast to Anvari et al., 2020). ...
... Recent researchers (e.g., Anvari et al., 2020Anvari et al., , 2022Freites et al., 2022) have attempted to correct previous methodological limitations, This document is copyrighted by the American Psychological Association or one of its allied publishers. ...
This article defines and illustrates therapist questions in individual psychotherapy and then reviews the naturalistic, empirical research on their effectiveness. The research on immediate impacts of questions in psychotherapy has been mixed. The available research indicates that positive impacts, particularly of open questions, include increased client emotional expressiveness and affective exploration. However, negative impacts have also been found, suggesting that questions may be related to negative client perspectives of the therapist’s empathy and helpfulness and session smoothness. The article focuses on definitions and clinical examples as well as research findings and limitations. The article concludes with training implications and therapeutic practice recommendations based on the empirical research.
... Furthermore, skills were not nested within clients and therapists in the Hill et al. (1988) study, so results could have been distorted given that some therapists used more questions than did others. Anvari et al. (2020Anvari et al. ( , 2022 corrected some of the problems with the previous studies in their investigations of the immediate outcomes for open questions for thoughts and feelings, although they did not compare these with closed questions. In Anvari et al. (2020), subsequent client emotional expression was higher for OQF than for OQT in third and fourth sessions of psychodynamic psychotherapy. ...
... Anvari et al. (2020Anvari et al. ( , 2022 corrected some of the problems with the previous studies in their investigations of the immediate outcomes for open questions for thoughts and feelings, although they did not compare these with closed questions. In Anvari et al. (2020), subsequent client emotional expression was higher for OQF than for OQT in third and fourth sessions of psychodynamic psychotherapy. In Anvari et al. (2022), client depth of affective exploration was similarly higher after OQF than after OQT, although depth of cognitive-behavioral exploration was about the same for OQF and OQT in session 10 of psychodynamic psychotherapy. ...
... In the studies reviewed above, several measures have been used to assess the immediate outcomes of questions: client and therapist helpfulness ratings, client experiencing levels, client emotional/ affective exploration, client cognitive-behavior exploration, client reactions, and client change talk (Anvari et al., 2020(Anvari et al., , 2022Apodaca et al., 2016;Gaume et al., 2009;Hill et al., 1983;1988;Romano et al., 2016). Although these outcomes seem appropriate for assessing the immediate outcomes of open questions for thoughts and feelings, they do not seem appropriate for assessing the purported effects of closed questions (e.g., providing information). ...
To investigate whether there are different antecedents and consequences of different types of therapist questions as this has implications for conducting psychotherapy and for training therapists.
We examined the antecedents and consequences of questions for 88 clients working with 33 doctoral student therapists in psychodynamic psychotherapy. Questions were coded into open questions for thoughts (OQT), open questions for feelings (OQF), closed questions for facts (CQF), and closed questions other (CQO). The antecedents and consequences were assessed in terms of self-referring pronouns (SRP), self-referring emotion words (SRE), and number of words.
In terms of antecedents, when clients were using a high number of SRP, therapists were more likely to ask OQT and CQO than CQF. When clients were using a high number of SRE, therapists were more likely to ask OQF than CQF. In terms of consequences, clients spoke less after CQF than the other three skills, used fewer SRP after CQF than after CQO, and used more SRE after OQF than CQF.
CQO were more similar in terms of antecedents and consequences to OQT and OQF than to CQF.
... Recently, Anvari et al. (2020) argued that there were methodological problems issues in the previous studies. First, in the studies evaluating the helpfulness of therapist skills, clients and therapists rated the helpfulness of entire speaking turns, many of which were comprised of multiple skills (e.g., a restatement followed by an open question). ...
... To begin to address these limitations, Anvari et al. (2020) trained judges to code client emotional arousal in clients' speaking turns (not including silence) preceding and following two carefully defined instances (i.e., when there was only one therapist skill used within a speaking turn) of the therapist use of restatements, reflection of feelings, open questions for thoughts, and open questions for feelings in the 3rd and 4th sessions of psychodynamic psychotherapy (36 clients nested within 22 therapists). Anvari et al. found that therapists used more paraphrases (combination of restatements and reflections of feelings) when clients already had high emotional expression, whereas they used more open questions (combined across feelings and thoughts) when clients had low emotional expression. ...
... Although Anvari et al. (2020) addressed many of the limitations of previous research, there were still crucial methodological limitations. First, to adhere to the inclusion criteria of having two instances of each skill per case, 52 cases (52 clients nested within 22 therapists) were excluded from the data set. ...
We examined how much 62 adult community clients working with 26 doctoral student therapists in the 10th session of individual, open-ended, psychodynamic psychotherapy engaged in affective and cognitive-behavioral exploration preceding and following four different therapist skills (restatement, reflection of feelings, open question for thoughts, open question for feelings). Overall, therapists used more skills focused on thoughts than feelings. At the between-therapists level, therapists tended to use more skills focused on affect when antecedent client affective exploration was high. An increase in affective exploration was associated with skills focused on feelings, however, clients low in attachment anxiety showed a decrease in affective exploration in response to paraphrases (i.e., restatements and reflections of feelings). Open questions for feelings were associated with an increase in cognitive-behavioral exploration, especially for clients low in attachment anxiety. Implications for practice and research are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
... These capabilities are essential for integrating conversational artificial intelligence (AI) into mental health applications. (2) For Challenge 2, We propose a general Sequential Multimodal Emotional Support Framework (SMES), a multitask method grounded in Therapeutic Skills Theory [19]- [22]. The SMES framework leverages the strengths of multimodal foundation models to extract emotional cues from video and audio. ...
