Researching what we practice-The paradigm of systemic family research: Part 2.

This is the second of two articles focusing on ideological and philosophical preferences for relating to and conducting research in the field of systemic couple and family therapy (CFT). To emphasize the need for the field of systemic CFT to be based on the best available knowledge, in the first article, we argue the benefits of applying the principles of evidence-based practice, and in the current article, we present the rationale behind the contents of a program for systemic family therapy research that safeguards methodological multiplicity. The need for multi-methodological systemic research is also recognized on the basis of the authors' self-reflexive accounts of overcoming barriers to learning skills and deepening their understanding of quantitative methods. We thus argue that trans-methodological reflexivity is necessary and we argue a preference for methodological multiplicity that includes statistical competency as regards the interdependence of observations (i.e., nonindependence), and we further argue that these are crucial components of a systemic research program.

Researching what we practice-The paradigm of systemic family research: Part 1.

This is part 1 of two articles that focus on the ideological and philosophical preference regarding how to relate to and conduct research in the field of systemic couple and family therapy. Thus, this article outlines the theoretical groundwork for part 2 of "Researching what we practice" in the same journal. Research in certain areas of systemic couple and family therapy (CFT), such as that influenced by social constructionism and postmodernism, has a different epistemological tradition than in the natural sciences. Thus, only research from a narrow, selected spectrum of epistemologies has been incorporated as a key source in the knowledge base of systemic CFT. The consequence is that the field of postmodern systemic CFT risks promoting only a limited range of research designs and knowledge while excluding other designs and knowledge types, reasoning that these are less useful in clinical practice. The rationale behind this perspective is derived from ideology and philosophy rather than scientific criteria. Accordingly, in our field of study, different epistemological perspectives are easily viewed as dichotomous, thus causing professional gaps in our field. This tendency constrains the mutual exchange and development that are needed. We present a possible way out of this dichotomized deadlock, first and foremost by acknowledging - and encouraging the use of - the great variety and breadth of existing research and knowledge. Referring to the guiding principles of evidence-based practice, we argue that this would endow the systemic CFT therapist and researcher with a greater knowledge base and range of research methodologies. This could help improve the quality of treatment provided to our clients and enhance the legitimacy of postmodern systemic CFT as a branch of psychotherapy.

Using ROM in family therapy.

BACKGROUND: Routine outcome monitoring (ROM) is in this article defined as a tool for feedback-informed therapy where clients' therapy relevant information is applied in real-time therapy. Because family therapy represents a comprehensive clinical setting, ROM is experienced as particularly useful. AIMS: In a vignette from family therapy practice, the use of ROM is demonstrated on individual, couple, and family levels with reference to integrative systemic therapy. DISCUSSION: ROM information is shown to play a central role in the different phases of treatment. It is demonstrated how ROM facilitates patient-centered assessment that strengthens the therapeutic collaboration such as the working alliance, identifying treatment targets, and possible constraints. In particular, ROM revealing alliance rupture followed by alliance repair is emphasized as a crucial therapeutic event in this treatment.

Treated together-changed together: The application of dyadic analyses to understand the reciprocal nature of alliances and couple satisfaction over time.

In a Norwegian study of 73 couples attending a residential couple therapy program lasting between 6 and 12 weeks, weekly self-report data on therapy alliance and couple satisfaction were collected using routine outcome monitoring (ROM). The aim was to show how dyadic analyses could be applied to examine the predictive association between alliances and couple satisfaction. Results showed that improved alliance between dyad members and their couple therapist predicted their spouses' couple satisfaction. Furthermore, improved couple satisfaction predicted improvement in spouse's alliance. The clinical implication of these findings should heighten awareness to the importance of establishing and maintaining the alliance of male partners in couple therapy, something that predicts their spouses' couple satisfaction. These findings help nuance the already existing literature on the working alliance. Furthermore, we propose that dyadic analyses should be widely used in any psychotherapeutic research that aims to understand the reciprocal effects of dyads.

