Testing and therapeutic alliance

According to Control-Mastery Theory, people come to therapy with an unconscious plan, to overcome their pathogenic beliefs and achieve adaptive goals. One of the primary ways patients work in therapy to disconfirm their pathogenic beliefs is by testing their validity in the therapeutic relationship. The clinician or researcher, based on the transcripts of the first hours of therapy, can reliably formulate the patient's plan using the Plan Formulation Method (Curtis & Silberschatz, 2007). Previous studies suggest that therapeutically effective interventions to patient tests are those compatible with the patient's plan, i.e., those that disconfirm his/her pathogenic beliefs and support him/her in achieving his/her goals (Silberschatz & Curtis, 1993; Silberschatz, 1986; Silberschatz et al., 1986; Horowitz et al.,1975). The aim of this study is partly to replicate the results of previous empirical research, suggesting that therapist’s pro-plan interventions to patient tests are predictive of patient’s within-session progress, but also to investigate whether these interventions are predictive of treatment outcome and of the positive working alliance. The transcripts of five brief psychodynamic psychotherapies were rated. For each case, patient's plan was formulated, patient-initiated critical incidents (tests) were identified, the case-specific accuracy of the therapist's responses to these incidents was rated, and the impact of these interventions on subsequent patient’s affect and behavior, on working alliance and on treatment outcome was measured. If these predictions are confirmed, the results of this study may increase our understanding of the link between psychotherapy processes and treatment outcomes

Patients' testing activity in psychotherapy, therapeutic alliance and treatment outcome

According to Control-Mastery Theory (Gazzillo, 2021; Silberschatz, 2005; Weiss, 1993), people come to therapy with an unconscious plan to overcome their pathogenic beliefs. The primary way patients work in therapy to disconfirm their pathogenic beliefs is by testing them in the therapeutic relationship. Previous studies suggest that therapist’s pro-plan responses to patient tests are predictive of patient’s within-session progress (e.g., Silberschatz & Curtis, 1993). The aim of this study is partly to replicate the results of previous research, but also to investigate whether these interventions are predictive of treatment outcome and strong therapeutic alliance. The transcripts of five brief psychodynamic psychotherapies were studied. For each case, the patients’ plan was formulated, patients’ tests were identified, the case-specific accuracy of the therapists responses to these incidents was rated, and the impact of these interventions on subsequent patient’s affect and behavior, on therapeutic alliance and on treatment outcome was measured. If our predictions are confirmed, the results of this study may increase our understanding of the link between psychotherapy processes and treatment outcome

The relationship between guilt, transference and personality in a sample of italian patients in therapy

