Instability and Uncertainty Are Critical for Psychotherapy: How the Therapeutic Alliance Opens Us Up

Tschacher and Haken have recently applied a systems-based approach to modeling psychotherapy process in terms of potentially beneficial tendencies toward deterministic as well as chaotic forms of change in the client’s behavioral, cognitive and affective experience during the course of therapy. A chaotic change process refers to a greater exploration of the states that a client can be in, and it may have a potential positive role to play in their development. A distinction is made between on the one hand, specific instances of instability which are due to techniques employed by the therapist, and on the other, a more general instability which is due to the therapeutic relationship, and a key, necessary result of a successful therapeutic alliance. Drawing on Friston’s systems-based model of free energy minimization and predictive coding, it is proposed here that the increase in the instability of a client’s functioning due to therapy can be conceptualized as a reduction in the precisions (certainty) with which the client’s prior beliefs about themselves and their world, are held. It is shown how a good therapeutic alliance (characterized by successful interpersonal synchrony of the sort described by Friston and Frith) results in the emergence of a new hierarchical level in the client’s generative model of themselves and their relationship with the world. The emergence of this new level of functioning permits the reduction of the precisions of the client’s priors, which allows the client to ‘open up’: to experience thoughts, emotions and experiences they did not have before. It is proposed that this process is a necessary precursor to change due to psychotherapy. A good consilience can be found between this approach to understanding the role of the therapeutic alliance, and the role of epistemic trust in psychotherapy as described by Fonagy and Allison. It is suggested that beneficial forms of instability in clients are an underappreciated influence on psychotherapy process, and thoughts about the implications, as well as situations in which instability may not be beneficial (or potentially harmful) for therapy, are considered.

Intervenções Psicológicas na Iminência do Suicídio à Luz da Gestalt-Terapia / Psychological Interventions in the Imminence of Suicide in the light of Gestalt Therapy

Resumo: A proposta deste artigo é discutir os processos de intervenção da Gestalt-terapia em situação de iminente suicídio, dentro do processo de psicoterapia. Para tal, foi realizada uma pesquisa qualitativa através de uma revisão bibliográfica, utilizando-se da análise de conteúdo do material encontrado. Desse modo, ressalta-se que a pesquisa percorre um caminho histórico do fenômeno suicida e da abordagem gestáltica, para assim, entender e discutir sobre possíveis intervenções frente a iminência do ato suicida. Ademais, pretende-se refletir sobre o papel do Gestalt-terapeuta, frente a esta demanda e como é visto a pessoa que atenta contra a sua própria vida. Posto isso, salienta-se o papel do Gestalt-terapeuta com o manejo as situações de suicídio, possibilitando uma abertura para ouvir o desejo de morte, atuando de modo a realizar desvios éticos, políticos e antropológicos, bem como prestando acolhimento ao sofrimento dos consulentes para a criação conjunta de novas possibilidades de futuro para além da morte. Logo, destaca-se a importância do compromisso ético-político do profissional psicólogo perante o sofrimento do sujeito frente ao suicídio. Palavras-chave: Gestalt-Terapia; Suicídio; Clínica psicológica. Abstract: The purpose of this article is to discuss the intervention processes of Gestalt therapy in situations of imminent suicide, within the psychotherapy process. To this end, a qualitative research was carried out through a literature review, using the content analysis of the material found. Thus, it is noteworthy that the research follows a historical path of the suicidal phenomenon and the gestalt approach, in order to understand and discuss possible interventions in view of the imminence of the suicidal act. Furthermore, it is intended to reflect on the role of the Gestalt-therapist, facing this demand and how the person who attacks his own life is seen. That said, the role of the Gestalt-therapist with the management of suicide situations is highlighted, enabling an opening to listen to the death wish, acting in a way to carry out ethical, political and anthropological deviations, as well as welcoming the suffering of the consultants for the joint creation of new possibilities for the future beyond death. Therefore, the importance of the ethical-political commitment of the professional psychologist is highlighted in the face of the subject's suffering in the face of suicide.Keywords: Gestalt-Therapy; Suicide; Psychological clinic.

