Dissociation and interpersonal autonomic physiology in psychotherapy research: an integrative view encompassing psychodynamic and neuroscience theoretical frameworks

Interpersonal autonomic physiology is an interdisciplinary research field, assessing the relational interdependence of two (or more) interacting individual both at the behavioral and psychophysiological levels. Despite its quite long tradition, only eight studies since 1955 have focused on the interaction of psychotherapy dyads, and none of them have focused on the shared processual level, assessing dynamic phenomena such as dissociation. We longitudinally observed two brief psychodynamic psychotherapies, entirely audio and video-recorded (16 sessions, weekly frequency, 45 min.). Autonomic nervous system measures were continuously collected during each session. Personality, empathy, dissociative features and clinical progress measures were collected prior and post therapy, and after each clinical session. Two-independent judges, trained psychotherapist, codified the interactions\u2019 micro-processes. Time-series based analyses were performed to assess interpersonal synchronization and de-synchronization in patient\u2019s and therapist\u2019s physiological activity. Psychophysiological synchrony revealed a clear association with empathic attunement, while desynchronization phases (range of length 30-150 sec.) showed a linkage with dissociative processes, usually associated to the patient\u2019s narrative core relational trauma. Our findings are discussed under the perspective of psychodynamic models of Stern (\u201cpresent moment\u201d), Sander, Beebe and Lachmann (dyad system model of interaction), Lanius (Trauma model), and the neuroscientific frameworks proposed by Thayer (neurovisceral integration model), and Porges (polyvagal theory). The collected data allows to attempt an integration of these theoretical approaches under the light of Complex Dynamic Systems. The rich theoretical work and the encouraging clinical results might represents a new fascinating frontier of research in psychotherapy

The rhythm of therapy: psychophysiological synchronization in clinical dyads

Rhythmicity and synchronization are fundamental mechanisms employed by countless natural phenomena to communicate. Previous research has found evidence for synchronization in patients and therapists during clinical activity, for instance in their body movements (Ramseyer & Tschacher, 2011) and physiological activations (e.g. Marci et al, 2007; Kleinbub et al., 2012; Messina et al., 2013). While this phenomenon has been found associated with different important aspects of clinical relationship, such as empathy, rapport, and outcome, and many authors suggested that it may describe crucial dimensions of the therapeutic dyad interaction and change, a clear explanation of its meaning is still lacking. The goals of the present work were to: 1) Provide a solid theoretical and epistemological background, in which to inscribe the phenomenon. This was pursued by crossing neurophenomenology’s sophisticated ideas on mind-body integration (Varela, 1996) and Infant Research’s detailed observations on development of infants’ Self through their relationships. The common ground for this connection was the complex systems theory (von Bertalanffy, 1968; Haken, 2006). 2) Contribute to literature through two replications of existing studies (Kleinbub et al., 2012; Messina et al., 2013) on skin conductance (SC) synchronization. In addition to the original designs, secure attachment priming (Mikulincer & Shaver, 2007) was introduced to explore if observed SC linkage was susceptible to manipulation, accordingly to the developmental premises defined in the theoretical chapters. Study 1 focused on synchrony between students and psychotherapists in simulated clinical sessions; Study 2 reprised the same methodology with two principal changes: first the clinician’s role was played by psychologists without further clinical trainings, and second, each psychologist was involved in two distinct interviews, in order to assess the impact of individual characteristics on SC synchrony. 3) Provide an ideographical exploration of the psychotherapy processes linked to matched SC activity. In study 3 the highest and lowest synchrony sequences of 6 sessions of psychodynamic psychotherapy were subject of a detailed phenomenological content analysis. These micro-categories were synthetized in more abstract ones, in order to attempt the recognizing of regularities that could shed light on the phenomenon. 4) To explore the pertinence of employing mathematical properties derived from the application of system theory in psychological contexts. In study 4, Shannon’s entropy and order equations (1948) were applied on the transcribed verbal content of 12 depression psychotherapies, to assess both intra-personal and inter-personal (dyad) order in verbal categories. Results from these studies provided further evidence for the existence of a synchronization mechanism in the clinical dyads. Furthermore the various findings were generally supporting the dyad system theoretical model, and its description of regulatory dynamics as a good explanation of the synchronization phenomena. Discrepancies with previous literature highlighted the need for further studies to embrace more methodological sophistication (such as employing lag analysis), and cautiousness in the interpretation of results