Guilt is a complex and distressing emotion with multiple determinants that can be experienced in a variety of different situations (Gazzillo et al., 2017). It may be chronic or transitory, as well as conscious or unconscious, and it occurs when a person has done or feels to have done something wrong or when a person feels wrong and dangerous for being how s/he is (Albertsen, O’Connor, & Berry, 2006; Bush, 2005). If according to the psychoanalytical point of view guilt derives primarily from unconscious wishes to hurt others and stems from motives such as revenge, envy, jealousy and hatred (Freud, 1923), recent developments in biological, psychological and social sciences led to a redefinition of conscious guilt as an interpersonal emotion based on the need to maintain attachment and/or care relationships and group bonds (Baumeister, Stillwell, & Heatherton, 1994; Haidt, 2012; O’Connor et al., 2000). The first Freudian hypothesis about unconscious mental functioning fall within a model that may be described as an automatic functioning hypothesis (Weiss et al., 1986), because they conceive the unconscious psychic system (Unc) as a dynamic system characterized by drives seeking immediate relief and defenses that automatically oppose them. Within this model, psychic life is mostly driven by search for pleasure and avoidance of pain (Freud, 1911), where considerations concerning reality play a secondary role (Gazzillo et al., 2018). This higher mental functioning hypothesis, which Freud developed in some of his later works, perfectly matches recent findings of neurosciences and cognitive and evolutionary sciences, according to which the human mind is characterized by a series of conscious and unconscious processes, selected by natural evolution, that allow the individual to adapt to her/his environment (Huang & Bargh, 2014; Kenrick, 2011, Kenrick & Griskevicius 2013; Lewicki et al., 1992; Panksepp & Biven 2012; Wilson, 2012). According to the Control-Mastery Theory (CMT; Weiss, 1993; Weiss et al., 1986; Gazzillo, 2016), the human mind is “wired”, from the beginning of life, to adapt to reality, and in particular to interpersonal reality. To accomplish this, it needs to develop reliable knowledges, or beliefs, on how the surrounding environment works. Moreover, in order to survive a child needs to feel that the people caring for him or her are loving and protective, strong and happy. If this is not the case, the child will feel responsible for the parents’ lack of love and unhappiness, and guilty about having caused it or not having been able to ameliorate it. So, the child may develop a series of pathogenic beliefs that associate the achievement of personal well-being and the pursuit of healthy, realistic goals, with a fear of losing vital relationships or hurting people s/he loves and cares about (in other words, with anxiety and guilt). So, while classic psychoanalytic authors (Freud, 1923, 1924, 1939; Klein 1935, 1946) focused mainly on the intrapsychic origin of guilt and the demand for self-punishment due to perverse and destructive impulses, according to CMT the origin of guilt is interpersonal and adaptive, and stems from Fear, Attachment and Care affect systems (Gazzillo et al., 2018). Furthermore, interpersonal guilt may be the source of defenses, transference and self-sabotaging behaviors. Following this theory, guilt, thought as interpersonal and prosocial, may become dysfunctional when fed by pathogenic beliefs (erroneous assumptions that bring the person to associate the pursuing of a healthy and pleasurable goal with a danger) and it may be one of the organizers of transference. The patient may idealize, sexualize or devaluate his therapist; he may be worried about being a source of pain for his analyst, in the same way he was worried, once, about causing pain to his relatives (Bush, 2005). It is on these theorical bases that this research project is founded. The aim of this study is to empirically investigate the relationship between interpersonal guilt, transference and personality. The tools used in this study are: the Clinical Data Form (CDF; Westen, 1999), an anamnestic chart to collect information about patients and therapists; the Interpersonal Guilt Rating Scale- 15 (Gazzillo et al., 2017), and the Interpersonal Guilt Questionnaire 67 (IGQ-67; O’Connor et al, 1997) to assess interpersonal guilt of patient respectively from the therapist and the patient perspective; the Personality Relationship Questionnaire (PRQ; Bradley et al., 2005; Tanzilli et al., 2018) to assess transference; the Psychodynamic Diagnostic Prototype (PDP; Gazzillo et al., 2010), and the Personality Inventory for DSM 5 brief form (PID-5-BF; APA, 2013), to assess personality disorders/styles from both the therapist and the patient perspective. Preliminary analyses showed significant relationships between different kinds of interpersonal guilt, transference dimensions and personalities styles. First of all, we investigated the relationship between transference and interpersonal guilt with the Generalized Estimated Equations and we found positive and significative relationship between these constructs. Then, we repeated the model to see the relationship between these two variables and personality. For example, dependent personality disorder seems to be correlated with positive/working alliance, anxious/ preoccupied and sexualized transference dimensions. This personality disorder is also related to separation guilt, that is in turn related to anxious/preoccupied and sexualized transference dimensions. These results confirm the hypothesis that guilt and transference are connected and may be both considered expressions of personality. Future research will investigate the mediational role of guilt in the transference-personality relationship

Interpersonal guilt, impostor phenomenon, depression, and anxiety

Impostor phenomenon (Clance, 1985) refers to the psychological experience of individuals who perceive themselves as intellectual frauds and fear of being exposed as impostors. Previous studies suggest that the fear of failure, the fear of success, and low self-esteem are preconditions that foster the occurrence of impostor feelings (e.g., Neureiter & Traut-Mattausch, 2016). The aim of this study was to investigate the relationship between the impostor phenomenon and interpersonal guilt as conceived in Control-Mastery Theory (Faccini et al., 2020), and their association with anxiety and depression. Methods. 343 subjects completed the Interpersonal Guilt Rating Scale-15s (IGRS-15s; Faccini et al, 2020), the Clance Impostor Phenomenon Scale (CIPS; Clance, 1985), the State-Trait Anxiety Inventory (STAI; Spielberger et al., 1983), and the Beck Depression Inventory II (BDI II; Beck et al., 1996). Results. As expected, impostor phenomenon was significantly associated with self-hate, survivor guilt and omnipotence guilt. The hypothesis that these kinds of guilt and the impostor phenomenon can contribute to anxiety and depression has also been confirmed. Conclusions. This study suggests that people who experience impostor fears struggle with maladaptive feelings of guilt related to pathogenic beliefs about oneself and significant others, favoring depression and anxiety. Therefore, working on these aspects can be essential in treating these patients