... To visually display the changes in strategy employed during the dialogue process, we divide the progression of the conversation into four phases for analysis. Fig. 3 shows the distribution of ten strategies across the conversation progress, derived from professional therapeutic theories [19]- [22]. ...
The integration of conversational artificial intelligence (AI) into mental health care promises a new horizon for therapist-client interactions, aiming to closely emulate the depth and nuance of human conversations. Despite the potential, the current landscape of conversational AI is markedly limited by its reliance on single-modal data, constraining the systems' ability to empathize and provide effective emotional support. This limitation stems from a paucity of resources that encapsulate the multimodal nature of human communication essential for therapeutic counseling. To address this gap, we introduce the Multimodal Emotional Support Conversation (MESC) dataset, a first-of-its-kind resource enriched with comprehensive annotations across text, audio, and video modalities. This dataset captures the intricate interplay of user emotions, system strategies, system emotion, and system responses, setting a new precedent in the field. Leveraging the MESC dataset, we propose a general Sequential Multimodal Emotional Support framework (SMES) grounded in Therapeutic Skills Theory. Tailored for multimodal dialogue systems, the SMES framework incorporates an LLM-based reasoning model that sequentially generates user emotion recognition, system strategy prediction, system emotion prediction, and response generation. Our rigorous evaluations demonstrate that this framework significantly enhances the capability of AI systems to mimic therapist behaviors with heightened empathy and strategic responsiveness. By integrating multimodal data in this innovative manner, we bridge the critical gap between emotion recognition and emotional support, marking a significant advancement in conversational AI for mental health support.
... However, we have surprisingly little evidence to support these assertions. In Anvari et al. (2020), we found that open questions focused on feelings were more directly associated with clients expressing emotions than were the other three interventions, perhaps because they clearly directed the clients to talk about feelings. Together with the findings from the earlier study on interpretations and probes for insight, these findings highlight the value of open questions for facilitating exploration. ...
... Interestingly in the Anvari et al. (2020) study, therapists offered more open questions when clients were less emotionally expressive (perhaps to direct them to the need to express feelings), whereas they offered more restatements and reflections of feelings when clients were already expressing their feelings (perhaps because they could then reinforce the expression of feelings). Thus, therapists need to be attentive to client emotional expression when they are deciding which interventions to use. ...
How to foster the integration of science (especially empirical research) and practice has been a vexing problem since the beginnings of counseling psychology and other applied fields. We propose that the basis for this problem is the very different, even contradictory, demands of empirical research and practice, and the resulting ways of being research scientists and practitioners. Focusing on psychotherapy, we posit seven such demands/pulls and ways of being and seven tactics for strengthening integration. Clinically relevant research on the therapeutic relationship and therapist skills/interventions conducted at the Maryland Psychotherapy Clinic and Research Lab is summarized. We emphasize that for science and practice to be mutually facilitative, the field will need to pay close and ongoing attention to ways of strengthening integration.
... This label implies that the therapist's responsiveness is directly related to his or her empathy (Spagnuolo Lobb et al., 2022;Cirasola et al., 2022;Brøsholen et al., 2022;Anvari et al., 2020;Hatcher, 2015;Bourke and Grenyer, 2010). ...
The purpose of this study is to examine therapeutic responsiveness across three different therapeutic models. The construct of responsiveness consists of two conceptual features: optimal responsiveness, which involves adapting therapist behavior to the unique therapeutic relationship, and appropriate responsiveness, a more refined concept. While aligned with interpersonal principles, the responsiveness construct challenges prevailing statistical methods by emphasizing the therapist’s adaptive responses. A comparative analysis of Gestalt, psychodynamic, and systemic therapies revealed unique patterns of responsiveness within each model, ranging from an emphasis on empathy and intuition to the significance of countertransference. Methodologically, a literature review and textual analysis using Atlas.ti allowed for nuanced exploration. The results also revealed a core commonality—"experience”—across these models, positioning responsiveness as an “extra-specific” factor amidst shared conceptual ground. In conclusion, this study sheds light on the nuances of responsiveness, which is central to advancing psychotherapeutic practice in an evolving landscape. An in-depth examination of the construct of responsiveness helps identify therapist characteristics that can be enhanced, enriched, and supported during training and supervision.
... Open questions about feelings, on the other hand, directly ask clients to talk about feelings in an unlimited fashion (e.g., "What are you feeling right now?"). In counseling sessions, open questions about feelings were found to be effective at promoting clients' emotional expression (Anvari et al., 2020(Anvari et al., , 2022Freites et al., 2023). Reflections of feelings may be more effective than open questions about feelings at facilitating emotional exploration because it more readily conveys empathy and directs clients to immerse themselves in a particular feeling (Hill, 2020). ...
Emotionally evocative narratives are a common strategy to spread vaccine-related misinformation on social media. This study tested the use of two emotional awareness strategies – affect labeling and reflections of feelings – to mitigate the impact of misinformation. The online experiment (N = 143) found that emotional awareness (vs. control) led to greater felt emotions and concerns about HPV vaccine safety among female participants. Felt emotions further mediated the effect of emotional awareness (vs. control) on intentions to share misinformation and concerns about HPV vaccine safety. These findings suggest that emotional awareness may be ineffective at addressing narrative misinformation on social media.
