In this reflexive thematic analysis, we explore 17 psychotherapists’ accounts of work-related regrets. Based on individual interviews with experienced clinical psychologists, we report how they describe these regrets as emotionally intense experiences with potential for development. To communicate how participants view work-related regrets to impact on their clinical practice, we formulated an overarching theme called “holding on to regret as a kind of enrichment.” Three subthemes summarize different aspects of this process: (a) increased awareness; (b) working to accept and model fallibility; and (c) the process of making changes based on regret experiences. We discuss our findings in relation to theory and research, and explore methodological strengths and limitations.

Personal therapy is a requirement in several psychotherapy-training programs, and more than 80

Qualitative single case studies offer insights into developmental processes within specific contexts. Case studies enables us to investigate how development takes place, since it allows for a detailed examination of therapeutic processes, relationship dynamics, and developmental trajectories. Traditionally, case studies were typically therapist-authored retrospective accounts. Contemporary approaches incorporate multiple perspectives. This includes patient and therapist narratives, researcher observations, and systematic data collection methods. Case studies can be beneficial for investigating exceptions to general trends and giving voice to underrepresented experiences in psychotherapy research. Case studies can be useful in knowledge transmission within communities of practice. There is a close connection between single case studies and psychotherapy as it is practiced since clinical competence necessarily is built case by case. Thus, case studies can be useful to integrate theoretical knowledge with practical application and thereby contribute to development of professional expertise, including practical wisdom and clinical flexibility. Since psychotherapy case studies often involve ethical dilemmas, they may be useful to help therapists to develop their ethical reasoning skills. Advice for how to do qualitative case study research are provided, highlighting practical and ethical implications.

BackgroundHospitalization can be an extremely distressing experience for seriously ill and injured children. Art therapy has a well-established clinical history, and recent research has begun to demonstrate its effectiveness in somatic pediatric wards. Descriptive and statistical research indicates that art therapy can alleviate anxiety and fear, improve mood, and enhance communication among children, parents, and healthcare professionals. This study aims to enhance our understanding of the specific elements of art therapy that facilitate a connection with the healthier aspects of the self.MethodA total of 12 hospitalized children, aged 4–12, participated in an art therapy session led by a certified art therapist. Verbalizations during the sessions were recorded, and subsequent observations were synchronized with verbatim transcriptions of audio recordings. A reflexive thematic analysis was conducted to identify relevant patterns of meaning.FindingsThe study identified four significant dimensions of the children’s experiences during art therapy: (1) The child feels safe, (2) The child becomes a competent artist, bursting with creativity, (3) The healthy child emerges, and (4) The child achieves something beyond its limits – a triumph.DiscussionThe active ingredients contributing to effective art therapy include the stimulation of creativity, guided art-making with scaffolding support, task variation, granting children control over the artistic process, encouragement of free expression, and the display of positive regard. This study also delves into the therapeutic alliance, emphasizing its role in facilitating children’s learning, self-expression, concentration, and the creation of work they take pride in. Additionally, certain psychotherapy-like interactions, such as control-mastery dynamics, were observed. Nevertheless, more extensive research with larger sample sizes is required to draw broader conclusions.

Abstract Background Research shows that only around half of all survivors of child sexual abuse (CSA) disclose the abuse during childhood and adolescence. This is worrying, as CSA is related to substantial suffering later in life. The proportion of children and adolescents who have been exposed to CSA is significantly higher in Child and Adolescent Psychiatry (CAP) than in the general population. Healthcare professionals report that uncovering CSA is a complex and challenging task. However, we know little about how they proceed when uncovering CSA. More knowledge of healthcare personnel’s experience is therefore necessary to facilitate and increase CSA disclosure. The study aims to explore how CAP healthcare professionals in Norway proceed when assessing and detecting CSA, how they experience this work, and what hinders or facilitates their efforts. Methods The study employed a mixed method approach. Data was collected through an anonymous online survey, generating both quantitative and qualitative data. The sample consisted of 111 healthcare professionals in CAP, of whom 84% were women, with a mean age of 40.7 years (range 24–72; sd = 10.8). Mean years of CAP clinical experience were 8.3 years (range 0–41; sd = 7.5). The quantitative data was analysed using descriptive statistics, correlations, and independent sample t-tests, while the qualitative data was analysed using a team-based qualitative content analysis. Results The results showed that detection of CSA was viewed as an important, but complex task in CAP, and the existing procedures were deemed to be insufficient. The therapists mostly felt confident about how to proceed when they suspected or detected CSA, yet they seldom detected CSA. In their initial assessment they applied standardised procedures, but if their suspicion of possible CSA persisted, they seemed to rely more on clinical judgement. Specific challenges and facilitators for CSA detection were identified, both in the individual and in the organisation. Conclusions The study highlights the challenges and complexities healthcare professionals and the CAP system face when assessing CSA, which may account for the low detection rate. The results show that healthcare professionals believe room for clinical autonomy and targeted competence development may improve CSA detection. Additionally, the findings suggest a need for CAP to define roles and responsibilities within and between agencies.

