Objective: The objective of this study was to analyze the effect of adherence to both specific technique factors and facilitative condition variables (e.g., therapists' involvement, understanding and support) in Cognitive Behavior Therapy (CBT) and Interpersonal Psychotherapy (IPT). In addition, we were interested in whether the effect of therapist adherence would depend on the level of the working alliance. Method: Three sessions each from 74 patients diagnosed with Major Depressive Disorder who were randomized to 14 sessions of IPT or CBT were rated for adherence using a modified version of The Collaborative Study Psychotherapy Rating Scale-6 (CSPRS-6). Data was analyzed using Multilevel Modeling. Results: No effects of adherence to specific factors on outcome were found in neither CBT nor IPT. Facilitative conditions were associated with better outcome in CBT but not in IPT, even after adjustment for the quality of the working alliance. No interaction effects were found. Conclusions: Our findings highlight the importance of relational factors in CBT, but do not support the need for specific adherence to any of the two treatments. Possible explanations of the findings and directions for future research are discussed.
Objective: Several studies have shown that the quality of the working alliance predicts symptomatic improvement sessionby-session, including in cognitive-behavioral therapy (CBT). We wanted to explore what characterizes CBT sessions with high and low alliances further using qualitative analysis. Method: Ten CBT-sessions were selected from eight patients' therapies in a larger research project on psychotherapy for patients with major depression. Five sessions were chosen from high- and five from low-alliance sessions, based on therapist- and patient-reported Working Alliance Inventory scores. Transcripts of these sessions were analyzed using thematic analysis. Results: The analysis yielded four themes, each structured into two sub-themes: Therapist style, Person in focus, Content focus, and Therapeutic direction. In contrast to low-alliance sessions, high-alliance sessions were characterized by a more exploring as opposed to expert therapist style; a focus on the patient's thoughts, feelings, and behavior, rather than a diffuse focus or a focus on other people's actions/external events; and a sense of moving forward rather than stagnation. Conclusion: Our qualitative analysis showed theoretically and clinically meaningful processes in CBT sessions of high- vs low working alliance. This method is a useful complement to quantitative within-patient analyses, to expand on the meaning of quantitative findings.
The author attempts to integrate the concepts of self used in psychoanalytic theory with the understanding of the nature of self as explained within the Buddhist meditative tradition. He divides different concepts of self in psychoanalytic theory into three major levels of consciousness and abstraction: self as experience, representational self and self as system. The representational level is defined as consisting of unconscious organizing structures of interaction: the system level is a hierarchically higher organization of representations, while the experiential level consists of the moment-to-moment flow of consciousness. He argues that for the sake of theoretical clarity these levels should be differentiated in discussions of self. He then describes the Buddhist psychology of self and tries to show how this perspective can enrich psychoanalytic understanding of the experiential self and of narcissism, which in Buddhist language would be described as clinging to (seeking or avoiding) images of self that arise in the mind. Last, he describes a model of therapeutic development using different levels of self and the interrelationship between them, showing how psychoanalytic psychotherapy and Buddhist insight meditation emphasize different levels of self using complementary rather than mutually exclusive methods.
In this commentary, I advance the view that the scientist-practitioner gap is partly due to the research designs commonly used in psychotherapy research. Specifically, I believe that randomized controlled trials, which are important for establish-ing treatment efficacy and as leverage when making the case for the value of psychotherapy in relation to various stake-holders, are limited for further development of clinical theories. Instead, I find recent advances in cross-lagged panel modeling to be both clinically intuitive and stronger for causal inference than most other nonexperimental designs. In addi-tion to discussing causal inference and clinical interpretation of cross-lagged panel models, I discuss the potential of improving mediation analysis, personalization of research, and studying issues of clinical timing. Finally, I briefly discuss some limitations of cross-lagged panel models. It is my belief that the use of these data analytic advances can make empir-ical research better live up to the innovations in Beck's work.
Background A good therapy relationship is viewed by many as a precondition for effective therapeutic work, and by some even a therapeutic factor in itself. In theory, the therapy relationship has been divided into the components working alliance, transference, and “real relationship”. Most empirical research has been conducted on the working alliance, which concerns the quality of collaboration between therapist and patient. Methods State-of-the-art position statement. Results Research on the working alliance has gone from fairly simple pre-post correlational designs to multi-level cross-lagged panel designs. Although almost all research is based on observational data, the “new generation” of alliance research takes account of temporal precedence and potential unobserved confounders that are stable over time. Research to date strongly suggests that patient-therapist dyads who establish a good-quality working alliance early in treatment are more likely to achieve good outcome. Moreover, the quality of the alliance in a given session is predictive of change in symptom distress by the following session. Conclusions Working alliance is predictive of psychotherapy outcome. Although later studies are stronger for drawing causal conclusions, none of the studies to date can conclusively rule out alternative explanations of alliance-outcome predictions. Whether alliance is facilitative of technical interventions or therapeutic in itself is also not clear. Future research should (1) find ways of ruling out alternative explanations of relationship variable findings, (2) study the interaction between relationship variables and technique, and (3) study the therapy relationship as a mediator of therapeutic interventions, and (4) study other relationship variables than alliance.