... Emotional processing calls for patients to become aware of, experience, and express emotions, and a meta-analysis of the psychotherapy process literature found that patients' in-session emotional expression is strongly positively predictive of better therapeutic outcomes. Further, Anvari et al. (2020) found that the therapist skill of directly asking patients to focus on feelings is particularly productive for eliciting patient emotional expression. Emotion-focused, experiential, and some psychodynamic therapy models differentiate between adaptive or activating emotions or feelings, which are "naturally" elicited by certain experiences-and inhibitory or secondary feelings, which patients commonly report but are usually reactions to important adaptive feelings (Greenberg, 2012). ...
Emotional processing interventions for trauma and psychological conflicts are underutilized. Lack of adequate training in emotional processing techniques and therapists’ lack of confidence in utilizing such interventions are barriers to implementation. We developed and tested an experiential training to improve trainees’ performance in a set of transtheoretical emotional processing skills: eliciting patient disclosure of difficult experiences, responding to defenses against disclosure, and eliciting adaptive emotions. Mental health trainees (N = 102) were randomized to experiential or standard training, both of which presented a 1-hr individual session administered remotely. Before and after training and at 5-week follow-up, trainees were videorecorded as they responded to videos of challenging therapy situations, and responses were coded for demonstrated skill. Trainees also completed measures of therapeutic self-efficacy, anxiety, and depression at baseline and follow-up. Repeated-measures analysis of variance indicated all three skills increased from pre- to posttraining for both conditions, which were maintained at follow-up. Importantly, experiential training led to greater improvements than standard training in the skills of eliciting disclosure (η² = .05, p = .03), responding to defenses (η² = .04, p = .05), and encouraging adaptive emotions (η² = .23, p < .001) at posttraining, and the training benefits for eliciting disclosure were maintained at follow-up. Both conditions led to improved self-efficacy. Trainees’ anxiety decreased in the standard training, but not in the experiential. One session of experiential training improved trainees’ emotional processing therapy skills more than didactic training, although more training and practice likely are needed to yield longer lasting skills.
... Like empathy, it might be of interest to investigate if the associations based on machine-learning processed large data sets align to those found in meta-analyses, thus offering criterion validity of using such methods. In addition, although explicitly conceptualized in motivational interviewing (Houck et al., 2010), open questioning or reflections are also found in other theoretical orientations to facilitate treatment processes (e.g., Anvari et al., 2020;Apodaca et al., 2016). However, there is a limited number of studies that assess these basic skills in naturalistic settings, which may be an important step given the prevalence of nonspecific skills in all treatments. ...
Supportive counseling skills like empathy and active listening are critical ingredients of all psychotherapies, but most research relies on client or therapist reports of the treatment process. This study utilized machine-learning models trained to evaluate counseling skills to evaluate supportive skill use in 3,917 session recordings. We analyzed overall skill use and variation in practice patterns using a series of mixed effects models. On average, therapists scored moderately high on observer-rated empathy (i.e., 3.8 out of 5), 3.3% of the therapists' utterances in a session were open questions, and 12.9% of their utterances were reflections. However, there were substantial differences in skill use across therapists as well as across clients within-therapist caseloads. These findings highlight the substantial variability in the process of counseling that clients may experience when they access psychotherapy. We discuss findings in the context of both the need for therapists to be responsive and flexible with their clients, but also potential costs related to the lack of a more uniform experience of care. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
... The interviewer was a pre-intern psychologist trained in consulting and therapy conversations and had skills to navigate an emotional conversation with each participant. She was trained in how to connect with people, which helped the participants be more open in expressing themselves and feeling emotions [2]. ...
Emotions are complicated psycho-physiological processes that are related to numerous external and internal changes in the body. They play an essential role in human-human interaction and can be important for human-machine interfaces. Automatically recognizing emotions in conversation could be applied in many application domains like health-care, education, social interactions, entertainment, and more. Facial expressions, speech, and body gestures are primary cues that have been widely used for recognizing emotions in conversation. However, these cues can be ineffective as they cannot reveal underlying emotions when people involuntarily or deliberately conceal their emotions. Researchers have shown that analyzing brain activity and physiological signals can lead to more reliable emotion recognition since they generally cannot be controlled. However, these body responses in emotional situations have been rarely explored in interactive tasks like conversations. This paper explores and discusses the performance and challenges of using brain activity and other physiological signals in recognizing emotions in a face-to-face conversation. We present an experimental setup for stimulating spontaneous emotions using a face-to-face conversation and creating a dataset of the brain and physiological activity. We then describe our analysis strategies for recognizing emotions using Electroencephalography (EEG), Photoplethysmography (PPG), and Galvanic Skin Response (GSR) signals in subject-dependent and subject-independent approaches. Finally, we describe new directions for future research in conversational emotion recognition and the limitations and challenges of our approach.
Aim: The purpose of this research is to compare the effectiveness of schema therapy and therapy based on emotional efficiency on rumination and emotional expression of divorced women in Tehran. Method: The research design was experimental studies with a semi-experimental design and a pre-test-post-test type with a control group. The current research population includes all divorced women in the 5th district of Tehran, of which 45 people were selected as the sample size by cluster sampling method, and were randomly divided into three experimental and control groups of 15 people. Both groups answered the rumination scale of Nalan Hoeksma and Maro (1991) and the emotion expression scale of King and Ammons et al. (1990) in two phases: pre-test, post-test and follow-up. The first experimental group received schema therapy based on Yang et al.'s (2003) protocol, and the second experimental group received emotional efficiency therapy based on McKay and West's (2016) protocol for ten sessions, and two 90-minute workshop sessions per week. Received, but the control group did not receive training. The data were analyzed by variance analysis with repeated measurements and Spss.22 software. Results: The results showed that schema therapy and therapy based on emotional efficiency was effective on rumination (F=8.00, P=0.009) and emotional expression (F=6.68, P=0.016) of divorced women. Also, the results showed that schema therapy had a greater effect on women's rumination and emotional expression compared to treatment based on emotional efficiency. Conclusion: It is possible to use both schema therapy and therapy based on emotional efficiency to improve the psychological problems of divorced women.
