Contemporary Psychotherapy

Psychotherapeutic Treatment of Depressive Symptoms in Patients with Narcissistic Disturbances: A Review Abstract This review sought to outline the common complicating and facilitating factors during treatment of depressive symptoms in patients with narcissistic pathology, including various specific treatment approaches. A systematic literature search was performed to identify literature describing the co-occurrence of depressive symptoms and narcissistic pathology along with psychotherapeutic considerations and methods used to treat depressive symptoms in such patients. Theory and research suggest that depressive symptoms often co-occur with narcissistic disturbances because depression may emerge when narcissistic defenses fail. Narcissistic disturbances are thought to oscillate between grandiose and vulnerable features, and patients often seek treatment when they are in the vulnerable state. Psychological factors that are frequently dysregulated in these patients are shame, perfectionism and aggression. These factors must therefore be recognized as a part of the narcissistic pathology, and should particularly be considered in order to build a psychotherapeutic alliance with the patient, to avoid premature termination of treatment, and to achieve a positive treatment response. Psychotherapy must primarily target the underlying narcissistic disturbance, and not the depressive symptoms per se. The review aims at outlining treatment approaches that may be useful for clinicians.

The Assessment of Mentalization: Measures for the Patient, the Therapist and the Interaction Abstract Mentalization has been clearly defined in the literature as a relational concept and yet in surveys and transcript-based measures it is almost universally treated as an individual capacity. That approach has value but may not capture the emergent nature of mentalization, as it is jointly constructed within a relational context. We report here on a critical evaluation of measurement approaches commonly used to conceptualize and assess mentalization and argue for the value of conversation analysis (CA) as an alternative approach. A variety of approaches have been shown to have utility in assessing mentalization as an individual capacity. We illustrate how conversation analysis allows for an in-depth-analysis of mentalization as it is co-created across different contexts in real-life therapy sessions. This method of analysis shifts the focus from content to process. Conversation analysis is a potentially valuable tool to support training, to assess treatment integrity, and to improve outcomes with mentalization-based interventions.

Valued Living Before and After CBT Abstract Whether and to what degree psychotherapy leads to changes in patients’ value-based actions is not well documented. In this study we examined whether cognitive behavioral therapy, without explicit values work, enhanced value-oriented action. We also explored the role of change in valued action for subsequent life satisfaction and continued change after therapy. Additionally, data on the reliability and validity of the Valued Living Questionnaire (VLQ) are reported. We analyzed the pre-, post-, and 6-month-follow-up-data of 3687 patients of a university psychotherapy outpatient clinic, most of which suffered from reliably diagnosed anxiety and mood disorders. Questionnaires included the VLQ (with 10 items each on the “importance” and “consistency” of values), symptom scales (Beck Depression Inventory; Brief Symptom Inventory), and the Satisfaction with Life Scale. Over the course of therapy significant improvements in value-oriented action were found (d = .34), especially in treatment responders (d = .51). Increase of value-oriented action significantly explained satisfaction with life at end of treatment, even after controlling for symptom reduction. Temporally preceding improvement on the VLQ predicted further symptom reduction until follow-up. Data indicate that psychotherapy positively affects valued living, even when it is not explicitly targeted in treatment. Valued living may have a role in the course and maintenance of therapeutic change.

Misophonia, Maladaptive Schemas and Personality Disorders: A Report of Three Cases Abstract Misophonia is a chronic condition in which specific sounds cause intense negative emotions and autonomic arousal. Misophonia is considered a psychological disorder without any relationship with specific alterations of hearing receptors and independent from physical characteristics of the sound. Moreover if misophonia can be defined as a specific psychiatric disorder or a correlate of other conditions is still under debate. The patients were two women and one man. In this case series we first identified the presence of triggers sounds inducing misophonia as reported during the psychotherapy sessions. At a qualitative level all the three patients perceived that the others were intentionally acting with the purpose of underline their maladaptive interpersonal schemas. All the patients were evaluated with the use of questionnaires. Regarding personality disorders (PD) all three patients suffered from at least one PD. As regard depression, one had moderate depression and one had severe depression. Two patients had moderate/severe anxiety. All the three patients can be considered as highly problematic in the interpersonal domain. Our findings have clinical implications for the treatment of misophonia because it seems to be sustained by underlying PD or maladaptive interpersonal schemas. The qualitative analysis of these cases has highlighted how patients with misophonia tended to ascribe intentionality to the people who emit the sounds that trigger their negative emotional reactions. Further studies are necessary to evaluate which kind of interpersonal patterns occur in these patients.

