Psychotherapy Works - An Inclusive and Affirming View to a Modern Mental Health Treatment.

Psychotherapy is a highly collaborative and individualized mental health practice developed in (post-) modern societies. The mental health outcomes of psychotherapy cover a broad range of psychological factors including the reduction of suffering/symptoms as well as the promotion of well-being, personal values, and personal strengths. There is extensive meta-analytic evidence that legitimate psychotherapy works remarkably well and robustly for most common mental disorders. In addition, there is a large body of meta-analytic evidence supporting the potential relevance of transdiagnostic relationship principles and transtheoretical psychotherapy factors. Based on this ongoing empirical evidence, we propose four relevant implications for future training and practice in transdiagnostic psychotherapy: 1) the development of a transtheoretical legal framework for psychotherapeutic treatments, 2) the formulation of evidence-based transtheoretical interpersonal skills, 3) an orientation toward transtheoretical therapeutic factors, and 4) the exploration of comprehensive psychotherapy outcomes. We conclude with some more general guidance for future directions.

Defining the therapeutic relationship in the context of alcohol use, other drug use, and behavior change: Principles and practices.

OVERVIEW: This article contributes to knowledge and practice of core processes that are shared by evidence-based alcohol or other drug (AOD) therapies. It is the fourth in a series with this aim, and here we discuss perhaps the most universally acknowledged ingredient of effective therapy - the therapeutic relationship. We consider various related terms and definitions in the literature, but in the present review, we offer a definition that underscores the context of behavior change. METHOD: This study conducted a literature review and qualitative content analysis to derive a set of principles and practices for facilitating and maintaining the therapeutic relationship. The sources for this review included government-issued practice guidelines, therapy manuals or books, demonstration videos, and peer-reviewed articles (61 sources). The content analysis was performed in NVIVO, and reliability analysis showed moderate agreement between raters (kappa = 0.60). RESULTS: Six principles and 16 practices were identified. The distribution of principles and practices could be broken into three categories: 1) the facilitation of client behavior change mechanisms (i.e., self-determination, motivation, self-efficacy), 2) partnership considerations (e.g., goal and task alignment), and 3) therapist interpersonal skills (e.g., empathy). CONCLUSIONS: The therapeutic relationship is foundational to the behavior change process. We frame it as a combination of broader interpersonal considerations and attention to key mechanisms of client behavior change. The present work provides a novel resource for trainees, clinicians, and clinical supervisors interested in fostering therapy relationships with clients in AOD or other behavior change settings.

Self-compassion and fear of compassion in the treatment of chronic depression: Mechanisms of change?

OBJECTIVE: The aim of this naturalistic process study was to investigate the relationship between self-compassion, fear of compassion from others, and depressive symptoms over the course of psychotherapy in patients with chronic depression. METHOD: A sample of 226 patients with chronic depression who received inpatient short-term psychodynamic psychotherapy (STPP) provided weekly self-report measures of self-compassion, fear of compassion, and depressive symptoms (Patient Health Questionnaire-9). Trivariate latent curve modeling with structured residuals was applied to investigate the between- and within-patient relationships among the variables. RESULTS: At the between-patient level, a significant positive correlation was found between slope of depression and the slope of fear of compassion. At the within-patient level, a lower than expected level of fear of compassion predicted a subsequent lower than expected level of depression (mean weekly effect size = 0.12), with a smaller reciprocal relationship (mean weekly effect size = 0.08). There was no significant within-patient effect of self-compassion predicting subsequent depression, but a significant effect of a lower than expected level of depression predicting a subsequent higher than expected level of self-compassion (mean weekly effect size = -0.13). No within-patient effect between self-compassion and fear of compassion was found. CONCLUSIONS: In the context of this study, it appears that fear of compassion may be a putative mechanism of change involved in alleviating depressive symptoms in patients with chronic depression treated with STPP. On the other hand, self-compassion appears to be an outcome of psychotherapy. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Measurement-based care professional practice guideline: Fine, but guidelines do not make good therapy.

Boswell et al. (2022) persuasively make the case for and propose professional practice guidelines (PPG) for measurement-based care (MBC). Although the evidence for MBC is robust, implementing MBC effectively in practice requires skills and processes not discussed in the PPG. We discuss five problems with the PPG for MBC: The "what's in a name?" problem, lack of actionable actions problem, the stopwatch problem, the stock market problem, and looking for the keys under the light problem. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Effectiveness of telemental health during the COVID-19 pandemic: A propensity score noninferiority analysis of outcomes.