Objectives:Avoidant personality disorder (AvPD) is a highly prevalent personality disorder, especially in clinical settings, yet scarcely researched. People diagnosed with AvPD have severe impairments in functioning and suffer greatly, yet we still lack meta-analytic evidence for therapy and only a few RCTs are conducted. Patient factors are the most important for outcome in therapy, in general. Lack of agency might be a core deficit in people diagnosed with AvPD. Their conditions might be improved if we understand their agency better. We review previous research regarding psychological mechanisms and interpersonal relationships that facilitate or hinder agency in AvPD in daily life and psychotherapy. Methods:Summarizing original literature in a narrative review with reflexive thematic analysis. Results:People diagnosed with AvPD seem to have significant impairments in their sense of agency due to a lack of emotional awareness, an overweight of inhibiting vs. activating emotions, and difficulties regulating emotions. Difficulties also seem related to high levels of attachment avoidance and fear, creating strong ambivalence in social needs, in addition to a strong tendency to subordinate to others. A weak sense of self with a poor narrative, self-doubt, and harsh self-critique makes a reflexive and intentional stand increasingly difficult for these people. Conclusion:This review gives a clinically meaningful understanding of core strengths and deficits in the personality functioning of AvPD that can help clinicians map out important therapeutic work, identify barriers to client-agency in therapy, and work through relational difficulties in the therapeutic alliance.

Under what life conditions do individuals turn to perfectionistic striving and ideals as a solution? The present paper examines how people with perfectionism narrate their relationship to our shared existential vulnerability; that we are vulnerable as human beings, and that the ways we relate to this vulnerability have consequences for psychological health. In the present qualitative study, we explored the life narratives told by nine students with perfectionism, drawing on semi-structured life-story interviews. We conducted an explorative-reflexive thematic analysis and identified five themes: 1) Outside—Feeling Alienated, 2) Relating to Chaos, 3) Trying to Control the Painful and Uncontrollable, 4) Islands of Just Being and Positive Contact, and 5) Heading Toward a Balance Between Doing and Being. Their perfectionism can be seen as a way of handling existential vulnerability at a point in their lives where relational resources needed to stay firm in a vulnerable state are lacking. Perfectionistic themes influence their personal identity in the domain of narrative constructions, values, belongingness, and embodiment. Accomplishments were dominant themes in the plots of their narrative self-constructions and values. They felt their “self-made” identities kept others at a distance. However, we also found strivings for a more fulfilling life with broader self-definitions.

Background Efforts are directed both towards prevention and early detection of Child sexual abuse (CSA). Yet, only about 50% of CSA survivors disclose before adulthood, and health professionals rarely are the first disclosure recipients. Increasing the detection rate of CSA within the context of Child and Adolescent Psychiatry (CAP) therefore represents a significant secondary prevention strategy. However, facilitating CSA disclosure when the survivor is reluctant to tell is a highly complex and emotionally demanding clinical task. We therefore argue that efforts to increase detection rates of CSA within CAP need to rest on knowledge of how both survivors and health professionals experience addressing CSA.Method Using meta-ethnography as method, we present separate sub-syntheses as well an overarching joint synthesis of how survivors and health professionals experience addressing CSA.Results Results show how both survivors and health professionals facing CSA disclosure feel deeply isolated, they experience the consequences of addressing CSA as highly unpredictable, and they need support from others to counteract the negative impact of CSA.Conclusion The results indicate that adapting the organization of CAP to knowledge of how the survivors and health professionals experience addressing CSA is critical to facilitate earlier disclosure of CSA within CAP.