In recent years, there has been increasing interest in utilizing time-lagged panel models to study mechanisms of change in psychotherapy. These models offer valuable insights into the dynamic relationships between variables over time and offer stronger causal inference capabilities than cross-sectional analyses. Therefore, they are wellsuited for modeling the intricate relationships between mechanisms of change and outcomes in psychotherapy studies, which are typically beyond experimental control. However, their complexity, coupled with the fact that detailed explanations are often embedded in dense statistical or econometric texts, poses challenges. This paper provides a background on cross-lagged panel models and delves deeper into explaining the issues of 1) dynamic panel bias, 2) long-run effects, and 3) testing whether different treatments work by different mechanisms. Using data from a psychotherapy study on treatment of adolescent depression, I demonstrate how these issues manifest in real data. In conclusion, I recommend using structural equation modeling to circumvent dynamic panel bias, reporting long-run effects to reveal the long-term impact of sustained therapeutic work on mechanisms of change, and carefully considering whether mediation, moderation, or a combination of both, best describes differential effects of mechanisms between treatments.
Therapists' in-session feelings in psychotherapy can be seen as indications of the development of the therapeutic relationship and the therapeutic process. To manage them appropriately, it is important to know to what extent they may be influenced by patients' pretreatment characteristics. This study aims to improve the understanding of therapists' emotional reactions in the psychotherapeutic setting by investigating if patients' pretreatment mentalization ability and attachment style predicted therapist in-session feelings. In a sample of 87 therapy dyads treated with interpersonal psychotherapy and cognitive behavioral therapy for depression, patient attachment was measured using self-reported Experiences in Close Relationships (ECR) and mentalization using Reflective Functioning (RF). ECR and RF were hypothesized to predict therapist feelings measured by the Feeling Word Checklist-24 at different treatment phases over the full course of treatment. Treatment method, patient age, gender, and pretreatment depression were evaluated as potential confounders. Multilevel modeling was used to analyze the data. Lower RF in patients predicted more negative therapist feelings in the mid- to late-treatment phases and less positive feelings in the late-treatment phase. Self-reported attachment anxiety or avoidance did not predict therapist feelings. Findings indicate that patients' ability to mentalize is important to consider when conducting psychotherapy, as it can influence therapists' feelings in the therapeutic process. Limitations of the present study's approach are discussed, and directions for future research are considered.
Objective: Brief Relational Therapy (BRT) includes the idea that the therapists use their in-session feelings in meta-communications about the therapy relationship to facilitate resolution of alliance ruptures. The current study aimed to explore the effect of therapist feelings on patient depressive symptoms in BRT compared to Interpersonal Psychotherapy (IPT). Methods: The effects of therapist feelings were studied in 40 patients randomized to 16 sessions of IPT or BRT, using the Feeling Word Checklist-24, the Patient Health Questionnaire-9 and the Working Alliance Inventory. Data was analyzed using dynamic structural equation modeling. Results: Negative therapist feelings predicted increase and positive feelings decrease in next-session PHQ-9 via the alliance and the patients' engaged feelings, in both treatments. The direct effect of negative therapist feelings on PHQ-9 differed significantly between BRT and IPT, with more negative feelings predicting a decrease in PHQ-9 in BRT but not in IPT. Conclusion: Negative therapist feelings may cause increase/less decrease and positive feelings more decrease in depressive symptoms via disruptions in the alliance. In BRT, if the alliance is unaffected by negative therapist feelings, the patient's depressive symptoms may improve. Findings need replication in a larger sample.
Causal inference in psychological research is typically hampered by unobserved confounding. A copula-based method can be used to statistically control for this problem without the need for instruments or covariates, given relatively lenient distributional assumptions on independent variables and error terms. The current study aims to: (1) provide a user-friendly introduction to the copula method for psychology researchers; and (2) examine the degree of non-normality in the independent variables required for satisfactory performance. A Monte Carlo simulation study was used to assess the behavior of the copula method under various combinations of conditions (sample size, skewness of independent variables, effect size, and magnitude of confounding). In addition, an applied example from research on the effects of parental rearing on adult personality and life satisfaction was used to illustrate the method. Simulations revealed that the copula method performed better at higher levels of skewness in the independent variables, and that the impacts of lower skewness can be offset to some extent by larger sample size. When skewness and/or sample size is too small, the copula method is biased towards the uncorrected model. In the applied example, parental rejection/punishment predicted less adaptive personality and life satisfaction, with no evidence of confounding. For parental control/overprotection, there was evidence that confounding attenuated the estimated relationship with personality/life satisfaction. Copula adjustment is a promising method for handling unobserved confounding. The discussion focuses on how to proceed when assumptions are not quite met, and outlines potential avenues for future research.
