The Role of Safety Behaviors in Panic Disorder Treatment: Self-Regulation or Self-Defeat? Abstract Safety behaviors (SBs) are generally perceived as ‘dysfunctional’ emotion-regulation strategies that reduce physical symptoms and prevent unrealistic feared consequences of panic attacks. However, it is unclear whether all types of SBs are a hindrance or whether some may promote self-regulation in treatment. We propose that the type of SBs might explain some of the variability between panic disorder (PD) patients, and might help to predict why treatment is more successful for some than for others. In this secondary analysis of a subsample of 65 PD patients who received Cognitive Behavioral Therapy in a two-site randomized controlled trial, we examined the associations between type of SB and pre-treatment characteristics and their predictive value on trajectories of change in treatment process and outcome (panic symptoms, interpersonal problems, alliance). An observer-rating system for five types of SBs (avoidance/distraction/control-function and object/people-focus) was developed and applied to videotaped early treatment sessions, with high reliability. Patients with higher levels of people-focused SBs reported higher levels of panic symptoms pre-treatment at both treatment sites. These people-focused SBs predicted poorer treatment response on panic symptoms at one of two sites. Avoidance, control, or distraction-function and object-focused SBs were not associated with treatment process or outcomes. People-focused SBs may worsen PD symptoms, and possibly slow treatment progress, although this latter finding was not consistent across sites. This study differentiated between types of SBs and identified people-focused SBs as possible predictor of symptom change in CBT for PD—potentially relevant for efforts to improve treatment response.

Resilience, Defense Mechanisms, and Implicit Emotion Regulation in Psychodynamic Child Psychotherapy Abstract Resilience is associated with the internal capacity for the regulation of unpleasant emotions in the face of adversity. These self-regulatory processes, linked with both explicit and implicit emotion regulation systems, have wide ranging implications for overall psychological health. Child psychotherapy can be conceptualized as helping children adapt more effectively to the external environment and develop a more comfortable sense of self as a result of improved emotion regulation and, thus, greater resilience. Most available treatments for youth promote resilience by addressing the explicit emotion regulation system. These treatments include helping parents improve their parenting skills or helping youth modify dysfunctional thinking patterns. In these treatments there is less consideration of the key role of implicit emotion regulation in the enhancement of resilience. The psychodynamic construct of defense mechanisms offers an observable and measurable manifestation of implicit emotion regulation. Thus, addressing the nature of a child’s maladaptive defense mechanisms in the clinical situation can strengthen the implicit emotion regulation system without explicitly instructing the parent or the child to act in a more pro-social manner. This paper utilizes a Regulation Focused Psychotherapy for Children (RFP-C) model to describe how iterative, systematic interpretation of children’s maladaptive defense mechanisms can target the implicit emotion regulation system. This intervention aims to improve the capacity for self-regulation, increase the flexibility of responses to the environment, promote proactivity towards change, and improve interpersonal relatedness. As a result of increases in these adaptive implicit emotion regulation capacities, there is a resultant increase in resilience, especially for children who respond to stressful events with externalizing behaviors. A brief clinical illustration is provided.

Psychological Correlates of Change in Emotion Regulation Over 8 Months of Psychotherapy Abstract Emotion regulation corresponds to the individual’s ability to identify and modulate emotional experiences and improvements thereof over the course of psychotherapy are associated with the reduction in psychiatric symptoms across multiple diagnoses. However, the extent to which changes in the capacity for emotion regulation over the course of therapy relate to individual differences in emotion-related self-perceptions, degree of psychiatric distress, and the reasons for seeking psychotherapy remain understudied. This study explored the relations between changes in the capacity for emotion regulation over 8 months of psychotherapy, as defined by all subscales of the Difficulties for Emotion Regulation Scale, trait emotional intelligence and psychological distress. In addition, this study examined whether changes in the capacity for emotion regulation differed between patients reporting at least one regulation treatment goal and those reporting other goals. Data were collected as part of an ongoing program evaluation at an urban community-based mental health clinic. Self-report questionnaires were completed by 74 patients prior to beginning psychotherapy and after completing 8 months of psychotherapy. We found that higher trait emotional intelligence and lower psychological distress were related to improvements in emotion regulation. Moreover, the capacity for emotion regulation, particularly emotional awareness and limited access to emotion regulation strategies, worsened among individuals who reported at least one regulation treatment goal relative to those who reported other goals. As such, an initial phase of psychotherapy that focuses on integrating skills and self-awareness of emotional sensations prior to or in conjunction with embarking on an open-ended exploratory treatment is recommended.