Background:Recurrent Major Depressive Disorder (MDD) is one of the most disabling mental disorders in modern society. Prior research has shown that self-compassion protects against ruminative tendencies, a key feature of recurrent MDD. In addition, self-compassion has been found to be positively related to higher psychophysiological flexibility (indexed by a higher vagally mediated heart rate variability; vmHRV) in young, healthy adults. To our knowledge, there is a lack of studies on how self-compassion relates to vmHRV in patients with recurrent MDD. The aim of the current study was to investigate whether higher self-compassion would associate with (1) lower ruminative tendencies and (2) higher vmHRV in a sample of adults with recurrent MDD.Methods:We included a sample of 63 patients (46 females) between 20 and 71 years old (M = 40.24, SD = 12.8) with a history of three or more depressive episodes. They filled out the Self-Compassion Scale (SCS), Beck Depression Inventory (BDI), and Rumination Rating Scale (RRS). ECG (used to derive vmHRV) was acquired while resting and the square root of the mean squared differences of successive RR interval values (RMSSD) was calculated as measure of vmHRV.Results:As hypothesized, self-compassion was associated with lower ruminative tendencies. However, self-compassion was not associated with level of vmHRV. Several confounding variables were controlled for in the statistical analyses, and higher age predicted lower vmHRV across all statistical analyses.Conclusion:The results confirmed our hypothesis that higher self-compassion would be associated with lower ruminative tendencies in recurrent MDD. Contrary to our expectation, we did not find that the tendency to be more self-compassionate was associated with higher vmHRV. As such, higher self-compassion seems to relate with a lower tendency to ruminate about past mistakes and events but does not seem to relate to a flexible autonomic stress response (as indexed by higher vmHRV). Other potential explanatory factors for lower vmHRV in recurrent MDD is suggested as focus for exploration in future studies.

Limited capacity and high demand for mental health care drive efforts to improve the efficiency of treatment and increasingly result in predetermined time limits for treatment, even in government-covered treatment in welfare systems. How do clients experience having predetermined time limits for psychotherapy? We analyzed the transcripts of interviews with 18 participants who had completed a return to work (RTW) intervention based on emotion-focused therapy (EFT) that had predetermined time limits. The analysis identified four experiential trajectories through therapy with predetermined time limits, representing four narrative themes: Trajectory A: It is ok to stop here-Not wanting more therapy; Trajectory B: Seeing the benefits of continued therapy, but ready to give life a go without treatment; Trajectory C: Being on one's own too early-Economic obstacles hindering the continuation of therapy; and Trajectory D: I need more than this-Securing continued therapy. Having the therapist communicate the timeframes for therapy clearly, while leaving room for individual tailoring of therapy, was experienced as very important by clients receiving psychotherapy with predetermined time limits.

Background Self-criticism is associated with an elevated risk of developing recurrent depressive episodes. Self-criticism can have different forms, functions and underpinning emotions. An investigation into variations of self-criticism and its antidotes is therefore warranted. The aim of this study, embedded within a randomised efficacy trial of mindfulness-based cognitive therapy (MBCT), was to explore the effect of MBCT on self-to-self relating within three domains: self-inadequacy, self-hate and the ability to self-reassure. We also investigated whether these forms of self-to-self relating predicted depressive relapse for the MBCT participants within a time frame of two years after the intervention. Methods Sixty-eight individuals with recurrent depressive disorder were randomised to MBCT or a waiting list condition (WLC). Participants in the MBCT intervention were assessed for depressive relapse at follow-up after 6, 12 and 24 months. Results Compared with WLC (N = 30), completers of MBCT (N = 26) showed a significant improvement in Reassure self (d = 0.69, p = .016) and a significant reduction in Inadequate self (d = 0.51, p = .021), measured with the Forms of Self-Criticizing and Reassuring Scale. There were no significant changes in Hated self. Improvements in the Reassure self during the intervention predicted non-occurrence of depressive relapse within a period of two years after the MBCT intervention. Conclusions Findings from the present study support evidence that MBCT can affect how individuals relate to themselves in difficult situations in ways that may act as protection against depressive relapse.

AIM:To explore experiences of change among participants in a randomized clinical trial of mindfulness-based stress reduction (MBSR) for anxiety disorders.METHOD:Semi-structured interviews were conducted to explore the subjective experiences of change for individuals with anxiety disorders after a course in MBSR. Interviews were analysed employing hermeneutic-phenomenological thematic analysis.RESULTS:Five main themes were identified: 1) Something useful to do when anxiety appears, 2) Feeling more at ease, 3) Doing things my anxiety wouldn't let me, 4) Meeting what is there, and 5) Better-but not there yet. Most participants used what they had learned for instrumental purposes, and described relief from anxiety and an increased sense of personal agency. A few reported more radical acceptance of anxiety, as well as increased self-compassion.CONCLUSION:Participants of MBSR both describe mindfulness as a tool to "fix" anxiety and as bringing about more fundamental change towards acceptance of their anxiety. The complexity of reported change corresponds with better handling of areas representing known transdiagnostic features of anxiety disorder, such as dysfunctional cognitive processes (including attentional biases), emotional dysregulation, avoidance behaviours, and maladaptive self-relatedness. This supports MBSR as a transdiagnostic approach to the treatment of anxiety disorders.