Data on the individual problems and strengths scale from the systemic therapy inventory of change. Clinical samples from Norway.

These data stem from 841 clients at different couple and family therapy sites in Norway that was collected between 2010 and 2016. They all answered the Individual Problems and Strengths scale (IPS) that is a part of the Systemic Therapy Inventory of Change (STIC) system in addition to some demographic variables. In addition to the 22 items constructing the IPS scale, the data contain 14 demographic variables describing age, educational level, civil status, prior therapeutic experience, use of medicine and year of data collection. Summary statistics are provided. Male and female clients between 12 and 72 years of age answered these questions prior to or at their first session of psychotherapy. The four sites collecting the data are located at different cities in the southern part of the country and represents low and high threshold agencies. The data can be used to test the construct validity of the measure for different populations. The data could, with a sample from the normal population, also be used for norming the scale and thus provide data to calculate cut off scores for clinical and non-clinical levels for each of the eight subscales. Further, the data could be used in combination with other measures of individual distress to test the construct validity of the scale within a Norwegian clinical sample and perhaps also within other countries.

Persistent level of mental distress in PTSD patients is not reflected in cytokine levels 1 year after the treatment.

OBJECTIVE: Cross-sectional data show that post-traumatic stress disorder (PTSD) patients often have increased levels of circulating inflammatory markers. There is, however, still a paucity of longitudinal studies with long follow-up times on levels of cytokines in such patients. The current study assesses patients with and without PTSD diagnosis 1 year after discharge from inpatient treatment. METHODS: Patients in treatment for serious non-psychotic mental disorders were recruited at the beginning of their treatment stay at a psychiatric centre in Norway. Ninety patients submitted serum samples and filled out the Hopkins Symptom Checklist-90 Revised Global Severity Index (HSCL-90R GSI) questionnaire during their mainstay and at a follow-up stay 1 year after discharge. Of these patients, 33 were diagnosed with PTSD, 48 with anxiety, depression, or eating disorder, while 9 patients had missing data. The patients were diagnosed using the Mini-International Neuropsychiatric Interview (MINI). RESULTS: At the follow-up stay (T3), PTSD patients had higher levels of GSI scores than non-PTSD patients (p = 0.048). These levels were unchanged from the year before (T2) in both groups. The levels of circulating cytokines/chemokine did not differ between the PTSD and non-PTSD patients at T3. At T2, however, the PTSD and non-PTSD groups exhibited different levels of interleukin 1ß (IL-1ß) (p = 0.053), IL-1RA (p = 0.042), and TNF-α (p = 0.037), with the PTSD patients having the higher levels. CONCLUSION: Despite exhibiting different mental distress scores, the PTSD and non-PTSD patients did not differ regarding levels of circulating inflammatory markers at 1-year follow-up.

Predicting change through individual symptoms and relationship distress: A study of within- and between-person processes in couple therapy.

OBJECTIVE: In couple therapy clients often suffer from a blend of individual psychiatric symptoms as well as severe relational distress. However, research is inconclusive on whether relational change predicts symptom change or vice versa. Because answers to this question could have important clinical implications on what to focus on in couple therapy at which time in treatment, more research is recommended. METHOD: In this study, data collected before every therapy session were used to test whether changes in relational functioning predicted symptom functioning or vice versa. The study used a multilevel modelling approach, and the variables of interest were disaggregated into within- and between-person effects. RESULTS: The results indicated that if an individual improved more than expected on relational functioning, this predicted more improvement than expected on individual symptoms. No significant reciprocal relationship was found between these variables. CONCLUSIONS: The clinical implication is discussed, suggesting that an emphasis on relational improvement seems to be an important mechanism during couple therapy that may facilitate the change on individual symptoms in the long run.

Alliance predicting progress in couple therapy.