Meccanismi di disimpegno morale nel disturbo ossessivo-compulsivo

Le persone sono motivate ad agire in linea con i propri standard morali ma, a volte, l’accordo tra principi e condotta morale può risultare impossibile o comportare dei sacrifici. Quando ciò accade, gli individui possono deattivare i processi di auto-regolazione, che normalmente inibiscono la messa in atto di una condotta non etica allo scopo di validare il coinvolgimento in essa. Bandura (2015) ha identificato otto meccanismi che consentono al trasgressore di agire in contraddizione con i propri valori morali senza rinunciare ad essi, mettendosi al riparo dalle emozioni negative che normalmente si associano a una condotta non etica. La ricerca ha ampiamente esplorato le risposte emotive derivanti dalla violazione dei propri standard morali e i meccanismi impiegati per farvi fronte, ma pochi studi (Tillman et al., 2018) hanno analizzato i sentimenti che l’individuo sperimenta quando apprende le conseguenze del proprio comportamento e i meccanismi a cui ricorre per convivere con esse. A partire dal dato per cui gli individui con Disturbo Ossessivo-Compulsivo sono più vulnerabili a sperimentare colpa (Mancini & Gangemi, 2022), l’obiettivo dello studio è di indagare se essi, rispetto a coloro che non ne sono affetti, sperimentino livelli più elevati di colpa sia in seguito alla decisione di mettere in atto un comportamento non etico, che all’aver appreso le sue conseguenze. Inoltre, si ipotizza che nel gruppo clinico elevati livelli di colpa correlino negativamente con il ricorso a meccanismi di disimpegno morale, mentre in quello non clinico ci si aspetta una relazione positiva. I partecipanti sono stati invitati a compilare dei questionari volti a valutare: (a) la presenza di sintomi ossessivo-compulsivi, (b) la disposizione ad agire in linea con i propri valori morali, (c) la propensione a sperimentare vergogna e diversi tipi di colpa, (d) la tendenza a ricorrere all’utilizzo di meccanismi di disimpegno morale e (e) le emozioni sperimentate in relazione a uno scenario che confronta il partecipante con un dilemma morale e con le conseguenze, più o meno gravi, derivanti dall’aver preferito la scelta non etica a quella etica. I risultati preliminari, ottenuti analizzando i dati del gruppo non clinico, indicano che i soggetti confrontati con la scelta non etica, rispetto a coloro che hanno agito eticamente, sperimentano livelli più elevati di emozioni negative sia in conseguenza alla presa di decisione che all’apprendimento dei suoi esiti. Inoltre, è emerso che coloro che sono maggiormente propensi a sperimentare colpa tendono a ricorrere ai meccanismi di dislocamento o diffusione della responsabilità, mentre coloro che sperimentano vergogna tendono a ridefinire la propria condotta o a minimizzarne le conseguenze. I risultati di questo studio potrebbero fornire un’ulteriore prova a sostegno della rilevanza dell’emozione di colpa nel Disturbo Ossessivo-Compulsivo e accrescere la nostra comprensione rispetto alle strategie utilizzate per farvi fronte

Chi è l'abusante? Un racconto a due voci sulle rotture dell'alleanza terapeutica nel trauma relazionale

La ricerca in psicoterapia ha tentato di individuare quali elementi, del paziente e del terapeuta, favoriscono e ostacolano la relazione terapeutica, ma pochi studi hanno analizzato come questi processi entrino in gioco e come possano modificarsi nel tempo, quando paziente e terapeuta condividono gli stessi fattori di vulnerabilità psicologica. Nel trauma relazionale sono presenti sentimenti di sfiducia, una percezione del mondo come pericoloso e imprevedibile e, in relazione agli altri, prevale una credenza di non amabilità. L’alleanza terapeutica può assumere una doppia valenza: se, infatti, la relazione di fiducia con il terapeuta fornisce le basi per elaborare i vissuti traumatici attraverso una nuova esperienza relazionale, è proprio la compromessa capacità del paziente di affidarsi a rendere difficoltoso il raggiungimento della stabilità nella relazione. Infatti, la sensazione di impotenza e inaiutabilità alla base del trauma porta la relazione a oscillare tra bisogni di vicinanza e di lontananza, innescando una spirale emotiva distruttiva, che può esitare nell’interruzione dell’espressività emotiva, della comunicazione e dell’intimità. Attraverso la presentazione di un caso clinico, viene messa in luce la complessità che assume la relazione terapeutica quando inserita in un ciclo interpersonale invalidante, in cui la paziente si sente trascinata a distruggere l’immagine della terapeuta, pur avvertendo il bisogno della relazione e il dolore derivante dalla sua perdita. I bisogni di sicurezza e attaccamento, uniti alla paura terrifica di perdere l’altro, attivano il bisogno di dominare l’ambiente, esitando in tentativi di soluzione basati sul controllo e sull’uso del potere, che costituiranno, nel presente caso, la principale causa di rottura del legame e il maggior fattore di mantenimento di una lunga impasse nel processo terapeutico, determinando un crollo delle competenze metacognitive e una caotica confusione di ruoli all’interno della relazione. Il setting terapeutico assume la forma di un tribunale nel quale paziente e terapeuta permangono per lungo tempo cercando, per mezzo delle proprie competenze cliniche, di trovare risposta a un unico quesito: chi è l’abusante e chi l’abusato? Per la prima volta, paziente e terapeuta espongono separatamente, in un unico contributo, il loro punto di vista nei momenti di impasse riguardo ai rispettivi ruoli nella relazione, nonché alle emozioni e tendenze all’azione attivate, in un racconto formato da due voci che si intrecciano armonicamente e si differenziano stonando. Cos’è accaduto realmente nelle loro menti? Come trovare una nuova connessione nella frammentarietà delle loro parti? Il presente contributo consente un’attenta analisi dei cicli interpersonali nella relazione terapeutica attraverso una lettura clinica integrata del paziente e del terapeuta, sostenendo il progresso della ricerca in psicoterapia volto allo sviluppo di strategie sempre più puntuali per garantirne l’efficacia