The Relationship Between Client Regulatory Focus and Treatment Use Intentions, Attitudes, Credibility Beliefs, and Outcome Expectations for Psychotherapy Abstract Client variables in psychotherapy have been shown to play an important role in psychotherapy, explaining a significant amount of variance in treatment engagement, the therapeutic alliance, and psychotherapy outcomes; however, little is known about how the client variables develop. Specifically, there may be internal characteristics of the client that underlie several client attitudinal variables that play a role in psychotherapy. The purpose of this study was to test one particular client internal characteristic (regulatory focus) as a predictor of the psychotherapy use intentions, attitudes, credibility beliefs, and outcome expectations that clients hold. Participants from a nation-wide sample of adult clients (N = 663) and a sample of college students (N = 192) completed measures of regulatory focus, treatment use intentions, attitudes toward psychotherapy, credibility beliefs, and outcome expectations. Taken together, participants’ promotion-focus and prevention-focus scores significantly predicted treatment use intentions, attitudes, credibility beliefs, and outcome expectations. Specifically, across both samples a greater promotion-focus was significantly associated with more positive attitudes, credibility beliefs, and expectations. In contrast, a greater prevention-focus was significantly associated with more negative attitudes and not significantly related to credibility beliefs for psychotherapy. These results suggest that researchers and clinicians may want to focus on increasing promotion-focused goals and attitudes in clients in order to increase psychotherapy treatment-seeking and engagement.

“The Nominees for Best Article …”: Awards for the Most Valuable Papers on Psychotherapy in 2018 Abstract Each year, many important articles are published that make valuable contributions to the field of psychotherapy. It is helpful to remain informed about recent developments in the field, and respect the useful refinements that are being proposed in various journal articles. Unfortunately, with so many journals in the field, it can be challenging to find the best articles, and some important papers may be overlooked. In recent years, the situation has become even worse with the expansion of many new and often predatory journals, publishing inferior papers. The Journal of Contemporary Psychotherapy awards program has two main goals. First, the review of the recent literature helps to highlight the useful papers published during the previous year. Second, the awards program helps to praise the best and inspire the rest, aiming to motivate the field to publish high quality papers. The awards selection process involved a review of numerous academic articles published during 2018 in 60 different professional journals. Then, a panel of judges reviewed 52 finalists for ten possible awards. Adequate agreement was found to provide awards for nine different categories of research studies or review articles. Each winning paper is reviewed, and most authors provide a behind-the-scenes look at the work involved in their valuable contribution to the field of psychotherapy.

Therapist Experience, Personal Therapy, and Distressing States of Mind: Regulation and Resonance as Dialectics of Therapeutic Empathy Abstract The current study is based on the notion of an empathic dialectic, marked by states of emotional resonance and regulation, which has been described by contemporary theories of therapeutic empathy and empirically supported by research on non-therapists. We operationalized emotional resonance as personal distress empathy, and we sought to examine how activities promoting self-regulation impact the association between personal distress empathy, and other facets of poor self-regulation. This was accomplished through an online study, which administered several self-report instruments to a sample of 158 non-therapists and 139 therapists of various levels of experience, collecting participants’ demographic information, attachment status, level of shame-proneness, the fear of invalidity, and personal distress empathy. We examined the impact of several moderators on the paths from attachment anxiety, shame-proneness, and the fear of invalidity to personal distress empathy; and, thus, on the indirect effect between attachment anxiety and personal distress empathy. For our first hypothesis, we expected therapist status to significantly moderate the paths in this proposed meditation. For our second hypothesis, we anticipated personal therapy sessions would significantly moderate this meditation. For our third hypothesis, we expected that both personal therapy and therapist experience level would moderate this mediation. Most notably, our results indicated that the fear of invalidity explained the association between attachment anxiety and personal distress empathy, and this mediation was stronger among non-therapists when compared to therapists. Yet, personal therapy did not similarly impact the relationships among these variables. Implications for future research are discussed.