The therapeutic alliance has gained status as a common factor in psychotherapy due to its robust predictive relationship with outcome. The current challenge in our field is to gain a more nuanced understanding of alliance's impact on the progress of treatment over the course of therapy. In the current study, alliance was measured on 3 dimensions: (a) the individual's as well as the couple's joint perception of alliance with the therapist ("self/group-therapist"), (b) each partner's perception of the alliance between the spouse and the therapist ("other-therapist"), and (c) the couple's assessment of alliance with each other ("within-system"). Based on self-reported data from 165 adult clients, we analyzed whether scores on these alliance dimensions at the beginning of therapy predicted the frequently measured outcomes on individual symptoms and relationship distress during treatment. We found that 2 of the alliance dimensions, the "self/group-therapist" and the "other-therapist," at the start of treatment predicted the slopes of the outcome measures. These findings add to established research suggesting that early establishment of alliance is an important predictor for progress during treatment. Variations in the results among the 3 alliance dimensions suggest the usefulness of the clinician assessing different aspects of alliance in couple therapy. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Circulating cytokine levels in the treatment of comorbid anxiety disorders.

Psychotherapy research aims to investigate predictors and moderators of treatment outcome, but there are few consistent findings. This study aimed to investigate cytokines in patients undergoing treatment for anxiety disorders and whether the level of cytokines moderated the treatment outcome. Thirty-seven patients with comorbid and treatment-resistant anxiety disorders were investigated using multilevel modelling. Serum cytokine levels were measured three times: pretreatment, in the middle of treatment, and at the end of treatment. Anxiety and metacognitions were measured weekly throughout treatment by self-report. The levels of monocyte chemoattractant protein-1, tumour necrosis factor-alpha, and interleukin-1 receptor antagonist did not change during therapy or were not related to the level of anxiety. Metacognitive beliefs predicted anxiety, but the relationship between metacognitions and anxiety was not moderated by cytokines. Limitations of the study include that the patients were not fasting at blood sampling, and we did not assess body mass index, which may affect cytokine levels. The lack of significance for cytokines as a predictor or moderator may be due to a lack of power for testing moderation hypotheses, a problem associated with many psychotherapy studies. Cytokines did not predict the outcome in the treatment of comorbid anxiety disorders in our sample. Furthermore, cytokines did not moderate the relationship between metacognitions and anxiety.

Cytokine concentrations are related to level of mental distress in inpatients not using anti-inflammatory drugs.

OBJECTIVE: Cross-sectional data show elevated levels of circulating cytokines in psychiatric patients. The literature is divided concerning anti-inflammatory drugs' ability to relieve symptoms, questioning a causal link between inflammatory pathways and psychiatric conditions. We hypothesised that the development of circulating cytokine levels is related to mental distress, and that this relationship is affected by the use of anti-inflammatory drugs. METHODS: The study was a longitudinal assessment of 12-week inpatient treatment at Modum Bad Psychiatric Center, Norway. Sera and self-reported Global Severity Index (GSI) scores, which measure psychological distress, were collected at admission (T0), halfway (T1) and before discharge (T2). Other variables known to distort the neuroimmune interplay were included. These were age, gender, diagnosis of PTSD, antidepressants and anti-inflammatory drugs. A total of 128 patients (92 women and 36 men) were included, and 28 were using anti-inflammatory medication. Multilevel modelling was used for data analysis. RESULTS: Patients with higher levels of IL-1RA and MCP-1 had higher GSI scores (p = 0.005 and p = 0.020). PTSD patients scored higher on GSI than non-PTSD patients (p = 0.002). These relationships were mostly present among those not using anti-inflammatory drugs (n = 99), with higher levels of IL-1RA and MCP-1 being related to higher GSI score (p = 0.023 and 0.018, respectively). Again, PTSD patients showed higher GSI levels than non-PTSD patients (p = 0.014). CONCLUSIONS: Cytokine levels were associated with level of mental distress as measured by the GSI scores, but this relationship was not present among those using anti-inflammatory drugs. We found no association between cytokine levels and development of GSI score over time.