Case Report: Oxytocin and Its Association With Psychotherapy Process and Outcome

The potential of Oxytocin (OT) as a facilitator of psychotherapy has been previously acknowledged, nonetheless, randomized controlled trials thus far have not yielded conclusive results. One approach suggested to clarify empirical inconsistencies is to refine the study hypotheses and data collection process by utilizing an in-depth idiographic exploration of the investigated phenomena. In this case illustration we provide an in-depth analysis comparing two patients hospitalized in a closed psychiatric ward with depression and undergoing psychotherapy twice a week. These two patients were randomly allocated to receive either OT or placebo, twice a day for a period of 4 weeks. Both patients completed longitudinal assessments of process and outcome measures, and therapists' clinical notes were extracted and reviewed. Reliable clinical change was calculated for all outcome and process measures. The results indicated that the patient receiving OT showed significant improvement in interpersonal distress, as well as in anxiety and depression symptoms, while the placebo patient showed no significant change during the study period. Furthermore, while both patients showed no significant changes in the therapeutic alliance ratings, the therapist of the OT patient regularly reported positive changes in alliance in the medical notes, while no such report was observed in the placebo patient. These results suggest that changes produced by OT administration may be more noticeable by the therapist. Implications for future studies aimed at assessing the effect of OT on psychotherapy process and outcome are discussed.

A Case Formulation of Avoidant Personality based on Self Psychology Approach

The present paper focuses on Self Psychology Approach and a case study following this approach. First, Self Psychology Theory will be introduced following the main ideas of theory’s founder Heinz Kohut. In this part, the structure and development of self, selfobject needs and self disorders will be explained. Mainly, two selfobject needs (mirroring and idealizing need) will be the focus. Following this introduction to the theory, self-psychologically oriented psychotherapy process will be discussed along with its major intervention principles. Then, a case with avoidant personality characteristics will be introduced and formulated according to Self Psychology. The case will be conceptualized as a self disorder; and the narcissistic needs possibly not enough met during childhood will be emphasized. At the final part, the psychotherapy process, and experiences of the therapist will be shared. Through this study, it is aimed to highlight that psychotherapists should focus on clients’ needs, stay in the here-in-now, listen, make an effort to understand, and show this effort to the clients. It is also emphasized that ruptures during therapy should not be the moments that therapists should be afraid of, but instead they should be perceived as opportunities for the growth of clients as well as the therapeutic relationship. Keywords: Self psychology, avoidant personality, case study, self disorders, narcissistic needs

More Light? Opportunities and Pitfalls in Digitalized Psychotherapy Process Research

While the evidence on the effectiveness of different psychotherapies is often strong, it is not settled whereby and how these therapies work. Knowledge on the causal factors and change mechanisms is of high clinical and public relevance, as it contributes to the empirically informed advancement of psychotherapeutic interventions. Here, digitalized research approaches might possess the potential to generate new insights into human behavior change, contributing to augmented interventions and mental healthcare practices with better treatment outcomes. In this perspective article, we describe recent findings of research into change mechanisms that were only feasible with digital tools and outline important future directions for this rather novel branch of research. Furthermore, we indicate several challenges and pitfalls that are to be solved, in order to advance digitalized psychotherapy process research, both methodologically and technologically.

Can we learn on Psychotherapeutic Process Dimensions with Single Case Study?

Relational psychoanalysis states that an adequate management of the intersubjective processes displayed in psychotherapy are essential to promote effective change. The analysis about some variables of the therapist and patient and the complex and co-determined interaction between them, give us new perspectives on the therapeutic process. This analysis leads us to question some topics and consider from a new view the therapist's functions and the patient's roles within the therapeutic process. A group of researchers in Spain, Argentine, Mexico and Germany have worked along a decade (1997-2008) in the Salamanca-Barcelona-Madrid Project on Psychotherapy Process Research. This project, an study conducting single case research (´The Publicist´ case), along the main phases of complete treatment (up to 200 recorded sessions), have given us the opportunity to adquire a better knowledge on therapeutic process, through the content analysis of sessions and with qualitative data using a wide variety of procedures. In this paper we are presenting relevant results concerning some inferences on therapeutic process along the whole treatment and their phases. Crossing all the studied dimensions, we propose a comprehensive model of change observed in the case object of study, considering all the approaches, both from quantitative and qualitative methods and process dimensions, both the contributions of the therapist and the patient to psychotherapeutic process. Results are discussed in the light of recent perspectives on active use of counter-transference as a therapist’s tool to improve the psychoanalytic psychotherapy process, controlling negative aspects of countertransference collusions.