أهداف الدراسة: هدفت الدارسة الحالية إلى بناء نموذج سببي مقترح للعلاقة بين التفهم الوجداني، والاستماع الفعَّال، وأنماط اتصال الاختصاصيِّين النفسيين مع المسترشدين في أثناء الجلسة الإرشادية. منهجية الدراسة: لتحقيق أهداف الدراسة، استُخدم المنهج الوصفي (الارتباطي)، وشملت عينة الدراسة (224) من الاختصاصيِّين النفسيين الذين يقدمون خدمات الرعاية النفسية للمسترشدين في مدينة الرياض، طُبق مقياس التفهم الوجداني الذي أعدَّه الطراونة (2019)، ومقياس الاستماع الفعَّال الذي أعدَّه (Asai, Hiraizumi, & Hanzawa,2020)، ومقياس أنماط الاتصال مع المرضى الذي أعدَّه السموحي (2015). نتائج الدراسة: أظهرت نتائج الدراسة وجود ارتباطات موجبة ذات دلالة إحصائية عند مستوى الدلالة (α≤0.05) بين مقياس التفهم الوجداني، والاستماع الفعَّال، ومقياس أنماط الاتصال مع المسترشدين في أثناء الجلسة الإرشادية، ووجودَ أثرٍ مباشرٍ ذي دلالة إحصائية لكل من التفهم الوجداني والاستماع الفعَّال في أنماط التواصل مع المسترشدين في أثناء الجلسة الإرشادية؛ إذ بلغ معامل الارتباط (R) (0.622)، وعدمَ وجود تأثيرات مباشرة دالة إحصائيًا عند مستوى الدلالة (α≤0.05) للاستماع الفعَّال في التفهم الوجداني؛ إذ بلغ معامل الارتباط (R) (0.018)، وأخيرًا أشارت معاملات المسار إلى أن مقياس الاستماع (بوصفه متغيرًا مستقلًّا) يفسر ما نسبته (20.1%) من تباين المتغير (أنماط الاتصال المتبعة مع المسترشدين في أثناء الجلسة الإرشادية).
Questions are one of the most frequently used strategies in therapy. There is a body of theoretical work on the kinds of questions that are preferred in specific treatment approaches. However, research on the use of questions in general, how they are formed and what specific therapeutic work they do, is relatively scarce in the literature. In this study, we use the conceptual framework and methods of conversation analysis (CA) to examine how systemic questions soliciting clients' perspective on the partners' thoughts and intents (Observer-Perspective Questions; OPQs) are realized interactively in actual clinical practice and the range of therapeutic work they perform in couples therapy. We identified 78 OPQs from archival data of videotaped time-limited couples therapies, a clinical population working with a professional therapist. From this set of 78 OPQs, five excerpts representing diverse use of OPQs were selected. These excerpts were transcribed in detail capturing not only the textual content but also the prosodic, gestural, and non-verbal aspects of these episodes. Using CA methodology, we identified four specific kinds of changes these questions can promote: progress toward relational optimism, support of positive aspects of the couple's relationship, promoting the concept that the couples' experiences and emotions are interlinked, and introducing new creative relational options. Detailed CA analyses of these clinical excerpts allowed us to identify how the OPQ sequences were built to realize these therapeutically useful moves using various conversational resources progressively and interactively. The conversational analysis of these sequences facilitated the exploration of relationships between the ways the questions are formed, timed, and delivered and the specific functions they perform to move the therapy forward. In conclusion, we make the general argument that examining important therapy events through a CA perspective provides a significant complementary vector to quantitative research on the therapy process.
Objective: We present a mixed methods systematic review of the effectiveness of therapist empathic reflections, which have been adopted by a range of approaches to communicate an understanding of client communications and experiences. Methods: We begin with definitions and subtypes of empathic reflection, drawing on relevant research and theory, including conversation analysis. We distinguish between empathic reflections, reviewed here, and the relational quality of empathy (reviewed in previous meta-analyses). We look at how empathic reflections are assessed and present examples of successful and unsuccessful empathic reflections, also providing a framework of the different criteria used to assess their effectiveness (e.g., association with session or treatment outcome, or client next-turn good process). Results: In our meta-analysis of 43 samples, we found virtually no relation between presence/absence of empathic reflection and effectiveness, both overall and separately within-session, post-session and post-treatment. Although not statistically significant, we did find weak support for reflections of change talk and summary reflections. Conclusions: We argue for research looking more carefully at the quality of empathy sequences in which empathic reflections are ideally calibrated in response to empathic opportunities offered by clients and sensitively adjusted in response to client confirmation/disconfirmation. We conclude with training implications and recommended therapeutic practices.