Intervention studies in psychology often focus on identifying mechanisms that explain change over time. Cross-lagged panel models (CLPMs) are well suited to study mechanisms, but there is a controversy regarding the importance of detrending-defined here as separating longer-term time trends from cross-lagged effects-when modeling these change processes. The aim of this study was to present and test the arguments for and against detrending CLPMs in the presence of an intervention effect. We conducted Monte Carlo simulations to examine the impact of trends on estimates of cross-lagged effects from several longitudinal structural equation models. Our simulations suggested that ignoring time trends led to biased estimates of auto- and cross-lagged effects in some conditions, while detrending did not introduce bias in any of the models. We used real data from an intervention study to illustrate how detrending may affect results. This example showed that models that separated trends from cross-lagged effects fit better to the data and showed nonsignificant effect of the mechanism on outcome, while models that ignored trends showed significant effects. We conclude that ignoring trends increases the risk of bias in estimates of auto- and cross-lagged parameters and may lead to spurious findings. Researchers can test for the presence of trends by comparing model fit of models that take into account individual differences in trends (e.g., autoregressive latent trajectory model, the latent curve model with structured residuals, or the general cross-lagged model).
Objective: Modeling cross-lagged effects in psychotherapy mechanisms of change studies is complex and requires careful attention to model selection and interpretation. However, there is a lack of field-specific guidelines. We aimed to (a) describe the estimation and interpretation of cross lagged effects using multilevel models (MLM) and random-intercept cross lagged panel model (RI-CLPM); (b) compare these models' performance and risk of bias using simulations and an applied research example to formulate recommendations for practice. Method: Part 1 is a tutorial focused on introducing/describing dynamic effects in the form of autoregression and bidirectionality. In Part 2, we compare the estimation of cross-lagged effects in RI-CLPM, which takes dynamic effects into account, with three commonly used MLMs that cannot accommodate dynamics. In Part 3, we describe a Monte Carlo simulation study testing model performance of RI-CLPM and MLM under realistic conditions for psychotherapy mechanisms of change studies. Results: Our findings suggested that all three MLMs resulted in severely biased estimates of cross-lagged effects when dynamic effects were present in the data, with some experimental conditions generating statistically significant estimates in the wrong direction. MLMs performed comparably well only in conditions which are conceptually unrealistic for psychotherapy mechanisms of change research (i.e., no inertia in variables and no bidirectional effects). Discussion: Based on conceptual fit and our simulation results, we strongly recommend using fully dynamic structural equation modeling models, such as the RI-CLPM, rather than static, unidirectional regression models (e.g., MLM) to study cross-lagged effects in mechanisms of change research. What is the public health significance of this article? We describe the differences between multilevel and structural equation modeling in the study of mechanisms of change in psychotherapy research. We argue that the common application of multilevel modeling assumes that there is no within-patient inertia in predictor or outcome variable, and the outcome variable does not impact the predictor, both of which seem highly unrealistic in psychotherapy research. Moreover, we demonstrate that violations of these assumptions may lead to severe bias in estimated coefficients, resulting in inaccurate recommendations for clinical practice. Thus, we recommend researchers to use structural equation modeling to estimate the effects of proposed change mechanisms over time.
Background: Existing literature suggests that patients' experiences of emotions, especially negative emotions, predict outcomes in psychotherapies for major depressive disorder. However, the specific mechanisms underlying this effect remain unclear. Based on studies pointing to the role of oxytocin (OT) in attachment relationships, we proposed and tested a mediation model where the therapists' hormonal responses, as represented by increases in their OT levels, mediates the association between negative emotions and symptomatic change. Method: OT saliva samples (pre- and post-session, N = 435) were collected on a fixed schedule over 16 sessions from the therapists of 62 patients receiving psychotherapy for major depression. The Hamilton Rating Scale for Depression was administered to the patients before the sessions, and the patients reported their in-session emotions after the sessions. Results: The findings support the proposed within-person mediation model: (a) higher levels of negative emotions in patients predicted greater increases in therapist OT levels pre- to post-session throughout treatment; (b) greater OT levels in therapists, in turn, predicted reduction in patients' depressive symptoms on the subsequent assessment; and (c) the therapists' OT levels significantly mediated the association between patients' negative emotions and reduction in their depressive symptoms. Limitations: This design precluded establishing a time sequence between patients' negative emotions and therapists' OT; thus, causality could not be inferred. Conclusion: These findings point to a possible biological mechanism underlying the effects of patients' experiences of negative emotions on treatment outcomes. The findings suggest that therapists' OT responses could potentially serve as a biomarker of an effective therapeutic processes.
Objective: The aim of this study was to investigate a sequence of associations between clients' pretreatment attachment style, the development of individuated-secure attachment to the therapist (i.e., therapeutic attachment), and the experience of increased comfort with emotional closeness (growing engagement) or independence (growing autonomy) in therapy. Moreover, the study explored whether clients' experience of growing engagement or growing autonomy was associated with a change in interpersonal problems at the end of therapy. Method: Three hundred thirty adult clients (mean age 40.2, 75% female) were seen by 44 therapists in individual psychotherapy. The associations between pretreatment attachment insecurity measured on the Experiences in Close Relationships scale, repeated measures of therapeutic attachment measured on the Client Attachment to Therapist Scale, repeated measures of a growing engagement or growing autonomy measured on the Therapeutic Distance Scale, and pre-post measures of interpersonal problems measured on the Inventory for Interpersonal Problems were analyzed using multilevel modeling. Two types of therapeutic attachment were estimated, one controlling for anxious attachment characteristics and one for avoidant. Results: Significant associations between higher levels of therapeutic attachment controlled for avoidant attachment characteristics and lower levels of growing autonomy in therapy were found. Moreover, higher levels of growing engagement in therapy and higher levels of therapeutic attachment controlled for anxious attachment characteristics were associated with a decrease in interpersonal problems at the end of therapy. Conclusions: Distinct types of therapeutic attachment may exert different influences on the process and outcome of therapy. Furthermore, therapists' attunement to clients' specific attachment needs in therapy may enhance interpersonal outcomes of treatment.
