The Action of Verbal and Non-verbal Communication in the Therapeutic Alliance Construction: A Mixed Methods Approach to Assess the Initial Interactions With Depressed Patients

In psychodynamic psychotherapy, verbal (structures and intents) and non-verbal (voice and interruptions) dimensions of communication intertwine conveying information and determining the mutual regulation between therapist and patient through conversational sequences. The communication components interplay is the foundation for building the therapeutic alliance, a relational dimension that predicts a psychotherapy outcome and change, influenced by patient-therapist exchanges from the initial stages of their encounter. Depressed patients present specific verbal and non-verbal communication and show difficulties in developing and maintaining the therapeutic alliance. Based on the reviewed literature, the main aim of this study was to analyze how the action of specific communicative modes, implemented by the therapist and depressed patients, affect the reciprocal construction of the early therapeutic alliance by each participant during the mutual regulation processes. We employed a mixed methods approach based on a systematic observation of communication and alliance ruptures and repairs within the audio recordings and verbatim transcripts of 20 psychotherapy sessions (6,232 speaking turns) with seven depressed patients. The observational design was nomothetic, follow-up, and multidimensional. The choice of methodology is justified because we developed a comprehensive procedure that integrates an ad hoc indirect observation system (the Communicative Modes Analysis System in Psychotherapy), analyzing verbal and non-verbal communication, and an observational tool with deductive categories (the Collaborative Interactions Scale-Revised), assessing the therapeutic alliance construction. Once we confirmed the intra-and inter-observer reliability for the ad hoc system and the inter-rater reliability for the tool with deductive (or theoretical) categories, we performed descriptive statistics (to describe quantitatively communicative modes and alliance ruptures and repairs), lag sequential analysis (to detect stable patterns in communication-alliance interactions), and polar coordinate analysis (to identify significant relationships between communicative modes and alliance ruptures and repairs). Results confirm that the therapist's verbal (asking and exploring) and non-verbal (elaborating and cooperatively interrupting) modes and the depressed patients' verbal (asserting and exploring) and non-verbal (expressing emotions and cooperatively interrupting) modes determine stable patterns and significant associations with collaborative behaviors connected to the reciprocal construction of alliance by each participant. All this may provide professionals with useful information to increase the psychotherapy effectiveness with depressed patients.