Abstract Background The aim of this randomized wait-list controlled trial was to explore the effects of Mindfulness–Based Cognitive Therapy (MBCT) on risk and protective factors for depressive relapse within the domains of cognition, emotion and self-relatedness. Methods Sixty-eight individuals with recurrent depressive disorder were randomized to MBCT or a wait-list control condition (WLC). Results Completers of MBCT (N = 26) improved significantly on measures assessing risk and protective factors of recurrent depression compared to WLC (N = 30) on measures of rumination (d = 0.59, p = .015), emotion regulation (d = 0.50, p = .028), emotional reactivity to stress (d = 0.32, p = .048), self-compassion (d = 1.02, p < .001), mindfulness (d = 0.59, p = .010), and depression (d = 0.40, p = .018). In the Intention To Treat sample, findings were attenuated, but there were still significant results on measures of rumination, self-compassion and depression. Conclusions Findings from the present trial contribute to evidence that MBCT can lead to reduction in risk factors of depressive relapse, and strengthening of factors known to be protective of depressive relapse. The largest changes were found in the domain of self-relatedness, in the form of large effects on the participants’ ability to be less self-judgmental and more self-compassionate. Trial registration ISRCTN, ISRCTN18001392 . Registered 29 June 2018

Background Dispositional mindfulness and self-compassion are shown to associate with less self-reported emotional distress. However, previous studies have indicated that dispositional self-compassion may be an even more important buffer against such distress than dispositional mindfulness. To our knowledge, no study has yet disentangled the relationship between dispositional self-compassion and mindfulness and level of psychophysiological flexibility as measured with vagally mediated heart rate variability (vmHRV). The aim was thus to provide a first exploratory effort to expand previous research relying on self-report measures by including a psychophysiological measure indicative of emotional stress reactivity. Methods Fifty-three university students filled out the “Five Facet Mindfulness Questionnaire” (FFMQ) and the “Self-Compassion Scale” (SCS), and their heart rate was measured during a 5 min resting electrocardiogram. Linear hierarchical regression analyses were conducted to examine the common and unique variance explained by the total scores of the FFMQ and the SCS on level of resting vmHRV. Results Higher SCS total scores associated significantly with higher levels of vmHRV also when controlling for the FFMQ total scores. The SCS uniquely explained 7% of the vmHRV. The FFMQ total scores did not associate with level of vmHRV. Conclusion These results offer preliminary support that dispositional self-compassion associates with better psychophysiological regulation of emotional arousal above and beyond mindfulness.

This pilot study examined the impact of mindfulness training on skills relevant for the well-being and therapeutic functioning of clinical psychology students. Twentyfive psychology students took part in an intensive mindfulness training programme, consisting of three 2.5-hr sessions and one all-day silent retreat. The students filled out self-report measures of rumination, emotional reactivity to stress, difficulties with emotion regulation, mindfulness and self-compassion. They also completed two cognitive tests (revised version of the Attention Network Test and a Stroop colourword inference task) before and after the course. The students reported significant decreases in rumination (d = 0.75, p =.001), emotional reactivity to stress (d = 0.81, p =.001) and difficulties in emotion regulation (d = 0.57, p =.008). They also reported increased mindfulness (d = 0.93, p =.001) and self-compassion (d = 0.81, p =.001). On both cognitive performance tests, the students showed an increase in executive control, that is the ability to prioritise among competing thoughts, feelings and responses (ANT, d = 1.48; p =.001; Stroop: d = 0.63; p =.004). The students also showed a moderate increase in cognitive flexibility (d = 0.66; p =.003), measured by Stroop. Conclusions: The study indicates that it may be beneficial to introduce personal mindfulness practice as a way of preparing novice therapists for their future profession. The findings also support the potential value of including measures of attentional capacities in future studies of psychotherapy training.

Previous psychometric analyses of the Frost Multidimensional Perfectionism Scale and the abbreviated version (FMPS-Brief) have resulted in inconsistent findings regarding the scale's bidimensionality or unidimensionality. Different studies evaluating the scale with different statistical analyses and comparative samples report different results and recommendations. This study assessed the FMPS-B's psychometric properties by conducting both confirmatory factor analysis (CFA) and pure bifactor modeling in order to address previous findings and guide future use of the scale. The results indicate that the two-factor model is the best fit. Going forward, the FMPS-B's subfactors "strivings" and "evaluative concerns" may be studied separately. Implications for future research and challenges in bifactor modeling are discussed.