BackgroundEmotion regulation difficulties underlie several psychiatric conditions, and treatments that focus on improving emotion regulation can have an effect on a broad range of symptoms. However, participants' in-depth experiences of participating in emotion regulation treatments have not been much studied. In this qualitative study, we investigated participants' experiences of a joint emotion regulation group skills training in a child and adolescent psychiatric outpatient setting.MethodsTwenty-one participants (10 adolescents and 11 parents) were interviewed about their experiences after they had participated in a seven-session transdiagnostic emotion regulation skills training for adolescents and parents. The aim of the skills training was to decrease emotion regulation difficulties, increase emotional awareness, reduce psychiatric symptoms, and enhance quality of life. The skills training consisted of psychoeducation about emotions and skills for regulating emotions. The interviews were transcribed and analysed using reflexive thematic analysis.ResultsThe analysis resulted in three overarching themes: Parent - Child processes, Individual processes, and Group processes. The result showed that participants considered an improved parent-child relationship to be the main outcome. Increased knowledge, emotion regulation skills and behavioural change were conceptualised as both mechanisms of change and outcomes. The group format, and the fact that parents and adolescents participated together, were seen as facilitators. Furthermore, the participants experienced targeting emotions in skills training as meaningful and helpful.ConclusionThe results highlight the potential benefits of providing emotion regulation skills training for adolescents and parents together in a group format to improve the parent-child relationship and enable the opportunity to learn skills.
Introduction The aim of the Common factors, Responsiveness and Outcome in Psychotherapy (CROP) study is to identify client and psychologist characteristics and therapeutic processes associated with the outcome of psychotherapy delivered by psychologists employed in the Danish primary sector or fully self-employed. The study addresses two main questions. First, how are specific characteristics of clients and psychologists related to the outcome of therapy and do these characteristics moderate the outcome of different psychotherapeutic approaches? Second, to what extent do therapists adapt their approach to client characteristics and preferences and how does such responsiveness impact the process and outcome of therapy? Methods and analysis The study is a naturalistic prospective cohort study carried out in collaboration with psychologists in private practice in Denmark. Self-reported data are collected from the participating psychologists and their participating clients before, during (weekly and postsession) and after psychotherapy (at end of treatment and 3 months follow-up). The estimated target sample size is 573 clients. The data are analysed using multilevel modelling and structural equation modelling approaches to capture predictors and moderators of the effect and rate of change in psychotherapy as well as session-to-session changes during the therapy process. Ethics and dissemination The study has been approved by the IRB at the Department of Psychology, University of Copenhagen (IRB number: IP-IRB/01082018) and the Danish Data Protection Agency. All study data are fully anonymised and all clients have given informed consent to participation in the study. The study findings will be presented in articles in international, peer-reviewed journals as well as to psychotherapy practitioners and other professionals across Denmark. Trial registration number NCT05630560.
Objective: Therapeutic alliance is one of the most stable predictors of outcome in psychotherapy, regardless of theoretical orientation. The alliance-outcome relationship in internet-based treatments has been investigated with mixed results. There is preliminary evidence that emotion regulation can work as a mediator for the alliance-outcome relationship. The present study aimed to investigate whether alliance predicted outcome session by session in two internet-based treatments for adolescent depression, and whether this relationship was mediated by emotion regulation. Method: Two hundred and seventy-two participants aged 15-19 years and diagnosed with depression were randomized to 10 weeks of internet-based psychodynamic or cognitive behavioral treatment. Both therapists and patients rated the alliance weekly. Patients also rated depressive symptoms and emotion regulation weekly. Analyses were made using cross-lagged panel modeling. Results: Alliance, as rated by both therapist and patient, predicted depression scores the following week. Emotion regulation rated by the patient also predicted depression scores the following week. Furthermore, alliance scores predicted emotion regulation scores the following week, which in turn predicted depression scores the week after, supporting the hypothesis that alliance influences outcome partly through emotion regulation. There were no group differences in any of these relationships. Conclusion: Alliance seems to play an important role in internet-based treatments, partly through emotion regulation. Clinicians working with text-based treatments should pay attention to the working alliance.