Survivor guilt: Theoretical, empirical, and clinical features

The aim of this paper is to give the reader an overview of several theoretical, empirical, and clinical features of survivor guilt, and to integrate recent contributions of psychodynamic theory and, in particular, of control-mastery theory into the understanding of the concept alongside the latest findings in social psychology about it. After introducing the concept of survivor guilt and its origins in clinical observations on the consequences of having survived severe traumas (e.g., internment in concentration camps), we will discuss the findings in social psychology on the concept of survivor guilt in everyday social interactions, which is based on a conception that does not connect it strictly to severe traumas. We will then focus our attention on clinical observations and empirical research studies about survivor guilt, discussing the hypotheses developed by several control-mastery theorists about its role in psychopathology. Finally, we will illustrate some manifestations of survivor guilt with a brief clinical vignette

Through flow and swirls: modifying implicit relational knowledge and disconfirming pathogenic beliefs within the therapeutic process

The aim of this paper is to describe and discuss the models of the process of change in psychotherapy developed by the Boston Change Process Study Group (2010), and by the San Francisco Psychotherapy Research Group (Gazzillo, 2016; Silberschatz, 2005; Weiss, 1993; Weiss, Sampson, & the Mount Zion Psychotherapy Research Group, 1986). The first model is centered on change in implicit relational knowledge and describes the process of change as being composed of “moving along” phases interspersed by “now moments” that can become “moments of meeting” if the clinician is able to give authentic and specifically fitted responses. A moment of meeting opens up space for a change in the implicit relational knowledge of the patient. The second model is centered on the idea that patients come to therapy with an unconscious plan to master traumas, pursue healthy and adaptive goals, and disprove their pathogenic beliefs, and points to how patients test their pathogenic beliefs in the relationship with the therapist, coaching the therapist about what they need. Passing patients’ tests means helping them disconfirm or undermine pathogenic beliefs that hopefully will lead to disproving them. This second model focuses on the subjective meaning of the therapeutic process as seen from the perspective of the patient. We will also try to show, using clinical examples, how these two models can be integrated and how their integration may give us a more comprehensive, tridimensional vision of the therapeutic process

Traumas and Their Consequences According to Control-Mastery Theory

The aim of this article is to introduce the reader to how control-mastery theory (CMT; Gazzillo, 2016; Silberschatz, 2005; Weiss, 1993), an integrative relational cognitive-dynamic theory of mental functioning, psychopathology, and psychotherapeutic process, understands traumas, their consequences, and their mastery. In the first part of this article, we will present an overview of the debate about the definition of trauma within the different editions of the Diagnostic and Statistical Manual of Mental Disorders. Then, we will focus on the concept of complex traumas and on their consequences on mental health. Finally, we will discuss how CMT conceptualizes traumas and their pathological consequences. We will stress in particular how, according to CMT, in order for a painful experience to become a trauma, its victim has to come to believe that s/he caused it in the attempt to pursue a healthy and adaptive goal. In order to master traumas and disprove the pathogenic beliefs developed from them, people attempt to reexperience situations similar to the traumatic ones in safer conditions while giving them happier endings