Feedback in Couple and Family Therapy: A Randomized Clinical Trial.

Routine Outcome Monitoring (ROM) is recommended as a psychotherapy procedure to serve as clinical feedback in order to improve client treatment outcomes. ROM can work as a warning signal to the therapist if the client shows signs of no change or deterioration. This study has investigated whether any difference in outcome could be detected between those clients in couple and family therapy who used the Systemic Therapy Inventory of Change (STIC) feedback system (ROM condition) versus those who were offered treatment without the use of STIC ("treatment as usual" or TAU condition). A sample of 328 adults seeking couple and family therapy in Norway was randomly assigned to ROM versus TAU conditions. Outcome measures were The Outcome Questionnaire-45 and The Revised Dyadic Adjustment Scale. The results demonstrated no significant differences in outcomes between the ROM and TAU. Possible explanations of this result related to design and implementation issues are discussed.

Individual distress and dyadic adjustment over the course of couple therapy and three-year follow-up: A replication study.

This replication study examined the change over time and the relationship between depressive symptoms and dyadic adjustment during residential couple therapy and at one- and three-year follow-up. Mixed models were used in the analyses, and a disaggregation procedure was applied to examine the results on a between-person as well as on a within-person level. Overall, the results of the previous study were replicated. Significant improvement (p < .001) occurred on measures assessing relationship satisfaction and depressive symptoms from admission to discharge (effect sizes .47 to.72) and from admission to three-year follow-up (effect sizes .59 to .66). The within-person finding implies that when a person experiences more depressive symptoms than usual for him/her, subsequent dyadic adjustment is poorer than usual. Thus, our previous clinical implication suggestion is reinforced in this study: When treating couples suffering from co-existing relational and symptomatic distress, couple therapy should include the aim of lowering individual depressive symptoms.

Physical Couple and Family Violence Among Clients Seeking Therapy: Identifiers and Predictors.

INTRODUCTION: Couple violence (CV) affects many, and the consequences of those actions are grave, not only for the individual suffering at the hand of the perpetrator but also for the other persons in the family. Violence often happens among more than just the adults within one family. Even if CV has been thoroughly investigated in the general population very few studies have investigated this objective on a clinical sample, and none of these have included family violence. AIM: This article identifies and describes the group of clients that have issues of physical couple and family violence. It analyses a model that can help to discover physical violence and help therapists to assess what actions to take in therapy to prevent further physical violence. METHODOLOGY: Descriptive analysis, t-tests, and structural equation modeling (SEM) are used on a sample of clients receiving couple and family therapy (CFT) in Norway (N = 830). Family violence is modeled by the partner's expectations toward each other, levels of anger, sexual satisfaction, and self-control. RESULTS: One-in-five clients experienced physical CV in their current relationship and one-in-four experienced physical family violence. The group of clients who experienced CV differed from those without such experiences in having lower income, more prior experience with psychotherapy, more experience with alcohol abuse in childhood, and far more physical family violence in their current family. Our model predicting physical couple and family violence explained as much as 53% of family violence and had three positive, significant predictors (expectation, anger, and sexual satisfaction) and one, significant negative predictor (self-control). Somewhat unexpected, sexual satisfaction was a positive, and not a negative, predictor of violence. CONCLUSION: Our study identified one-in-four clients in CFT experience physical CV. Unreasonable expectation from one partner toward the other, anger and sexual satisfaction were positive predictors of physical violence, while self-control was found to be a negative predictor of physical violence. Implications for therapeutic work and the prevention of physical violence are discussed.

PTSD patients show increasing cytokine levels during treatment despite reduced psychological distress.