Background Adolescent major depressive disorder (MDD) is highly prevalent and associated with lifelong adversity. Evidence-based treatments exist, but accessible treatment alternatives are needed. We aimed to compare internet-based psychodynamic therapy (IPDT) with an established evidence-based treatment (internet-based cognitive behavioural therapy [ICBT]) for the treatment of adolescents with depression. Methods In this randomised, clinical trial, we tested whether IPDT was non-inferior to ICBT in the treatment of adolescent MDD. Eligible participants were 15-19 years old, presenting with a primary diagnosis of MDD according to DSM-5. Participants were recruited nationwide in Sweden through advertisements on social media, as well as contacts with junior and senior high schools, youth associations, social workers, and health-care providers. Adolescents who scored 9 or higher on the Quick Inventory of Depressive Symptomatology for Adolescents (QIDS-A17-SR) in an initial online screening were contacted by telephone for a diagnostic assessment using the Mini International Neuropsychiatric Interview. Participants were randomly assigned to ICBT or IPDT. Both interventions comprised eight self-help modules delivered over 10 weeks on a secure online platform. The primary outcome was change in depression severity measured weekly by the QIDS-A17-SR. Primary analyses were based on an intention -to-treat sample including all participants randomly assigned. A non-inferiority margin of Cohen's d=0.30 was predefined. The study is registered at ISRCTN, ISRCTN12552584. Findings Between Aug 19, 2019, and Oct 7, 2020, 996 young people completed screening; 516 (52%) were contacted for a diagnostic interview. 272 participants were eligible and randomly assigned to ICBT (n=136) or IPDT (n=136). In the ICBT group, 51 (38%) of 136 participants were classified as remitted, and 54 (40%) of 136 participants were classified as remitted in the IPDT group. Within-group effects were large (ICBT: within-group d=1.75, 95% CI 1.49 to 2.01; IPDT: within-group d=1.93, 1.67 to 2.20; both p<0.0001). No statistically significant treatment difference was found in the intention-to-treat analysis. Non-inferiority for IPDT was shown for the estimated change in depression during treatment (d=-0.18, 90% CI -0.49 to 0.13; p=0.34). All secondary outcomes showed non-significant between-group differences. Interpretation IPDT was non-inferior to ICBT in terms of change in depression for the treatment of adolescents with MDD. This finding increases the range of accessible and effective treatment alternatives for adolescents with depression. Copyright (C) 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.
Objective: Termination in psychodynamic therapy (PDT) is a potentially conflictual and turbulent phase for patients, with a risk for increases in symptoms. However, few studies of PDT have assessed symptoms frequently enough during the treatment to determine whether such setbacks are in fact common in PDT. Method: In a doubly randomized clinical preference trial, 217 adults, female = 163; M age = 34.8 (12.6), with panic disorder with or without agoraphobia were treated with panic-focused psychodynamic psychotherapy (PFPP) or panic control treatment (PCT), a form of cognitive behavioral therapy. Participants completed the Panic Disorder Severity Scale Self-Report (PDSS-SR) weekly during treatment (Weeks 1–12), and 6, 12, and 24 months after treatment. Using piecewise latent growth curve modeling, we tested the trajectories of change focusing on the termination phase in PFPP. Results: Week-to-week improvement on the PDSS-SR stopped (a termination setback [TS]) in PFPP during Weeks 10–12, whereas PCT participants continued to improve. Larger symptom reductions up to Week 10 in PFPP predicted a more severe TS. Less avoidant attachment and less severe interpersonal problems also predicted more severe TS. The TSs tended to last, as evidenced by inferior outcomes, up to the 12-month follow-up. Conclusions: This study provides evidence of a TS in PDT. Resurgence of symptoms as termination approached was more common in PFPP than in PCT. Studies involving weekly assessment of primary and comorbid symptoms, as well as qualitative analyses of the patient experiences of the therapeutic process during termination, in different forms of PDT, are warranted.
Objective: The effects of panic-specific psychotherapy on occupational functioning remain under-researched. This study tests whether two brief psychotherapies for Panic Disorder with or without Agoraphobia (PD/A) may generate improvement in work ability. Methods: Adults (N = 221) with a primary diagnosis of PD/A were randomised to wait-list, panic-focused psychodynamic psychotherapy (PFPP), panic control treatment (PCT), or to the choice between the two treatments. Participants completed the Work Ability Inventory (WAI) at baseline, post-treatment, and during 24-month follow-ups. Change in WAI scores were assessed using segmented multilevel linear growth models, and mediation was explored through path analysis. Results: WAI scores changed from the moderate to good range between baseline and post-treatment (SMD = 0.45; 95% CI [0.33, 0.57]) and continued to increase throughout the follow-up (SMD = 0.16; 95% CI [0.03, 0.28]) with no differences between treatments or allocation forms. In PFPP (but not in PCT) pre- to post-treatment change in WAI was mediated by reduction in panic symptoms and WAI predicted employment status and absences. Conclusions: Two brief panic specific psychotherapies, one cognitive behavioural and one psychodynamic, produced short and long-term increases in work ability.