This article serves as both the foreword and the afterword to the special section of Psychotherapy Research devoted to research reviews of psychotherapist skills and methods: it introduces the interorganizational Task Force that guided the reviews and then features its conclusions. We begin by operationally defining therapist skills and methods and then contrasting them with other components of psychotherapy. Next, we consider the typical assessment of skills and methods and how they are linked with outcomes (immediate in-session, intermediate, and distal) in the research literature. We summarize the strength of the research evidence on the skills and methods reviewed in the 8 articles in this special section and in the companion special issue in Psychotherapy. We end with diversity considerations, research limitations, and the formal conclusions of the interorganizational Task Force on Psychotherapy Skills and Methods that Work.
This article analyzed the process of change and the effectiveness of 10 sessions of Family Constellations (FC), explored elements that may aid reconciliation effectiveness, and decrypted factors underlying four variables of interest: suicidal ideation, verge of divorce, depression, and anxiety. Using a mixed methods design, this single case study used a triangulation of data: quantitative (DASS-21) and qualitative (the notes from the consultations and the patient’s responses to the Psychotherapeutic Process Data Mining Questionnaire, or PPDMQ). The Reliable Change Index (RCI) was used to gauge clinical change in the DASS-21 scores. RCI analysis showed a clinically and statistically significant change at process termination, and at the 6-month follow-up, on the patient’s symptoms of anxiety and depression. As a member of a couple on the verge of divorce, by undoing that drive to divorce, the suicidal ideation of the patient seemed to stop. Two focuses of interventions are proposed to mitigate divorce rates, suicide rates linked to divorce, as well as depression and anxiety levels associated with divorce and suicidal ideations. FC, as a psychotherapy, seems to possess a substantial financial and societal positive change potential (e.g., at the judicial sphere) and perhaps needs to be addressed from an unbiased perspective.
(PsycInfo Database Record (c) 2021 APA, all rights reserved)
We investigated the process and outcome of the first silence event for each of 86 clients and 26 doctoral student therapists in individual psychodynamic psychotherapy. Antecedent client collaboration and client attachments styles did not predict type of client or therapist behavior during silence events. Client collaboration increased from before to after silence events if therapists were productive (mostly invitational) and if clients were productive (mostly emotional and expressive) during silence events. Furthermore, subsequent client collaboration was higher when productive therapist silence occurred with clients who were lower rather than higher in attachment anxiety. In contrast, subsequent client collaboration was higher when productive client silence occurred with clients who were higher rather than lower in attachment anxiety. These results suggest that type of silence and client attachment styles are important factors in the immediate outcomes of silence events.
We investigated the process and outcome of the first silence event for each of 86 clients and 26 doctoral student therapists in individual psychodynamic psychotherapy. Antecedent client collaboration and client attachments styles did not predict type of client or therapist behavior during silence events. Client collaboration increased from before to after silence events if therapists were productive (mostly invitational) and if clients were productive (mostly emotional and expressive) during silence events. Furthermore, subsequent client collaboration was higher when productive therapist silence occurred with clients who were lower rather than higher in attachment anxiety. In contrast, subsequent client collaboration was higher when productive client silence occurred with clients who were higher rather than lower in attachment anxiety. These results suggest that type of silence and client attachment styles are important factors in the immediate outcomes of silence events.
Clinical Impact Statement
Psychodynamic theorists consider client collaboration and insight to be desirable, but minimal evidence exists about what skills therapists should use to facilitate these processes. Question: We examined whether therapist interpretations (Ints) and probes for insights (PIs) facilitate client collaboration and insight. Findings: When the client was initially collaborative but not insightful and the therapist gave PIs, the client was likely to be more collaborative. When the client was more insightful than usual with the therapist, the client was likely to gain insight. Meaning: Therapists need to be aware of the client level of collaboration and insight when deciding about giving Ints and PIs, and PIs are more likely than Ints to facilitate collaboration, but both are equally likely to facilitate insight. Next Steps: Researchers could examine other cases, whether other therapist interventions facilitate client collaboration and insight and whether Ints and PIs facilitate other client outcomes.
We investigated the antecedents, occurrences, and consequences of 183 silence events in the first 5 and last 5 sessions of a 73-session case of successful psychodynamic psychotherapy. Silences generally occurred within client speaking turns, such that the client often paused to reflect while speaking. In the last 5 sessions, as compared with the first 5 sessions, the client was more collaborative before and after silences, silences were shorter, the therapist was more connectional during silences (e.g., shared emotion and meaning with client), and the client was more emotional after silences. Antecedent client collaboration, duration of the silence, therapist behavior during silence events, client behavior during silence events, and who broke the silence all related to change in collaboration from before to after the silence events. We concluded that silence was helpful in this case because of client factors (the client naturally paused a lot during discussion, the client was quite reflective and insightful), therapist factors (the therapist was comfortable with and believed in silence), and relationship factors (there was a strong therapeutic relationship).
Although emotion has long been considered important to psychotherapeutic process, empirical assessment of its impact has emerged only recently. The present study applied two meta-analyses to explore the association between therapist expression of emotion and psychotherapy outcome, and client expression of emotion and psychotherapy outcome. Overall, 66 studies (13 for the therapist meta-analysis and 43 for the client meta-analysis) were included. A significant medium effect size was found between the therapist's emotional expression and outcomes (d-0.56) and a significant medium-to-large effect size between the client's emotional expression and outcomes (d-0.85). Third-party rating of emotional expression emerged as a significant moderator of outcomes. Limitations of the research, diversity considerations, and therapeutic practices that conclude the article are then presented.
