Wilcox (2024) and Boswell (2024) make a number of important observations about facilitating process sensitivity training, and here, we respond to those suggestions. We postulate that cultivating ...process sensitivity is complementary, not antithetical, to traditional training in viewing therapy from a theoretical lens, and thus, can serve to enhance, rather than replace one's existing psychotherapy skills. Moreover, we argue that seeing the impact of process adjustments in real time can be a significant motivator for training in process sensitivity since the benefits are more immediately obvious. We further argue that the field can be more thoughtful about the use of simulations in training and the emerging interactive training platforms using video stimuli, since they facilitate exposure to clinical situations in a safe manner. Finally, while learning to identify process markers can play a valuable role in optimizing the timing of interventions, we argue that this pales in comparison to the value of process sensitization as a means of attending to outcome information in the moment ("little outcome"). If successful, this opens up the possibility of developing expertise in psychotherapy, which hitherto was considered not possible. However, these propositions require rigorous testing in studies on training and supervision.
Exposure therapy is an effective approach for treating anxiety disorders, although a substantial number of individuals fail to benefit or experience a return of fear after treatment. Research ...suggests that anxious individuals show deficits in the mechanisms believed to underlie exposure therapy, such as inhibitory learning. Targeting these processes may help improve the efficacy of exposure-based procedures. Although evidence supports an inhibitory learning model of extinction, there has been little discussion of how to implement this model in clinical practice. The primary aim of this paper is to provide examples to clinicians for how to apply this model to optimize exposure therapy with anxious clients, in ways that distinguish it from a ‘fear habituation’ approach and ‘belief disconfirmation’ approach within standard cognitive-behavior therapy. Exposure optimization strategies include 1) expectancy violation, 2) deepened extinction, 3) occasional reinforced extinction, 4) removal of safety signals, 5) variability, 6) retrieval cues, 7) multiple contexts, and 8) affect labeling. Case studies illustrate methods of applying these techniques with a variety of anxiety disorders, including obsessive-compulsive disorder, posttraumatic stress disorder, social phobia, specific phobia, and panic disorder.
•We summarize the research related to an inhibitory model of exposure therapy.•Includes strategies for the acquisition, consolidation and retrieval of extinction.•Case studies provide useful guides for implementing these strategies with patients.
Since Freud, clinicians have understood that disturbing memories contribute to psychopathology and that new emotional experiences contribute to therapeutic change. Yet, controversy remains about what ...is truly essential to bring about psychotherapeutic change. Mounting evidence from empirical studies suggests that emotional arousal is a key ingredient in therapeutic change in many modalities. In addition, memory seems to play an important role but there is a lack of consensus on the role of understanding what happened in the past in bringing about therapeutic change. The core idea of this paper is that therapeutic change in a variety of modalities, including behavioral therapy, cognitive-behavioral therapy, emotion-focused therapy, and psychodynamic psychotherapy, results from the updating of prior emotional memories through a process of reconsolidation that incorporates new emotional experiences. We present an integrated memory model with three interactive components - autobiographical (event) memories, semantic structures, and emotional responses - supported by emerging evidence from cognitive neuroscience on implicit and explicit emotion, implicit and explicit memory, emotion-memory interactions, memory reconsolidation, and the relationship between autobiographical and semantic memory. We propose that the essential ingredients of therapeutic change include: (1) reactivating old memories; (2) engaging in new emotional experiences that are incorporated into these reactivated memories via the process of reconsolidation; and (3) reinforcing the integrated memory structure by practicing a new way of behaving and experiencing the world in a variety of contexts. The implications of this new, neurobiologically grounded synthesis for research, clinical practice, and teaching are discussed.
If meta-analysis is to provide valuable answers, then it is critical to ensure clarity about the questions being asked. Here, we distinguish two important questions concerning cognitive bias ...modification research that are not differentiated in the meta-analysis recently published by Cristea
(2015) in this journal: (1) do the varying procedures that investigators have employed with the intention of modifying cognitive bias, on average, significantly impact emotional vulnerability?; and (2) does the process of successfully modifying cognitive bias, on average, significantly impact emotional vulnerability? We reanalyse the data from Cristea
to address this latter question. Our new analyses demonstrate that successfully modifying cognitive bias does significantly alter emotional vulnerability. We revisit Cristea
's conclusions in light of these findings.