Objective: To better understand the complexity of dyadic processes, such as the mechanisms of the working alliance, researchers recommend taking advantage of innovations in data analytic procedures when studying the interactions between therapists and patients that are associated with favorable therapeutic outcomes. Inspired by a recent line of alliance research using dyadic multilevel modeling, the present study investigated the hypothesis that convergence in the patient-therapist working alliance (i.e., increased similarity in ratings of the alliance across treatment) would be associated with better outcomes. Method: Data were retrieved from two samples: 1. A randomized controlled trial for treatment resistant depression (N = 96 dyads), and 2. An archival dataset of naturalistic psychotherapies from public health care (N = 139 dyads). Multilevel growth curve analysis was employed to investigate the degree of change in session-to-session agreement of global WAI ratings between therapists and patients (i.e., alliance convergence) as a predictor of symptom reduction in the BDI-II and the SCL-90R. Results: Contrary to our expectations, alliance convergence did not predict outcome in either sample, but was negatively associated with symptom severity in Study 2. Implications for understanding the complexity of dyadic processes and alliance work in psychotherapy are discussed.
Evidence-Based Medicine (EBM) have contributed to improved clinical practice with increased use of effective and life-saving treatments for severe diseases. However, the EBM model is less suitable for psychotherapy research than for pharmacological research and somatic medicine. The randomized controlled trial (RCT) design is an example of experimental methodology, which inevitably has more imperfections in psychotherapy research because psychotherapy RCTs cannot use double-blinding and the treatments tested are composite treatment packages. Long-term psychotherapy for severe and complex mental disorders is especially difficult to study with an RCT design. During the last decades, advanced analytic methods have been developed in psychotherapy process research, which enables investigation of causal connections regarding change mechanisms in psychotherapy. Therefore, we propose that the top of the research evidence hierarchy for psychotherapy should encompass: (1) RCT for circumscribed disorders, (2) cohort studies for complex disorders, and (3) advanced process studies for change mechanisms.
Objective:The objective was to test the hypothesis that externalizing and internalizing helpfulness beliefs and learning styles at baseline moderate panic severity and overall mental illness as short-term and long-term outcomes of two panic-focused psychotherapies, Panic Control Treatment (PCT) and Panic-Focused Psychodynamic Psychotherapy (PFPP).Method:Participants were 108 adults with DSM-IV Panic Disorder with or without Agoraphobia (PD/A) who were randomized to treatment in a trial of PCT and PFPP. Piece-wise/segmented multilevel modeling was used to test three-way interactions (Treatments x Moderator x Time), with participants and therapists as random factors. Outcome variables were clinician-rated panic severity and self-rated mental illness post-treatment and during follow-up.Results:Patients' externalizing (but not internalizing) helpfulness beliefs moderated mental illness outcomes during follow-up (but not during treatment); low levels of Externalization were facilitative for PFPP but not PCT. Internalizing and externalizing helpfulness beliefs and learning style did not moderate clinician-rated panic severity, whether short- or long-term.Conclusions:These results suggest that helpfulness beliefs and learning style have limited use in assignment to either PCT or PFPP for PD/A. Although further research is needed, low levels of helpfulness beliefs about externalizing coping may play a role in mental illness outcomes for PFPP.
ABSTRACTObjective: To examine whether working alliance quality and use of techniques predict improvement in Panic-Specific Reflection Function (PSRF), and misinterpretation of bodily sensations in treatments for panic disorder. Method: A sample of 161 patients received either CBT or PFPP (Panic-focused Psychodynamic therapy) within a larger RCT. Data were collected on patient-reported working alliance, misinterpretations, PSRF, observer-coded use of techniques, and interviewer-rated panic severity. Random-Intercept Cross-Lagged Panel Models assessed bi-directional associations, disentangling within- and between-patient effects, and accounting for prior change. Results: Higher alliance predicted subsequent within-patient improvement in PSRF in PFPP, but worsening in CBT. In both treatments, focus on interpersonal relationships predicted PRSF improvement (with stronger effects in CBT), while focus on thoughts and behaviors predicted worsening in PSRF. In CBT only, early focus on affect and moment-to-moment experience predicted reduced misinterpretation, while high focus on thoughts and cognitions predicted subsequent increase in misinterpretation. Conclusion: The quality of the alliance has differential effects on PSRF in distinct treatments. Interpersonal, rather than cognitive or behavioral focus, even when delivered differently within distinct treatments with high adherence, could facilitate improvement in PSRF. Additionally, early focus on affect and moment-to-moment experiences in CBT could reduce misinterpretations.
Objective: The aim of this paper was to introduce the Asymmetric Fixed Effects model to psychotherapy mechanisms of change researchers as a novel way of studying the effects of improvements and deteriorations in the candidate mechanism(s) separately. Alliance-outcome research was used to illustrate the possibility of estimating separate effects of improvements and deteriorations in the alliance
Method: Two archival datasets were used. One was from community-based primary care services in Sweden using theClinical Outcomes in Routine Evaluation — Outcome Measure (CORE-OM) and the Working Alliance Inventory—Short form (WAI-S, therapist form) each session with 1096 patients. The other dataset was from a university counseling center in China using the Session Rating Scale (SRS) and the Outcome Rating Scale (ORS) each session with 292 patients. Data was analyzed using the asymmetric fixed-effects model.
Results: The findings indicated that with raw scores, improvements in alliance from one session to the next were followed by lower symptoms/distress scores by the next session, but alliance deteriorations had no effect on next-session symptoms/distress. With alliance deteriorations and improvements defined relative to the sample’s average linear change over time, improvements and deteriorations had equal but opposite effects on next session symptom level.