We studied 814 client laughter events nested within 330 sessions nested within 33 clients nested within 16 therapists at one community clinic in which doctoral student therapists provided psychodynamic psychotherapy to adult community clients. Each laughter event in Sessions 1 to 5 and 16 to 20 was rated for cheerfulness, politeness, reflectiveness, contemptuousness, and nervousness. Across all clients, there was an average of about one laughter even per session. The average laughter event lasted 3.5 seconds, and was characterized primarily by politeness and reflectiveness. Overall amount of client laughter and the characteristics of client laughter did not change across sessions. Most of the variance in the laughter characteristics was at the session level, with less variance attributable to clients and therapists. When client attachment avoidance was high, laughter was less cheerful and more contemptuous. When client attachment anxiety was high, laughter was more nervous. Sessions with more reflective laughter were evaluated more positively by clients, and therapists whose clients had more reflective laughter had more positive client session evaluations. Furthermore, within a therapist’s caseload, clients with the most nervous and contemptuous laughter evaluated sessions most positively. Implications are discussed.
12 sessions of personal, insight-oriented counseling were conducted by a female psychologist with a female undergraduate with a dominating, melodramatic communication style. The client's presenting problems were difficulties with her boyfriend and family, anxiety, and headaches. The counselor's style was interpretive, confrontive, and experiential within the context of a safe, supportive, therapeutic atmosphere. Process measures indicated that the client increased amount of experiencing and insight and decreased amount of time spent describing her problems both within and across sessions. Mechanisms of change seemed to be interpretations, direct feedback, gestalt exercises, and discussion of the counselor-client relationship, following the establishment of rapport and support. Client's scores on the Hopkins Symptom Checklist and Tennessee Self-Concept Scale showed that treatment had resulted in an improvement that was maintained at 2 mo, but the client had relapsed at a 7-mo follow-up. Process analyses suggested that relapse occurred because counseling was too brief, not allowing enough time for the client to incorporate changes. (46 ref) (PsycINFO Database Record (c) 2006 APA, all rights reserved).
Conversation is a fundamental human experience that is necessary to pursue intrapersonal and interpersonal goals across myriad contexts, relationships, and modes of communication. In the current research, we isolate the role of an understudied conversational behavior: question-asking. Across 3 studies of live dyadic conversations, we identify a robust and consistent relationship between question-asking and liking: people who ask more questions, particularly follow-up questions, are better liked by their conversation partners. When people are instructed to ask more questions, they are perceived as higher in responsiveness, an interpersonal construct that captures listening, understanding, validation, and care. We measure responsiveness with an attitudinal measure from previous research as well as a novel behavioral measure: the number of follow-up questions one asks. In both cases, responsiveness explains the effect of question-asking on liking. In addition to analyzing live get-to-know-you conversations online, we also studied face-to-face speed-dating conversations. We trained a natural language processing algorithm as a “follow-up question detector” that we applied to our speed-dating data (and can be applied to any text data to more deeply understand question-asking dynamics). The follow-up question rate established by the algorithm showed that speed daters who ask more follow-up questions during their dates are more likely to elicit agreement for second dates from their partners, a behavioral indicator of liking. We also find that, despite the persistent and beneficial effects of asking questions, people do not anticipate that question-asking increases interpersonal liking.
Nelson (2005) associated 3 types of crying (inhibited, protest, despair) with 3 dimensions of attachment (avoidant, anxious, and secure). To test this theory, trained judges rated the intensity of inhibition, protest, and despair in 347 crying episodes for 40 clients and 14 therapists in 1,074 psychotherapy sessions. Crying occurred once out of every 7 sessions, and usually was characterized by protest or inhibition. Pre-therapy attachment dimensions of both therapist and client influenced crying. Therapists with high attachment avoidance had clients who cried frequently but less over time, whereas therapists with high attachment anxiety had clients who cried with more protest over time. Clients with high attachment anxiety initially cried with more protest and inhibition, but decreased over time, whereas clients with low attachment anxiety increased protest over time. Throughout the course of psychotherapy, therapists who were seen by their clients as establishing a secure attachment elicited more overall crying and a higher intensity of protest, whereas therapists who were seen by their clients as establishing insecure attachments had clients who cried less. Clients who established a secure or avoidant relationship with their therapists, relative to other clients of that therapist, cried infrequently and with inhibition, whereas clients who established a preoccupied relationship cried relatively often. Changes are suggested for Nelson’s (2005) typology.