Rorschach assessment in suicide survivors: Focus on suicidal ideation

Background: The study of Suicidal ideation (SI) in people bereaved through suicide (Suicide Survivors, SSs) could be hampered by the person's willingness to admit it, or by their limited awareness of it. Our main hypothesis is that SI is common in these people, especially if they are parents or children of the victim. For its potential in shedding light on specific unconscious processes, Rorschach test was chosen for our investigation, for the first time in SSs literature. Rorschach suicide ideation and selected variables were further analyzed to better delineate their psychological profile. Method: Rorschach according to Exner's Comprehensive System was administered to 21 people bereaved through suicide presenting as outpatients at SOPROXI Project Service-Padova Mental Health Center- and 23 healthy controls. Beck Depression Inventory (BDI) was routinely administered to SSs and considered in the study. Results: T-tests showed significantly higher mean SI score (S-Con) as it emerged from the Rorschach test S-Con scores in SSs compared to control participants. SI found only weak correlation with the BDI item in which SSs can explicitly state the desire for their death. Within-group analysis revealed higher S-Con mean scores in bereaved children and parents of the victim compared to other kind of kinships. Morbid content (MOR) has been fund as the most characterizing variable in SSs' S-Con in terms of effect size, followed by a low number of responses with an ordinary form (X +%). Human movements (M), Special Scores related to thought slippage (ALOG, FABCOM2, INCOM2, and CONTAM) and poor human representations (PHR) have been shown to be more significantly present in SSs compared controls. Discussion: Psychodynamic interpretations of our results are provided. Clinical practice should consider Rorschach as one of eligible tools of investigation on this field

The words of the body: psychophysiological patterns in dissociative narratives

Trauma has severe consequences on both psychological and somatic levels, even affecting the genetic expression and the cell\u2019s DNA repair ability. A key mechanism in the understanding of clinical disorders deriving from trauma is identified in dissociation, as a primitive defense against the fragmentation of the self originated by overwhelming experiences. The dysregulation of the interpersonal patterns due to the traumatic experience and its detrimental effects on the body are supported by influent neuroscientific models such as Damasio\u2019s somatic markers and Porges\u2019 polyvagal theory. On the basis of these premises, and supported by our previous empirical observations on 40 simulated clinical sessions, we will discuss the longitudinal process of a brief psychodynamic psychotherapy (16 sessions, weekly frequency) with a patient who suffered a relational trauma. The research design consists of the collection of self-report and projective tests, pre-post therapy and after each clinical session, in order to assess personality, empathy, clinical alliance and clinical progress, along with the verbatim analysis of the transcripts trough the Psychotherapy Process Q-Set and the Collaborative Interactions Scale. Furthermore, we collected simultaneous psychophysiological measures of the therapeutic dyad: skin conductance and hearth rate. Lastly, we employed a computerized analysis of non-verbal behaviors to assess synchrony in posture and gestures. These automated measures are able to highlight moments of affective concordance and discordance, allowing for a deep understanding of the mutual regulations between the patient and the therapist. Preliminary results showed that psychophysiological changes in dyadic synchrony, observed in body movements, skin conductance and hearth rate, occurred within sessions during the discussion of traumatic experiences, with levels of attunement that changed in both therapist and the patient depending on the quality of the emotional representation of the experience. These results go in the direction of understanding the relational process in trauma therapy, using an integrative language in which both clinical and neurophysiological knowledge may take advantage of each other

Training in psychotherapy: A call for embodied and psychophysiological approaches

Psychotherapy research studies are increasingly focused on the clinical process, which has allowed for the definition of general models about clinical functioning and the role of the therapist. Embodiment-based research has shown that interpersonal processes, such as synchrony and attunement, are critical for the development of crucial therapist skills and that these mechanisms are mediated by physiological processes. Although the connection between these embodied processes and clinical practice is currently a topic of investigation in psychotherapy research, its implications for clinical training are potentially broad, but they remain unexplored. The present contribution proposes the idea of embodied trainings for psychotherapy trainees, which could support their acquisition of clinical skills through implicit, embodied, and affective learning. We present detailed potential mechanisms, study designs, and psychological variables that could be used to develop such an in vivo training and suggest some possible applications, ranging from biofeedback sessions to experimental settings and roleplaying. Additional research in this field can help bridge the gap between psychotherapy research and psychotherapy training, by overcoming some of the limitations of post-session and external evaluations, by enriching psychotherapy training programs, and by facilitating the implicit and automatic attunement of the attitudes of the students who will become tomorrow's therapists