Juvenile onset of Major Depressive Disorder (MDD) is associated with increased likelihood of recurrent episodes of depression and more detrimental clinical trajectories. The aim of the current study was to investigate the effect of juvenile onset of MDD on emotion regulation as measured by self-report and Heart Rate Variability (HRV). Furthermore, we wanted to assess whether juvenile onset impacted the association between rumination and depressive symptoms. Sixty-four individuals with at least three prior episodes of MDD were recruited and filled out self-report questionnaires measuring rumination and emotion regulation abilities. In addition, electrocardiographic assessments were used to calculate HRV. Based on self-reported age of MDD onset, individuals were divided in two groups: Juvenile onset of MDD (first MDD episode before the age of 18, n = 30) and adult onset of MDD (first MDD episode after the age of 18, n = 34). Results showed that individuals whose first depressive episode occurred in childhood and adolescence reported more rumination and less emotional clarity compared to individuals who had their first episode of MDD in adulthood. Moreover, the tendency to ruminate was strongly associated with depressive symptoms in the juvenile onset of MDD group, whereas no such association was found in the adult onset group. There was no significant group difference for HRV. The findings are discussed in light of existing literature, in addition to suggesting how our findings may inform clinical practice and future research. We conclude that juvenile onset of MDD may lead to difficulties in emotion regulation and that these difficulties may increase depressive symptoms and vulnerability for relapse in this particular subgroup.

Background: The therapeutic relationship is regarded as an important source of change in emotion-focused therapy (EFT) (Greenberg, 2014; Watson, 2018), but few qualitative studies have specifically investigated how clients experience the role of the relationship in EFT. Aim: The purpose of the present study was to explore what clients experienced as helpful or hindering aspects of the therapeutic relationship when undergoing EFT for depression, anxiety, and severe self-criticism. Methods: We interviewed 18 clients after a clinical trial of time-limited EFT, to explore their experiences of the relationship with their therapist during treatment. The interviews were analyzed using hermeneutic-phenomenological thematic analysis (Braun and Clarke, 2006; Binder et al., 2012). Results: We identified four main themes: (1) Forming a trusting relationship or finding it hard to connect, (2) Collaborating and struggling to find new ways to relate to painful feelings, (3) Alliance ruptures and needs for repair when working with distressing emotions, and (4) The significance of new relational experiences. Conclusion: Clients described therapists' genuineness and the establishment of trust in the relationship as important preconditions to open up to vulnerability and painful feelings, and engaging fully in specific EFT interventions. The findings also indicate that the therapists need to be mindful of different client preferences and monitor potential alliance ruptures when working to change distressing emotions in therapy.

Objective: The aim of this study was to explore how patients with personality disorder (PD) and substance use disorder (SUD) experience mentalization-based treatment (MBT), in particular what they consider useful and less useful elements of the therapy. Method: Semi-structured qualitative interviews with 13 participants were conducted. Participants were interviewed on their experience of the different elements of MBT, their experience of working in the transference, and their view on MBT as a whole. Thematic analyses were performed within a hermeneutical-phenomenological epistemology, with an emphasis on researcher reflexivity. Results: The following themes were found in the material: “I am not alone,” “Taking blinders off,” “Just say it,” “The paradox of trust,” and “Follow me closely.” Three of these themes concerned therapist interventions; these involved addressing the relationship with the patients, addressing negative or unspoken feelings in the sessions, and validating and tolerating patients’ affect. Two themes concerned group therapy experiences; these were the experience of sameness with co-patients in group and the experience of discovering different perspectives in group. Conclusions: Patients’ experiences of useful elements in MBT resonate with theoretical tenets of (borderline) personality pathology, in particular attachment disturbances and emotional dysregulation. Patients highlight what we would label working in the therapeutic relationship, addressing transferential and counter-transferential processes explicitly, emotional validation, and enhancing mentalizing in its own right.

Introduction Pharmacological interventions are viewed as central to clinical work with people diagnosed with bipolar disorder. But what is the meaning of medicine? How do clinicians view the role of medication in recovery processes in bipolar disorder? The aim of this study was to explore the perspectives of experienced therapists regarding the role of medicine in the treatment of people with bipolar disorder. Methods In a Norwegian specialist mental health care setting, we conducted 12 semi-structured individual interviews with experienced therapists and analysed the resulting transcripts using a team-based thematic analysis method. Findings We identified four themes: (a) the bedrock of therapy; (b) an imperfect answer and a dangerous tool; (c) the hallmark of insight; and (d) negotiating medicine, negotiating meaning. Conclusion We relate our findings to the shortcomings of the dominant medical model and argue that a recovery perspective can be a helpful tool for counsellors and psychotherapists in understanding the meaning of medicine for people with bipolar disorder.