This article investigates whether patients' sense of self and therapists' interventions aimed at orienting patients toward affect produce an affective activation in the patient. Both the independent contribution of sense of self and therapist intervention, as well as sense of self's moderating effect on therapist interventions, were investigated. Fifty cluster C patients were analyzed using 2 psychotherapy process measures and multilevel modeling. The results indicate that patients' affect experience increases over time. Both the therapist orienting the patient toward affect and the patient's sense of self predicted affect activation for the within-person effect (i.e., the patient's or therapist's standing in any given session relative to his or her baseline), but only sense of self was significant for the between-person effect (i.e., the patient's standing relative to all other patients). The relationship between a therapist orienting the patient toward affect and the patient's affective response was moderated by the patient's sense of self. The results have implications for therapists who want their patients to experience affect in a session. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
The purpose of this study was to test the notion that complementary attachments are best for achieving a secure base in psychotherapy. Specifically, we predicted third to fifth session alliance from client- and therapist-rated attachment style interactions. Using a combined sample of 46 therapy dyads from a community mental health clinic and university counseling center, the client- and therapist-perceived therapy alliance, attachment anxiety, and attachment avoidance were examined at the beginning of therapy. The results of an Actor-Partner Interdependence Model (APIM; Kenny & Cook, 1999, Partner effects in relationship research: Conceptual issues, analytic difficulties, and illustrations. Personal Relationships, 6, 433-448.) indicated that there was no direct effect of either client or therapist attachment style on therapist or client early ratings of the alliance. One significant interaction emerged and indicated that client-perceived alliance was influenced by therapist and client attachment anxiety. The client-perceived early alliance was higher when more anxious therapists worked with clients with decreasing anxiety. The client early alliance was higher when less anxious therapists worked with clients with increasing anxiety. The findings partially support the notion that different attachment configurations between the therapist and client facilitate greater alliance, but this was the case only when assessing client-perceived early alliance and only with regards to the dimension of attachment anxiety. There were no significant main effects or interactions when exploring therapist-perceived alliance. Implications of the findings are discussed along with recommendations for future study and clinical training. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
This study supported evidence of reliability and validity of the Theoretical Orientation Profile Scale-Revised (TOPS-R) scores. The TOPS-R was designed to measure theoretical orientation among counselors and trainees. Factor analysis yielded a 6-factor solution accounting for 87.5% of the total variance in the scale. The 6 factors corresponded to 6 schools of psychotherapy (i.e., psychoanalytic/psychodynamic, humanistic/existential, cognitive-behavioral, family systems, feminist, and multicultural).
This study investigated client and counselor trainee attachment as predictors of session evaluation and countertransference behavior in 93 first counseling sessions. Results indicated that client attachment predicted aspects of session evaluation, whereas counselor attachment and the interaction of client and counselor attachment predicted aspects of countertransference. Specifically, client fearful attachment was negatively associated with client ratings of session smoothness and depth and with counselor ratings of session smoothness. Counselor dismissing attachment was positively associated with supervisor ratings of hostile countertransference. Furthermore, interactions between client and counselor attachment predicted hostile and distancing countertransference reactions, such that countertransference was highest when the client had a preoccupied attachment pattern and the counselor trainee had a fearful or dismissing attachment pattern. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Examined the effects of counselor verbal behavior (reflections, probes, and restatements) and nonverbal behavior (presence or absence of nodding and smiling) on the verbal responses of 48 undergraduates. Each S participated in a half-hour counseling session which was divided into 4 time periods (baseline, counselor intervention, baseline, and counselor intervention). It was observed that probes resulted in more discussion of feelings than did either reflections or restatements. Nonverbal behavior did not affect discussion of feelings. Possible reasons for the effectiveness of the probe are considered. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
A standard criterion for judging the value of a psychotherapy process component (e.g., reflection of feeling) is the degree to which it correlates with outcome measures. It is argued that this model overlooks wide variation in client requirements for particular process components and therapist responsiveness to those requirements. Any such responsiveness tends to attenuate (and may even reverse) the process–outcome correlation. Under optimum conditions, process components covary responsively with client requirements but not with outcomes. Deviations from optimum would not improve outcomes. Thus, for expertly conducted therapy, the expected correlation of process components with outcomes approaches zero, even for components that help to cause those outcomes. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The purpose of this study was to understand how the real relationship (RR) relates to important process and outcome variables from both the clients’ and therapists’ perspectives. Using a sample of 31 therapist/client dyads at a university counseling center, the authors examined the RR at the 3rd session of therapy and at termination. The results revealed that client adult attachment avoidance was negatively correlated with client RR, while client adult attachment anxiety was uncorrelated. Therapists’ ratings of negative transference were negatively correlated with therapist-rated RR and were uncorrelated with client-rated RR. Hierarchical linear modeling analyses were conducted to predict postintervention outcome from client and therapist perceptions of the RR. Therapists’ ratings of the RR accounted for a significant amount of variance in client posttreatment symptoms while controlling pretreatment symptoms. Client-rated RR total scores and client and therapist 3rd-session alliance scores were not significant predictors of postsymptom ratings. Implications of the usefulness of measuring the RR in psychotherapy are discussed, as are recommendations for future study. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
We examined therapist response modes in 127 sessions of eight cases of brief psychotherapy with experienced therapists and anxious-depressed clients. Response modes had a significant effect on immediate outcome, with self-disclosure, interpretation, approval, and paraphrase being the most helpful response modes. Therapist response modes were then examined in conjunction with therapist intentions and client experiencing in the previous speaking turn, both of which accounted for more of the variance in immediate outcome than did response modes. Large individual differences were found in frequency of use and effectiveness of the response modes for different clients. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Empirical evidence supports the efficacy of psychodynamic therapy. Effect sizes for psychodynamic therapy are as large as those reported for other therapies that have been actively promoted as “empirically supported” and “evidence based.” In addition, patients who receive psychodynamic therapy maintain therapeutic gains and appear to continue to improve after treatment ends. Finally, nonpsychodynamic therapies may be effective in part because the more skilled practitioners utilize techniques that have long been central to psychodynamic theory and practice. The perception that psychodynamic approaches lack empirical support does not accord with available scientific evidence and may reflect selective dissemination of research findings.
Attachment style describes characteristic patterns of relating to close others and has important implications for psychotherapy. This chapter provides an original meta-analysis of 36 studies (3,158 patients) to determine the association of patient attachment with psychotherapy outcome. Patients with secure attachment pretreatment show better psychotherapy outcome than insecurely attached patients. Further, improvements in attachment security during therapy coincides with better treatment outcome. Moderator analyses suggest that those who experience low attachment security may find better treatment outcome in therapy that focuses on interpersonal interactions. The chapter closes with research limitations, training implications, diversity considerations, and therapeutic practices.