BACKGROUND: A reciprocal relationship between activated innate immune system and changes in mood and behavior has been established. There is still a paucity of knowledge on how the immune system responds during psychiatric treatment. We aimed to explore circulating cytokines and assess psychiatric symptom severity scores during 12 weeks of inpatient psychiatric treatment. METHODS: The study was a longitudinal assessment of 124 patients (88 women and 36 men) in treatment at Modum Psychiatric Center, Norway. The patient sample comprised a mixed psychiatric population of whom 39 were diagnosed with posttraumatic stress disorder (PTSD). Serum blood samples for cytokine analysis and measures of mental distress using Global Severity Index were collected at admission (T0), halfway (T1), and before discharge (T2). Other factors assessed were age, gender, and the use of antidepressants and anti-inflammatory drugs. Multilevel modeling was used for longitudinal analyses to assess the repeated cytokine samples within each patient. RESULTS: Overall level of IL-1RA was higher in PTSD patients when compared to those without PTSD (P=0.021). The level of IL-1ß, MCP-1, and TNF-α increased over time in PTSD compared to non-PTSD patients (P=0.025, P=0.011 and P=0.008, respectively). All patients experienced reduced mental distress as measured by self-reported Global Severity Index scores. Stratified analysis showed that PTSD patients who used anti-inflammatory drugs had higher levels of IL-1ß (P=0.007) and TNF-α (P=0.049) than PTSD patients who did not use such drugs. CONCLUSION: The study indicates that traumatized patients may have a distinct neuroimmune development during recovery. Their activated immune system shows even further activation during their rehabilitation despite symptom reduction.

The effect of trauma and alcohol on the relationship between level of cytokines and depression among patients entering psychiatric treatment.

BACKGROUND: Depression is associated with immunological responses as reflected by altered levels of circulating cytokines. Alcohol use and trauma may modulate immune activity, and few studies have investigated these factors in depressed patients. We aimed to explore the association between circulating peripheral cytokine levels and degree of depressive symptoms, taking trauma and alcohol into account. METHODS: The study was a cross-sectional assessment of patients at admission to a specialized psychiatric center in Norway. A total of 128 patients were included. Information was gathered using the self-administered questionnaires Beck Depression Inventory-II (BDI-II) and the Alcohol Use Disorders Identification Test (AUDIT), in addition to clinical interviews recording childhood or adult life trauma. Serum levels of the cytokines Interleukin-1ß (IL-1ß), Interleukin-1 Receptor Antagonist (IL-1RA), Tumor Necrosis Factor-α (TNF-α) and the chemokine Monocyte Chemoattractant Protein-1 (MCP-1) were assessed. A Luminex bead-based multiplex assay was used for cytokine measurements. Patient cytokine levels were compared to those of healthy volunteers by the Mann-Whitney U test. RESULTS: Levels of cytokines did not differ across patients with mild, moderate and severe depression. AUDIT score was not related to cytokine levels, but to level of depression. A history of trauma was related to higher levels of IL-1RA and TNF-α (p = 0.048 and p = 0.033, respectively), especially among the severely depressed. Serum levels of MCP-1 and TNF-α were significantly higher among psychiatric patients than in healthy volunteers. CONCLUSIONS: Findings indicate that depression was not related to levels of circulating cytokines among patients in treatment, but that traumatized patients had higher levels of IL-1RA and TNF-α than patients without trauma experience. The lack of relationship between cytokine level and depression was evident both in those without and with trauma.

The course of dyadic adjustment and depressive symptoms during and after couples therapy: a prospective follow-up study of inpatient treatment.

A clinical sample of adult patients suffering from relational distress and concurrent psychiatric symptoms was followed from admission, through residential couple therapy, to 1-year follow-up. At follow-up, 9.8% were separated. The remaining couples showed significant improvement in dyadic adjustment at posttreatment. However, at 1-year follow-up, a subgroup of 25% of the positive treatment responders had deteriorated to below their admission levels of dyadic adjustment. Contrary to expectation, the deteriorated group had showed significantly less distress both in depressive symptoms and in one early maladaptive schema domain-Impaired Autonomy-at admission, when compared with the rest of the sample, which suggests the need for further research and possible replication in this area.