The Therapists’ Training and Their Attitudes Towards Therapy as Predictors of Therapeutic Interventions Abstract Previous results have demonstrated that psychotherapists working in a practice setting have a relatively low treatment adherence, regardless of the therapy school to which they were affiliated. The objective of this study was to investigate whether the therapist’s attitudes in therapeutic matters are a better predictor of interventions employed than the therapeutic method in which the therapist was trained. The relationships between various types of psychotherapeutic intervention and both predictors were tested by means of Markov Chain Monte Carlo simulations. A total of 162 therapy sessions conducted by 18 therapists affiliated to 6 different therapeutic methods were analyzed. The interventions were classified according to the criteria of essentiality and commonality. The analysis showed that 40% of the examined intervention types were significantly associated with at least one of the nine attitude scales considered, whereas only 14% exhibited a significant association with the completed type of therapy training. The latter predictor was only associated with interventions of the kind essential/not common, whereas the attitude scales were related with both essential and common interventions. The rather weak association between the type of completed training and preferred therapeutic intervention types means that many essential intervention techniques acquired during training assume a subordinate role in a practice setting. Choice of therapeutic action is conditioned to a greater extent by nuances in individual attitudes, which may change throughout a professional career. The reciprocal influence of a psychotherapist’s attitude and his or her professional development is discussed.

Emotion-Focused Therapy: A Transdiagnostic Formulation Abstract Recent years have seen the emergence of transdiagnostic psychotherapeutic treatments, typically targeting depression, anxiety and related disorders. The rationale for developing transdiagnostic protocols is based on a number of factors; shared etiology and maintenance mechanisms, high co-morbidity, hypothesising that discrete disorders may be underpinned by common psychological vulnerabilities, and the burden currently placed on clinicians to master multiple disorder-specific interventions. This paper describes a transdiagnostic model of emotion-focused therapy (EFT-T), which combines modular (targeting specific clusters of symptoms) and shared mechanisms (targeting underlying vulnerability) approaches to the treatment of depression, anxiety and related disorders such as obsessive–compulsive and trauma/stressor related disorders. The model proposes that clients’ core vulnerabilities are linked to specific chronic painful feelings, and that these chronic feelings are constellations of sadness/loneliness, shame, and fear-based emotions, idiosyncratically shaped by personal history. The paper describes how EFT-T addresses problematic symptoms but primarily focuses on transforming emotion vulnerability, or Core Pain, by activating adaptive emotional responses, such as compassion and protective anger, to embedded unmet needs. As all hitherto presented transdiagnostic protocols have emanated from within the cognitive behavioural paradigm, the aim of the described model is to increase the choice of evidence-based transdiagnostic interventions available to clinicians and clients.

Constructions of Nonagency in the Clients’ Initial Problem Formulations at the Outset of Psychotherapy Abstract This multiple case study investigated how clients construct nonagentic positions when formulating their problems in the beginning of their first psychotherapy session. The initial problem formulations of nine clients entering psychotherapy were analyzed with a detailed model drawing on discursive methodology, the 10 Discursive Tools model (10DT). We found ten problem formulation categories, each one distinguished by the tool from the 10DT model primarily used to construct nonagency. All clients gave several problem formulations from different categories and constructed nonagentic positions with a variety of discursive tools. When the resulting problem formulation categories were read in comparison with the descriptions of the client’s stance at the outset of psychotherapy as presented in two change process models, the Assimilation of Problematic Experiences Sequence and the Innovative Moments Coding System, some similarities were found. However, the 10DT model brought out much variation in the client’s nonagentic positioning in the formulations, forming a contrast with the more simplified presentations of the client’s initial nonagency given in the change process models. Therapists should pay close attention to how clients express their sense of lost agency at the outset of psychotherapy and how this positions both the client and the therapist as future collaborators in psychotherapy.