The COVID-19 pandemic forced governments to implement a range of public health measures that disrupted the personal and professional lives of many, including an abrupt adoption of telemental health services. Using data from a nonprofit counseling practice, we tested whether telemental health services delivered during the pandemic were inferior to face-to-face services delivered prior to the pandemic. We first characterized patients seeking therapy services before and during the pandemic to ascertain whether the demographics and presenting concerns of patients pre- and during COVID-19 differed and found that pandemic patients reported greater anxiety, greater overall distress, were more likely female and not partnered, and earned less than before the pandemic. We used a propensity score matching analysis to account for these differences and investigated whether or not telemental health therapy was inferior to face-to-face therapy. Based on the propensity-matched samples (2,180 patients in each condition), telemental health services were found not to be inferior to in-person services, allaying concerns about the effectiveness of telemental health services delivered during the COVID-19 pandemic. The present study also illustrates the usefulness of propensity matching for examining treatment effects in naturalistic settings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The alliance in mental health care: conceptualization, evidence and clinical applications.

The concept of alliance reflects the collaborative relationship between a clinician and a patient, defined as consisting of three elements: a) the agreement on the goals of treatment; b) the agreement on a task or series of tasks; c) the development of a bond. Although much of the theory and research on the alliance comes from the domain of psychotherapy, the concept is applicable to any practice involving a person seeking help and a socially sanctioned healer. An extensive research evidence suggests that the alliance (typically measured at the third or fourth session) is a robust predictor of the outcomes of various forms of psychotherapy, even when prior symptom improvement and other factors are considered. Both the clinician and the patient bring to the therapy situation different capacities to form an alliance. Factors concerning the patient include, among others, the diagnosis, attachment history and style, motivation, and needs for affiliation. However, the benefits of the alliance have been found to be mostly due to the therapist's contribution, in particular his/her facilitative interpersonal skills, including verbal fluency, communication of hope and positive expectations, persuasiveness, emotional expression; warmth, acceptance and understanding; empathy, and alliance rupture-repair responsiveness. Placebo studies have allowed to experimentally manipulate aspects of the relationship between a therapist and a patient in non-psychotherapy contexts. In these settings, two components of the relationship have emerged: an emotional one (involving being cared for and understood by the clinician) and a cognitive one (including the belief in the competence of the therapist to select and administer an effective treatment). Here we propose a model that describes three pathways through which the alliance creates benefits, named CARE (caring, attentive, real and empathic), EXPECTANCY, and SPECIFIC. Although research and clinical attention have mostly focused on the alliance between a clinician and a patient in face-to-face interactions, there is preliminary evidence concerning the alliance between patients and other clinic staff, systems of care, or the program in Internet-mediated services. These new research areas clearly require further development.

Threat alert: The effect of outliers on the alliance-outcome correlation.

Meta-analyses have established the alliance as the most robust predictor of outcome in psychotherapy. A growing number of studies have evaluated potential threats to the conclusion that alliance is a causal factor in psychotherapy. One potential threat that has not been systematically examined is the possibility that the alliance-outcome association is driven by low alliance outliers. We examined the influence of removing low alliance outliers on the alliance-outcome association using data drawn from two large-scale, naturalistic psychotherapy data sets (Ns = 1,052; 11,029). These data sets differed in setting (university counseling center, community mental health center), country (United States and Canada), alliance measure (four-item Working Alliance Inventory Short Form Revised, 10-item Session Rating Scale), and outcome measure (Counseling Center Assessment of Psychological Symptoms-34, Outcome Questionnaire-45). We examined the impact of treating outliers in five different ways: retaining them, removing values three or two standard deviations from the mean, and winsorizing values three or two standard deviations from the mean. We also examined the effect of outliers after disaggregating alliance ratings into within-therapist and between-therapist components. The alliance-outcome correlation and the proportion of variance in posttest outcomes explained by alliance when controlling for pretest outcomes were similar regardless of how low alliance outliers were treated (change in r ≤ .04, change in R² ≤ 1%). Results from the disaggregation were similar. Thus, it appears that the alliance-outcome association is not an artifact of the influence of low alliance outliers. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The Effectiveness of an Intensive Inpatient Psychotherapy Program for Chronic Depression: A naturalistic comparison with wait list.