Rorschach Assessment in Suicide Survivors: Focus on Suicidal Ideation

Background: The study of Suicidal ideation (SI) in people bereaved through suicide (Suicide Survivors, SSs) could be hampered by the person's willingness to admit it, or by their limited awareness of it. Our main hypothesis is that SI is common in these people, especially if they are parents or children of the victim. For its potential in shedding light on specific unconscious processes, Rorschach test was chosen for our investigation, for the first time in SSs literature. Rorschach suicide ideation and selected variables were further analyzed to better delineate their psychological profile.Method: Rorschach according to Exner's Comprehensive System was administered to 21 people bereaved through suicide presenting as outpatients at SOPROXI Project Service—Padova Mental Health Center- and 23 healthy controls. Beck Depression Inventory (BDI) was routinely administered to SSs and considered in the study.Results:T-tests showed significantly higher mean SI score (S-Con) as it emerged from the Rorschach test S-Con scores in SSs compared to control participants. SI found only weak correlation with the BDI item in which SSs can explicitly state the desire for their death. Within-group analysis revealed higher S-Con mean scores in bereaved children and parents of the victim compared to other kind of kinships. Morbid content (MOR) has been fund as the most characterizing variable in SSs' S-Con in terms of effect size, followed by a low number of responses with an ordinary form (X +%). Human movements (M), Special Scores related to thought slippage (ALOG, FABCOM2, INCOM2, and CONTAM) and poor human representations (PHR) have been shown to be more significantly present in SSs compared controls.Discussion: Psychodynamic interpretations of our results are provided. Clinical practice should consider Rorschach as one of eligible tools of investigation on this field

Parental-Bonding and Alexithymia in Adolescents with Anorexia Nervosa, Their Parents, and Siblings

Anorexia nervosa (AN) patients and their family-members share alexithymia, anxiety, depression, and other psychological symptoms, in the context of altered attachment. These domains have been individually studied in the context of eating disorders; few attempts have been made to study their interaction, especially including family members. In this study, alexithymia, parental-bonding, and psychopathology were assessed in 32 Italian families consisting of an adolescent AN patient, a sibling, and their parents. We aimed to (a) describe a sample of Italian families with a child affected by AN, notably including siblings; (b) investigate interactions between assessed constructs in patients and their siblings; and (c) investigate possible intergenerational effects. Results showed high alexithymia and psychopathological symptoms in patients but not in siblings, although the latter reported high obsession-compulsion and paranoid ideation scores. Patients' and siblings' alexithymia correlated with psychopathology. Parents reported generally low alexithymia. Perceived parental bonding was found to be suboptimal in most participants, yet no clear relationship was found between specific parenting styles and other measured traits, nor did we find any other relevant intergenerational effect. Anorexia nervosa implies psychological difficulties for all family members. Siblings' psychopathological traits are especially concerning and currently understudied. Implications for future research and clinical interventions are discussed

Symbolic Meaning of Drugs in Psychotherapy: A Psychodynamic Perspective

Compared with the huge number of research on psychotropic drugs (PDs), and their wide use made to manage the symptoms of psychological and psychiatric disorders, little attention has been devoted in providing a psychodynamic interpretation of their symbolic meanings during psychotherapy. Our theoretical contribution, based on a critical overview of 5 decades of literature, focuses on the psychodynamic meaning attributed to PDs, and examines how their role in transference- countertransference exchanges depends on patients' personalities and psychological traits, considering recent acquisitions also in the study of the placebo-nocebo effect. We therefore describe how the symbolic meaning of PDs can be mutually shaped by the therapeutic dyad during the treatment. Clinical vignettes are used to illustrate how the therapist's ability to understand the symbolic meaning of PDs can be crucial in the clinical process and, consequently, for the outcome of treatment. The potential influence of the meaning attributed to PDs on the neuroscientific perspective is also discussed. Neglecting the psychodynamic processes related to PDs may lead to negative consequences in many domains of patients' treatment, including a lack of adherence and a failure of the therapeutic alliance. Future challenges should include exploring new transference paradigms in the light of an encouraged interest on the meaning attributed to PDs in therapeutic relationshi

Physiological synchronization in the clinical process: A research primer

Physiological synchronization is the study of how individuals in interaction coregulate their physiology. The topic has sparked increasing interest in counseling and psychotherapy research, where it has been found to be associated with the therapeutic alliance, clinicians' empathy and patients' outcome. Physiological synchronization allows researcher to investigate subtle but fundamental aspects of the clinical process through objective measures. In this article, we aim to offer a guide to researchers and clinicians to explore this growing field of study. We begin by reviewing the existing literature of physiological synchronization in clinical relationships, and then we provide practical guidelines for research. We discuss the various aspects involved in synchronization studies: study design, selection of physiological signals, data analytic approaches, and interpretation of results. To better illustrate how to implement these types of design, we provide a running example describing the data collection and analysis of a single-case study. In the example we discuss both how to conduct a longitudinal nomothetic analysis, as well as a moment-to-moment idiographic exploration of the clinical content. In this latter analysis, in particular, we show how physiological synchronization can be used in combination with 2 transcripts analysis tools, the Patient Attachment Coding System, and the Therapist Attunement Scales to reach a deeper understanding of the ongoing processes. We conclude by arguing that research in counseling and psychotherapy has much to gain from and contribute to the overall development of our understanding of physiological synchronization in human interaction