Process analyses revealed that interpretations and exploration of feelings were helpful across two cases. Other interventions were helpful for one case but not the other.
Abstract The purpose of this study was to investigate the use and perceived effects of immediacy in 16 cases of open-ended psychodynamic psychotherapy. Of 234 immediacy events, most were initiated by therapists and involved exploration of unexpressed or covert feelings. Immediacy occurred during approximately 5% of time in therapy. Clients indicated in post-therapy interviews that they remembered and profited from immediacy, with the most typical observed consequences being clients expressing feelings about the therapist/therapy and opening up/gaining insight. Amount of immediacy was associated with therapists' but not clients' ratings of session process and outcome. Therapists focused more on feelings and less on ruptures, and initiated immediacy more often with fearfully than with securely attached clients. Implications for practice, training, and research are offered.
12 sessions of personal, insight-oriented counseling were conducted by a female psychologist with a female undergraduate with a dominating, melodramatic communication style. The client's presenting problems were difficulties with her boyfriend and family, anxiety, and headaches. The counselor's style was interpretive, confrontive, and experiential within the context of a safe, supportive, therapeutic atmosphere. Process measures indicated that the client increased amount of experiencing and insight and decreased amount of time spent describing her problems both within and across sessions. Mechanisms of change seemed to be interpretations, direct feedback, gestalt exercises, and discussion of the counselor–client relationship, following the establishment of rapport and support. Client's scores on the Hopkins Symptom Checklist and Tennessee Self-Concept Scale showed that treatment had resulted in an improvement that was maintained at 2 mo, but the client had relapsed at a 7-mo follow-up. Process analyses suggested that relapse occurred because counseling was too brief, not allowing enough time for the client to incorporate changes. (46 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
A strong or weak message was introduced to 160 undergraduates with either rhetorical questions or statements under high or low issue involvement. Introductions with rhetorical questions were found to produce more favorable thoughts and a more positive attitude than statements when strong arguments were employed, and more unfavorable thoughts and less positive attitude when weak arguments were employed. Introductions with rhetorical questions led to more favorable thoughts than statements when involvement was low and to more unfavorable thoughts and a less positive attitude when involvement was high. It is argued that introductions with questions arouse the reader's uncertainty and motivate more intensive processing of message content than statements. The possibility of a nonmonotonic relation between issue involvement and persuasion given a strong counter-attitudinal message is suggested. (31 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Designed for undergraduate and first-year graduate students in counseling curricula, this textbook presents a 3-stage model of helping: exploration, insight, and action. Grounded in client-centered, psychoanalytic, and cognitive-behavioral theory, this approach recognizes the critical role of affect, cognition, and behavior in the process of change. Each skill is defined in separate chapters with a discussion of the rationale for each skill's use and the nuances of application in a helping session. Discussion questions and role playing exercises related to personal and professional growth are also included. The book is accompanied by a test booklet that covers all of the chapters in the textbook as well as some overall short answer and essay questions. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
In an investigation of the exploration stage of single counselling sessions with 26 anxious female volunteer clients and 13 female doctoral student therapists, no overall association was found between client narrative processing modes and subsequent therapist verbal response modes. There was evidence in a third of the sample for an association between therapist response modes and subsequent client narrative modes, such that clients used more internal than external or reflexive narrative processing modes when therapists used open questions about feelings and reflections of feelings. Client and therapist helpfulness ratings did not differ for different therapist response modes or client narrative process modes. Hence, overall results suggested that all four therapist response modes (open questions about thoughts, open questions about feelings, restatements, reflections of feelings) are effective during the exploration stage.
The authors systematically examined the relationship between therapist facilitation of patient emotional experience/expression and outcome in psychodynamic psychotherapy.
Computer and manual searches were conducted for relevant publications, and 10 independent samples of short-term dynamic psychotherapy were included in a meta-analysis. Data analysis included calculation of an overall effect size of the relationship between therapist affect focus and outcome, statistical significance, and test for homogeneity. In addition, moderator analyses were conducted to examine the potential impact of type of outcome construct used and the methodological quality of individual studies.
The overall average weighted effect size across all outcome types was statistically significant (r=0.30), and the homogeneity statistic was nonsignificant. Moderator analyses indicated a statistically significant relationship between therapist facilitation of patient emotional experience/expression and outcome when more than one outcome construct was included but not when either a single or an unclear outcome construct was used. There were no significant relationships between methodological quality and the size of the effects, although use of audio- or videotaping for supervision demonstrated a moderate effect.
These data indicate that therapist facilitation of patient affective experience/expression is associated with patient improvement over the course of psychodynamic psychotherapy. Although the size of this relationship was not significantly related to methodological quality, results suggest the importance of close supervision of actual techniques through the use of audio- or videotapes. Additionally, results highlight the importance of defining outcome in a multidimensional way to properly assess theoretically relevant effects.
Methodological issues in studying psychotherapy processes and outcomes
- C E Hill
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Hill, C. E., & Lambert, M. J. (2004). Methodological issues in
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Emotion recognition in psychotherapy: Impact of therapist level of experience and emotional awareness
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Psychoanalytic psychotherapy: A practitioner's guide
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McWilliams, N. (2004). Psychoanalytic psychotherapy: A practitioner's guide. New York: Guilford.