Prolonged exposure (PE) is an empirically-supported treatment for posttraumatic stress disorder (PTSD), but the precise mechanism(s) by which PE promotes symptom change are not well established. ...Understanding how PE works is critical to improving clinical outcomes, advancing dissemination efforts, and enhancing transdiagnostic models of psychopathology. However, mechanisms research conducted in clinical treatment settings is complex, and findings may be difficult to interpret without appropriate context. This is the first review of potential mechanisms of PE to provide such context, by rigorously evaluating empirical findings in line with essential criteria for effective research on mechanisms (or mediators). We begin by describing six putative mechanisms identified by emotional processing theory and contemporary models of fear extinction, before thoroughly reviewing empirical findings from clinical research on PE and similar PTSD treatments. We provide a detailed description of each study and mechanism test, as well as ratings of strength of evidence and quality of evaluation based on a novel rating scheme. We highlight variables with strong evidence (belief change and between-session habituation), intermediate evidence (inhibitory learning and emotional engagement), and minimal support (narrative organization and within-session habituation). After discussing limitations of the extant literature and this review, we summarize specific challenges for research on PE mechanisms and highlight directions for future study based on clinical and research implications.
•Empirical evidence for six putative PE mechanisms is reviewed.•Belief change and between-session habituation have strongest evidence base.•Extinction and emotional engagement have an intermediate level of evidence.•Trauma narrative change and within-session habituation have weak evidence base.•Recommendations for future mechanism studies are discussed.
To our knowledge, this is the first placebo-controlled randomized clinical trial to evaluate the efficacy of antidepressant pharmacotherapy, with and without complicated grief psychotherapy, in the ...treatment of complicated grief.
To confirm the efficacy of a targeted complicated grief treatment (CGT), determine whether citalopram (CIT) enhances CGT outcome, and examine CIT efficacy without CGT.
Included in the study were 395 bereaved adults who met criteria for CG recruited from March 2010 to September 2014 from academic medical centers in Boston, Massachusetts; New York, New York; Pittsburgh, Pennsylvania; and San Diego, California. Co-occurring substance abuse, psychosis, mania, and cognitive impairment were exclusionary. Study participants were randomized using site-specific permuted blocks stratified by major depression into groups prescribed CIT (n = 101), placebo (PLA; n = 99), CGT with CIT (n = 99), and CGT with PLA (n = 96). Independent evaluators conducted monthly assessments for 20 weeks. Response rates were compared under the intention-to-treat principle, including all randomized participants in a logistic regression with inverse probability weighting.
All participants received protocolized pharmacotherapy optimized by flexible dosing, psychoeducation, grief monitoring, and encouragement to engage in activities. Half were also randomized to receive manualized CGT in 16 concurrent weekly sessions.
Complicated grief-anchored Clinical Global Impression scale measurments every 4 weeks. Response was measured as a rating of "much improved" or "very much improved."
Of the 395 study participants, 308 (78.0%) were female and 325 (82.3%) were white. Participants' response to CGT with PLA vs PLA (82.5% vs 54.8%; relative risk RR, 1.51; 95% CI, 1.16-1.95; P = .002; number needed to treat NNT, 3.6) suggested the efficacy of CGT, and the addition of CIT did not significantly improve CGT outcome (CGT with CIT vs CGT with PLA: 83.7% vs 82.5%; RR, 1.01; 95% CI, 0.88-1.17; P = .84; NNT, 84). However, depressive symptoms decreased significantly more when CIT was added to treatment (CGT with CIT vs CGT with PLA: model-based adjusted mean standard error difference, -2.06 1.00; 95% CI, -4.02 to -0.11; P = .04). By contrast, adding CGT improved CIT outcome (CIT vs CGT with CIT: 69.3% vs 83.7%; RR, 1.21; 95% CI, 1.00-1.46; P = .05; NNT, 6.9). Last, participant response to CIT was not significantly different from PLA at week 12 (45.9% vs 37.9%; RR, 1.21; 95% CI, 0.82-1.81; P = .35; NNT, 12.4) or at week 20 (69.3% vs 54.8%; RR, 1.26; 95% CI, 0.95-1.68; P = .11; NNT, 6.9). Rates of suicidal ideation diminished to a substantially greater extent among participants receiving CGT than among those who did not.
Complicated grief treatment is the treatment of choice for CG, and the addition of CIT optimizes the treatment of co-occurring depressive symptoms.
clinicaltrials.gov Identifier: NCT01179568.