The Common Process of Supervision Process: The Supervision Session Pyramid as a Teaching Tool in the Beginning Supervision Seminar Abstract We take up three fundamental considerations: (a) regardless of supervisory perspective adopted, there is a common process to supervision session process; (b) supervision is a cyclical affair across sessions and, oftentimes, even within sessions; and (c) beginning supervisor trainees, whatever the supervisory perspective to which they will eventually subscribe, can benefit from having a simple conceptual way of thinking about the commonalities of supervision session structure. Although the supervision process (e.g., supervision stages) is a widely considered topic, supervision session process—the workings of each individual session—is comparatively a far less considered facet of the supervisor-supervisee interaction. But beginning supervisor trainees often struggle mightily with that very issue: They lack any sort of conceptual perspective on how to best proceed in the moment to moment unfolding of the supervision hour and can understandably feel anxious and awed as a result. We propose a simple, straightforward way of thinking about supervision session flow—the Supervision Session Pyramid—as a teaching tool for use in supervisor education. Reflecting an integrated amalgam of views, the SSP provides beginning supervisor trainees with an easily-accessible visual that (a) captures a common structure of session action that is trans-theoretically applicable and (b) accentuates the ever cycling and recycling nature of the supervisory experience. Thus, we recommend that the SSP be used as a discussion stimulus in the beginning supervision seminar, or even in the supervision of supervisor trainees, as a way to organize and galvanize thinking about supervision session process.

Schematic Functioning, Interpersonal Dysfunctional Cycles and Cognitive Fusion in the Complementary Paradigmatic Perspective: Analysis of a Clinical Sample Abstract Previous research has shown that transdiagnostic variables, such as dysfunctional schemata, interpersonal cycles, and cognitive fusion, are strongly related to psychological disorders and mental health. In this sense, this study sought to clarify, identify, and differentiate to what extent early maladaptive schemas, interpersonal dysfunctional cycles, and cognitive fusion relate to each other and to determine what are their differential contributions to the regulation of psychological needs, well-being, psychological distress, and symptomatology. For this purpose, we assessed a clinical group (n = 58) and found strong associations between schemas, interpersonal cycles, and cognitive fusion within a composite model. These transdiagnostic variables predicted the regulation of psychological needs. Overall, where there is a high presence of schemas, dysfunctional cycles, and psychological rigidity, the ability to the regulation of psychological needs decreases, which in turn decreases well-being levels and increases psychological distress and symptomatology. These results may be important to case conceptualization and clinical decision making focused on the patient’s characteristics, styles of communication and needs.

The Psychotherapeutic Treatment of Schizophrenia: Psychoanalytical Explorations of the Metacognitive Movement Abstract Metacognition refers to the set of activities which allow persons to have a sense of oneself and of others available to them within the flow of daily experience. These activities range from awareness of discrete aspects of experience to their synthesis into larger, more complex ideas. Following research documenting the existence and influence of metacognitive deficits in schizophrenia, psychotherapeutic frameworks have emerged aiming to improve metacognition in this group. Metacognitive Reflection and Insight Therapy (MERIT) is one such integrative psychotherapy framework. Therapeutic targets and principles of MERIT are intended to be integrative but share common characteristics with psychoanalytical tradition in the treatment of schizophrenia. This paper accordingly explores how psychoanalytic theory can help explain how the effects of MERIT upon metacognition and self-experience in schizophrenia may reflect its effects on repairing the collapse of the boundary/connection between self and the world, mental fragmentation, and the lack of symbolization.