Rejection Sensitivity and Self-Regulation of Daily Interpersonal Events Abstract The present research case sought to illustrate how self-regulatory patterns of interpersonal behavior manifest within a rejection sensitive individual at the daily level. Cross-sectional research has demonstrated negative relational outcomes associated with rejection sensitivity, but less attention has been paid to how this manifests in daily relational events. Expanding upon prior research evaluating the daily interpersonal functioning of those with high rejection sensitivity in a large sample, the research case study of Mary demonstrates how findings from research may manifest within a rejection sensitive individual who was asked to rate her interpersonal events over the course of a week. For Mary, covariations among her interpersonal perceptions suggest a negativity bias that may be basis of a self-fulfilling prophecy, in which her rejection expectancies come to be realized through her treating agency as unfriendly behavior. The implications for psychotherapy of interpersonal patterns typically observed in rejection sensitive clients are discussed.

Panic-Focused Reflective Functioning and Comorbid Borderline Traits as Predictors of Change in Quality of Object Relations in Panic Disorder Treatments Abstract The aim of this study was to investigate whether (a) baseline levels of panic-specific reflection function (PSRF; i.e. patients’ capacity to reflect on their panic symptoms) and improvement in this capacity over treatment, (b) baseline borderline personality disorder (BPD) traits and pre–post treatment improvement in BPD traits predict change in patients’ quality of object relations (QORs). A subsample of 102 patients diagnosed with panic disorder from a larger randomized controlled trial received either Cognitive-Behavioral Therapy or Panic-Focused Psychodynamic Psychotherapy. We investigated whether baseline levels and change in both PSRF and BPD traits (as measured by the Structured Clinical Interview for DSM-IV Axis II) predicted pre–post change in QORs, while controlling for pre–post treatment change in panic symptoms assessed by the Panic Disorder Severity Scale. In both treatments, higher baseline levels of PSRF and lower levels of BPD traits, as well as pre–post decrease in BPD traits, predicted improvement in QOR when controlling for symptomatic change. The findings suggest that reduction in comorbid BPD traits can facilitate improvement in patients’ QORs even in brief symptom-focused psychotherapies. Additionally, patients with higher baseline levels of symptom-focused reflective function and lower BPD traits are more likely to demonstrate interpersonal change over the course of psychotherapy for panic disorder. Finally, our study highlights the importance of examining therapeutic change beyond reduction in symptoms, particularly in domains of interpersonal functioning.

Enhancing Empathy in Emotion-Focused Group Therapy for Adolescents with Autism Spectrum Disorder: A Case Conceptualization Model for Interpersonal Rupture and Repair Abstract Adolescents with autism spectrum disorder (ASD) are vulnerable to trauma-related experiences due to difficulties in emotion recognition, including recognising their own and others’ emotions, leading to interpersonal conflict and problems in making and maintaining friendships. There are limited intervention methodologies of how to work with interpersonal conflict and relational repair. This paper presents, for the first time, a case conceptualization model of relational rupture and repair as a clinical strategy to guide therapists working therapeutically with clients with ASD. The model is constructed from a task analysis applied to dyads of therapy and Interpersonal Process Recall sessions of Emotion-Focused Group Therapy with autistic adolescents (EFGT-AS). This model shows that when therapists use Interpersonal Process Recall of shared trauma-related experiences and misempathy encounters as a process-guiding method, it leads to a deepening of emotional processing in both cognitive and affective empathy. Autistic adolescents are able to use EFGT-AS to explore self-agency within interpersonal ruptures and enhance self and other cognitive-affective empathy within a relational repair process. This rational-empirical model for working with relational rupture and repair stands as a hypothesis for future testing.

Effects of Dialectical Behavior Therapy on Executive Functions, Emotion Regulation, and Mindfulness in Bipolar Disorder Abstract Bipolar disorder (BD) is a debilitating psychiatric disorder characterized by recurrent depression, manic, and hypomanic episodes. Patients with BD are also likely to experience difficulties with executive functions and emotion regulation. The literature review states that little research has been done on dialectical behavior therapy (DBT) for BD, and there has not been an examination of this therapy on BD patients’ executive functions and emotion regulation. The present study addresses this absence of research with a pilot study on 60 BD patients. Participants in the intervention group received twelve 90-min sessions adapted from a standard DBT protocol for BD and the control group was on a wait-list for treatment. Participants completed measures of mental wellbeing and executive functioning at baseline, immediately after the intervention, and 3 months later as a follow-up. Results showed that the intervention group improved over time, having lower scores in mania, depression, and emotion disregulation than the control group post-treatment. Further, the intervention group had higher scores in mindfulness, planning, problem-solving, and cognitive flexibility than the control group. The findings highlight that DBT, alongside prescription medication, can be an effective therapy for BD as well as leading to reduced manic and depression symptoms and improved executive functions, emotion regulation, and mindfulness.