New research provides evidence that certain speech patterns and expressions can predict the bond between therapists and their patients. The study, published in iScienceused artificial intelligence to analyze the use of personal pronouns and speech hesitations during psychotherapy sessions.
The motivation behind this research arose from a long-standing challenge in psychotherapy: accurately assessing and improving the therapeutic alliance. This alliance is the mutual understanding and partnership between a therapist and his or her patient, recognized as the cornerstone of effective therapy.
Traditional methods for measuring this relationship have relied heavily on subjective self-reports and observer interpretations, which are time-consuming and often fail to capture the dynamic nature of therapy sessions. With the advent of machine learning in healthcare, researchers at the Icahn School of Medicine at Mount Sinai saw an opportunity to objectively study the elements of therapeutic communication, with the goal of identifying clear and actionable markers of a strong therapeutic alliance.
The researchers recruited a diverse group of participants, consisting of 28 patients undergoing psychotherapy and 18 therapists from outpatient clinics at academic hospitals in New York City. These participants participated in 28 different therapy sessions spanning a variety of psychiatric conditions, ensuring a broad representation of therapeutic encounters.
Before diving into therapy sessions, the study employed a preparatory phase in which patients assessed their alliance with previous therapists and their attachment styles through online surveys. This step was crucial in establishing the basis for understanding individual predispositions toward therapeutic relationships.
The therapy sessions themselves were recorded using two wireless microphones per session, allowing for clear separation of patient and therapist speech for later transcription and analysis. This setup was instrumental in capturing the nuanced verbal exchanges that are integral to therapy.
To assess the therapeutic alliance, the study used the Working Alliance Inventory – Short Form, a validated questionnaire that measures the strength of the alliance from the perspective of both the patient and the therapist. This tool assesses key components of the therapeutic relationship, including agreement on therapy goals and tasks and the emotional bond between patient and therapist.
Additionally, the trust game, a behavioral economics paradigm, was introduced as an innovative measure of trust and reciprocity within the therapeutic relationship. This game involved simulated monetary exchanges between participants, offering a novel, quantitative measure of trust that complemented the subjective assessments of the questionnaires.
The heart of the study’s methodology lies in the use of natural language processing (NLP) techniques to analyze transcripts of therapy sessions. The researchers focused on identifying specific language features, such as the use of personal pronouns (“I,” “we”) and markers of disfluency (e.g., “um,” “like”), which, according to hypothesis, they reflected aspects of the language. The therapeutic alliance.
The researchers found that therapists’ and patients’ use of personal pronouns was closely related to the strength of the therapeutic alliance. Specifically, therapists’ use of “we” was associated with patients’ lower alliance ratings, particularly in the context of personality disorders. This finding challenges conventional wisdom that inclusive language naturally fosters stronger connection.
Similarly, frequent use of “I” by both therapists and patients was negatively correlated with alliance ratings, highlighting the potential drawbacks of an overemphasis on self within therapy sessions. Consistent with these findings, the trust game revealed that patients’ payment behaviors (an indicator of trust) were negatively correlated with therapists’ use of both “we” and “I.”
The researchers also explored the semantic contexts of pronoun use. Sentences containing “I” followed by action or thought verbs (e.g., “I think,” “I do”) were frequently used in sessions characterized by lower alliance ratings. This points to the importance of how therapists and patients articulate their thoughts and feelings, with certain patterns of self-referential discourse potentially hindering the development of a strong therapeutic bond.
An intriguing aspect of the findings concerned non-fluency markers, such as hesitations or filler words (“um,” “like”), used by patients. Contrary to the often negative perception of such speech patterns in other contexts, the study found that these markers were positively correlated with higher alliance ratings. This suggests that moments of disfluency in patients’ speech may contribute to a more authentic and engaged therapeutic interaction, possibly because they reflect genuine thought processes and emotional honesty.
“Our study provides the first computational evidence that both first-person pronoun and disfluencies are potential language markers that predict therapeutic alliance and interpersonal trust during psychotherapy treatment,” the researchers wrote.
While the study offers groundbreaking insights into the language of therapy, the researchers acknowledge several limitations. The study had a relatively small sample and the observational nature of the study means that causality cannot be inferred. For example, while the data suggest a possible negative impact of therapists’ use of “we” on the therapeutic alliance, this correlation does not necessarily imply causation. It is possible that a greater frequency of “we” in a therapist’s language may reflect an attempt to bridge a gap and foster a sense of unity with a patient who may be more reserved or distant.
Future research is poised to build on these preliminary insights, potentially incorporating larger sample sizes and exploring the context in which specific language patterns occur to deepen our understanding of effective therapeutic communication.
The study, “A natural language processing approach reveals first-person pronoun use and disfluencies as markers of therapeutic alliance in psychotherapy,” Jihan Ryu, Stephen Heisig, Caroline McLaughlin, Michael Katz, Helen S. Mayberg, and Xiaosi Gu.