Conclusion: Findings confirm the utility of the Asymmetric Fixed Effect model across two cross-national samples in showing that alliance deteriorations and improvements can predict next session symptoms separately at the within-person level. Findings raise new questions regarding the use of detrending in within-patient mechanism of change studies.
ObjectiveResearch has given limited attention to the distinction between patients from rural and urban areas, especially concerning the frequent overlap between rural living and low socio-economic status (SES). To shed more light on this, we explored the differential treatment processes between patients from rural and urban areas.MethodSeven hundred and fourteen patients recruited from a university counseling center in China filled out the questionnaires for Outcome Expectation (OE), Session Alliance Inventory (SAI) and Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) each session. Data was analyzed using the disaggregated cross-lagged panel model and the asymmetric fixed-effect model.ResultsThe findings indicated a reciprocal within-patient relation between OE and SAI for the whole sample. SAI mediated the effect of OE on next-session CORE-OM for patients from rural areas, with a significantly greater indirect effect than for patients from the urban areas. Asymmetric effects were found for OE among patients from urban areas, for whom drops in OE predicted worse next-session CORE-OM more strongly than improvements in OE predicted improved CORE-OM.ConclusionThis study provided preliminary evidence for differential OE-alliance-outcome predictions between patients with different SES and affirmed a reciprocal OE-alliance relation in a Chinese sample during the transition period of college.
INTRODUCTION: It remains unclear whether offering psychiatric patients their preferred treatment influences outcomes at the symptom level. OBJECTIVE: To assess whether offering patients with panic disorder with/without agoraphobia (PD/A) a choice between 2 psychotherapies yields superior outcomes to random assignment. METHODS: In a doubly randomised, controlled preference trial (DRCPT), 221 adults with PD/A were randomly assigned to: choosing panic-focused psychodynamic therapy (PFPP) or panic control treatment (PCT; a form of cognitive behavioural therapy); random assignment to PFPP or PCT; or waiting list control. Primary outcomes were PD/A severity, work status and work absences at post-treatment assessment. Outcomes at post-treatment assessment, 6-, 12-, and 24-month follow-ups were assessed using segmented multilevel linear growth models. RESULTS: At post-treatment assessment, the choice and random conditions were superior to the control for panic severity but not work status/absences. The choice and random conditions did not differ during treatment or follow-up for the primary outcomes. For panic severity, PCT was superior to PFPP during treatment (standardised mean difference, SMD, -0.64; 95% confidence interval, CI, -1.02 to -0.25); PFPP was superior to PCT during follow-up (SMD 0.62; 95% CI 0.27-0.98). There was no allocation by treatment type interaction (SMD -0.57; 95% CI -1.31 to 0.17). CONCLUSIONS: Previous studies have found that offering patients their preferred treatment yields small to moderate effects but have not employed designs that could rigorously test preference effects. In this first DRCPT of 2 evidence-based psychotherapies, allowing patients with PD/A to choose their preferred treatment was not associated with improved outcomes. Further DRCPTs are needed.
Objective: Evidence is inconclusive on whether variability in alliance ratings within or between therapists is a better predictor of treatment outcome. The objective of the present study was to explore between and within patient and therapist variability in alliance ratings, reciprocity among them, and their significance for treatment outcome. Method: A large primary care psychotherapy sample was used. Patient and therapist ratings of the working alliance at session three and patient ratings of psychological distress pre-post were used for analyses. A one-with-many analytical design was used in order to address problems associated with nonindependence. Results: Within-therapist variation in alliance ratings accounted for larger shares of the total variance than between-therapist variation in both therapist and patient ratings. Associations between averaged patient and therapist ratings of the alliance for the individual therapists and their average treatment outcome were weak but the associations between specific alliance ratings and treatment outcome within therapies were strong. Conclusions: The results indicated a substantial dyadic reciprocity in alliance ratings. Within-therapist variation in alliance was a better predictor of treatment outcome than between-therapist variation in alliance ratings.
The aim of this study was to examine cross-cultural differences, as operationalized by Schwartz's refined theory of basic values, in burnout levels among psychotherapists from 12 European countries during the coronavirus disease (COVID-19) pandemic. We focused on the multilevel approach to investigate if individual- and country-aggregated level values could explain differences in burnout intensity after controlling for sociodemographic, work-related characteristics and COVID-19-related distress among participants. 2915 psychotherapists from 12 countries (Austria, Bulgaria, Cyprus, Finland, Great Britain, Serbia, Spain, Norway, Poland, Romania, Sweden, and Switzerland) participated in this study. The participants completed the Maslach Burnout Inventory-Human Service Survey, the revised version of the Portrait Values Questionnaire, and a survey questionnaire on sociodemographic, work-related factors and the COVID-19 related distress. In general, the lowest mean level of burnout was noted for Romania, whereas the highest mean burnout intensity was reported for Cyprus. Multilevel analysis revealed that burnout at the individual level was negatively related to self-transcendence and openness-to-change but positively related to self-enhancement and conservation values. However, no significant effects on any values were observed at the country level. Male sex, younger age, being single, and reporting higher COVID-19-related distress were significant burnout correlates. Burnout among psychotherapists may be a transcultural phenomenon, where individual differences among psychotherapists are likely to be more important than differences between the countries of their practice. This finding enriches the discussion on training in psychotherapy in an international context and draws attention to the neglected issue of mental health among psychotherapists in the context of their professional functioning.