Objective: There is a need for rigorous methods to study the mechanisms that lead to individual-level change (i.e., process-outcome research). We argue that panel data (i.e., longitudinal study of a ...number of individuals) methods have 3 major advantages for psychotherapy researchers: (1) enabling microanalytic study of psychotherapeutic processes in a clinically intuitive way, (2) modeling lagged associations over time to ensure direction of causality, and (3) isolating within-patient changes over time from between-patient differences, thereby protecting against confounding influences because of the effects of unobserved stable attributes of individuals. However, dynamic panel data methods present a complex set of analytical challenges. We focus on 2 particular issues: (1) how long-term trajectories in the variables of interest over the study period should be handled, and (2) how the use of a lagged dependent variable as a predictor in regression-based dynamic panel models induces endogeneity (i.e., violation of independence between predictor and model error term) that must be taken into account in order to appropriately isolate within- and between-person effects. Method: An example from a study of working alliance in psychotherapy in primary care in Sweden is used to illustrate some of these analytic decisions and their impact on parameter estimates. Results: Estimates were strongly influenced by the way linear trajectories were handled; that is, whether variables were "detrended" or not. Conclusions: The issue of when detrending should be done is discussed, and recommendations for research are provided.
What is the public health significance of this article?
This article provides recommendations on how to study psychotherapy processes using dynamic panel data models to strengthen causal inferences. Accurate estimates of what drives individual development in psychotherapy are needed to generate recommendations on what therapists should focus on in therapy. Using the alliance-outcome association as an example, we show that estimated effect sizes may vary greatly depending on which modeling approach is used, with the decision on whether to remove time-trends from the outcome variable making the largest difference.
Hundreds of genetic loci increasing risk for neuropsychiatric disorders have recently been identified. This success, perhaps paradoxically, has posed challenges for therapeutic development, which are ...amplified by the highly polygenic and pleiotropic nature of these genetic contributions. Success requires understanding the biological impact of single genetic variants and predicting their effects within an individual. Comprehensive functional genomic annotation of risk loci provides a framework for interpretation of neurobiological impact, requiring experimental validation with in vivo or in vitro model systems. Systems-level, integrative pathway analyses are beginning to elucidate the additive, polygenic contributions of risk variants on specific cellular, molecular, developmental, or circuit-level processes. Although most neuropsychiatric disease modeling has focused on genes disrupted by rare, large-effect-size mutations, common smaller-effect-size variants may also provide solid therapeutic targets to inform precision medicine approaches. Here we enumerate the promise and challenges of a genomics-driven approach to uncovering neuropsychiatric disease mechanisms and facilitating therapeutic development.
Mentalizing-the capacity to understand others' and one's own behavior in terms of mental states-is a defining human social and psychological achievement. It involves a complex and demanding spectrum ...of capacities that are susceptible to different strengths, weakness, and failings; personality disorders are often associated with severe and consistent mentalizing difficulties (Fonagy & Bateman, 2008). In this article, we will argue for the role of mentalizing in the therapeutic relationship, suggesting that although mentalization-based treatment may be a specific and particular form of practice, the "mentalizing therapist" is a universal constituent of effective psychotherapeutic interventions.
In this article, we review the history and definition of countertransference, as well as empirical research on countertransference, its management, and the relation of both with psychotherapy ...outcome. Three meta-analyses are presented, as well as studies that illustrate findings from the meta-analyses. The first meta-analysis indicated that countertransference reactions are related inversely and modestly to psychotherapy outcomes (r = −.16, p = .02, 95% CI −.30, −.03, d = −0.33, k = 14 studies, N = 973). A second meta-analysis supported the notion that countertransference management factors attenuate countertransference reactions (r = −.27, p = .001, 95% CI −.43, −.10, d = −0.55, k = 13 studies, N = 1,065). The final meta-analysis revealed that successful countertransference management is related to better therapy outcomes (r = .39, p < .001, 95% CI .17, .60, d = 0.84, k = 9 studies, N = 392 participants). In all meta-analyses, there was significant heterogeneity across studies. We conclude by summarizing the limitations of the research base and highlighting the therapeutic practices predicated on research.
Clinical Impact Statement
Question: What are the potential effects on outcome of psychotherapists' reactions that are based on their unresolved personal conflicts, and how can these reactions be managed effectively? Findings: Psychotherapists' unresolved personal conflicts can give rise to reactions that negatively affect the outcome of therapy, and successfully managing these reactions seems to be an important element in positive therapy outcomes. Meaning: Psychotherapists of all theoretical orientations need to attend to their personal conflicts and monitor their reactions to clients as a routine part of effective clinical practice. Next steps: Additional research would provide insight into various ways that psychotherapists can manage their countertransference reactions, and studies are especially needed across therapeutic modalities and with culturally diverse therapists and clients.
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