Objective: The aim of this study is to examine the amount of the total variance of the subjective well-being (SWB) of psychotherapists from 12 European countries explained by between-country vs. between-person differences regarding its cognitive (life satisfaction) and affective components (positive affect [PA] and negative affect [NA]). Second, we explored a link between the SWB and their personal (self-efficacy) and social resources (social support) after controlling for sociodemographics, work characteristics, and COVID-19-related distress.Methods: In total, 2915 psychotherapists from 12 countries (Austria, Bulgaria, Cyprus, Finland, Great Britain, Serbia, Spain, Norway, Poland, Romania, Sweden, and Switzerland) participated in this study. The participants completed the Satisfaction with Life Scale (SWLS), the International Positive and Negative Affect Schedule Short Form (I-PANAS-SF), the General Self-Efficacy Scale, and the Multidimensional Scale of Perceived Social Support.Results: Cognitive well-being (CWB; satisfaction with life) was a more country-dependent component of SWB than affective well-being (AWB). Consequently, at the individual level, significant correlates were found only for AWB but not for CWB. Higher AWB was linked to being female, older age, higher weekly workload, and lower COVID-19-related distress. Self-efficacy and social support explained AWB only, including their main effects and the moderating effect of self-efficacy.Conclusions: The results highlight more individual characteristics of AWB compared to CWB, with a more critical role of low self-efficacy for the link between social support and PA rather than NA. This finding suggests the need for greater self-care among psychotherapists regarding their AWB and the more complex conditions underlying their CWB.
BACKGROUND: Child and adolescent mental health problems account for a significant proportion of the local and global burden of disease and is recognized as a growing public health concern in need of adequate services. Studies carried out in Kenya suggest a need for a robust service for the treatment, prevention, and promotion of child and adolescent mental health. Despite a few existing services to provide treatment and management of mental health disorders, we need more knowledge about their effectiveness in the management of these disorders. This paper describes a study protocol that aims to evaluate the process and outcomes of psychotherapies offered to children and adolescents seeking mental health services at the Kenyatta National Hospital in Kenya. METHODS: This study will use a prospective cohort approach that will follow adolescent patients (12-17 years of age) receiving mental health services in the youth clinics at the Kenyatta National Hospital for a period of 12 months. During this time a mixed methods research will be carried out, focusing on treatment outcomes, therapeutic relationship, understanding of psychotherapy, and other mental health interventions offered to the young patients. In this proposed study, we define outcome as the alleviation of symptoms, which will be assessed quantitatively using longitudinal patient data collected session-wise. Process refers to the mechanisms identified to promote change in the adolescent. For example, individual participant or clinician characteristics, therapeutic alliance will be assessed both quantitatively and qualitatively. In each session, assessments will be used to reduce problems due to attrition and to enable calculation of longitudinal change trajectories using growth curve modeling. For this study, these will be referred to as session-wise assessments. Qualitative work will include interviews with adolescent patients, their caregivers as well as feedback from the mental health care providers on existing services and their barriers to providing care. CONCLUSION: This study aims to understand the mechanisms through which change takes place beyond the context of psychotherapy. What are the moderators and through which mechanisms do they operate to improve mental health outcomes in young people?
Various models of specialized foster care have been developed, but research on them is limited. This longitudinal, exploratory study analysed data on adaptive functioning, emotional and social problems and self-concept in a specialized foster care service in Sweden. The focus of the study was on the development of the children and young people in placement. The Adaptive Behaviour Assessment System (ABAS-II) was used to measure adaptive functioning, and the Beck Youth Inventories of Emotional and Social Impairment (BYI) was used to measure self-rated emotional and social problems and self-concept. Self-ratings showed significant improvements in disruptive behaviour, anger, anxiety and depression. Adaptive functioning as rated by foster parents improved but not enough to catch up with the non-clinical norm group. The average adaptive functioning among the participants at baseline was considerably below the Swedish norm group. Similar to the results of a previous study of the same treatment model, children and young people rated improvement while their foster parents did not do so to the same extent. Possible explanations for this are discussed in the paper. The study is limited by the lack of a control group and by data attrition.
Highlights
Knowledge about the development of mental health in young people in foster care is limited. This naturalistic study examined the effects of a relational and mentalization-focused treatment in foster families in Sweden on the placed young people’s mental health. The Achenbach System of Empirically Based Assessment (ASEBA) was used to measure change in psychiatric symptoms. Self-ratings showed significant improvements and medium to strong effects after 24 months in both boys and girls. No significant changes were found in the foster parents’ ratings or in the school staff’s ratings. Foster parents’ ratings suggested that girls’ behavioral problems decreased, but not the boys’. Based on these findings, we want to emphasize the importance of evaluating treatment effects using self-ratings by the young people in addition to parents’ and parent substitutes’ ratings.