BACKGROUND: Patients with chronic depression (CD) typically have an early symptom onset, more psychiatric comorbidities, more treatment attempts, and more frequent and longer inpatient hospitalizations than patients with major depressive disorders. The main purpose of this study was to investigate the effectiveness of an intensive inpatient psychotherapy program for patients with chronic depression (CD). The primary research question was whether two intensive psychodynamic inpatient treatments, affect phobia therapy (APT) and VITA, were superior to an outpatient wait list condition, receiving treatment as usual (TAU), at completion of treatment. To investigate if a potential difference between the intensive treatment and the wait list control group was dependent on a specific psychotherapeutic model, the study contrasted two therapies with similar intensity, but different theoretical rationales. METHODS: Two hundred eighty patients with CD were included in a naturalistic study. Patients were assessed at four time points; assessment, start of therapy, end of therapy and 1-year follow-up. Three comparisons were performed with patients matched across groups; Intensive inpatient treatment program (APT + VITA) vs wait list during treatment, APT vs VITA during treatment and APT vs VITA during follow-up. The outcome measure was the BDI-II. RESULTS: Intensive inpatient treatment program vs. wait list showed a significant difference in favor of the intensive treatment. No significant differences were found between APT and VITA during therapy or follow-up; but both groups had large effect sizes during treatment, which were maintained during follow-up. CONCLUSIONS: The intensive inpatient psychotherapy program showed superior effect on chronic depression over an outpatient wait list condition receiving treatment as usual (TAU), but no significant differences were found between the two intensive inpatient psychodynamic treatments. The results provide support for the effectiveness of an intensive inpatient psychotherapy program in treatment of chronic and severe disorders, such as CD, which could be of benefit for policymakers and the health care sector as they are allocating recourses efficiently. TRIAL REGISTRATION: This study has been retrospectively registered on ClinicalTrials.gov (NCT05221567) on February 3rd, 2022.

What Is the Common Ground for Modern Psychotherapy? A Discussion Paper Based on EACLIPT's 1st Webinar.

Psychotherapy as it is implemented today, can be seen as the composition of unconnected groups of practitioners and scientists pursuing different theories. The idea of finding a common "umbrella" for all evidence-based treatments in the field of psychotherapy is gaining more interest. Based on this background, experts in clinical psychology from various backgrounds led a fundamental discussion about modern psychotherapy and its basic mechanisms. Process-Based Therapy (PBT) was presented by Stefan Hofmann as a possible novel approach to clinical research and practice. In this article we present the different perspectives of the four panelists on PBT and in how far the model builds a common ground for different treatment approaches. Learning mechanisms and the therapeutic alliance were almost unanimously considered as indispensable factors in a global model of psychotherapy. In conclusion, the panelists emphasized a much-needed focus on characteristics and competencies of therapists themselves e.g., in communication, listening and empathy. These core competencies should be trained and promoted independently of the therapeutic approach.

Emotional clarity and tolerance of emotional distress as mechanisms of change in short-term psychodynamic psychotherapy for chronic depression.

OBJECTIVE: The aim of this naturalistic process study was to investigate the relationship between emotional clarity and tolerance of emotional distress and depressive symptoms over the course of short-term psychodynamic psychotherapy for chronically depressed patients. METHOD: Weekly self-reports of emotional clarity, tolerance of emotional distress, and depressive symptoms (PHQ-9) were provided by 252 patients with chronic depression who were admitted to a 13-week inpatient treatment program. Latent curve modeling with structured residuals (LCM-SR) was applied to investigate the between- and within-person effects of week-to-week change in emotional clarity and tolerance of emotional distress as predictors of subsequent depression. The relationship between emotional clarity and tolerance of emotional distress was also investigated. RESULTS: At the within-person level, higher level of emotional clarity and tolerance of emotional distress predicted subsequent lower level of depression. A reciprocal relationship was found for tolerance of emotional distress (lower level of depression predicted subsequent level of tolerance emotional distress) but not for emotional clarity. No within-person effect between emotional clarity and tolerance of emotional distress was found. DISCUSSION: The results indicate that emotional clarity and tolerance of emotional distress may be mechanisms of change in short-term psychodynamic psychotherapy for chronic depression. The results are consistent with previous findings of the importance of emotional clarity and tolerance of emotional distress in psychotherapy. This study demonstrated the utility of LCM-SR as a method to identity mechanisms of change in psychotherapy. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The relative efficacy of bona fide cognitive behavioral therapy and applied relaxation for generalized anxiety disorder at follow-up: A longitudinal multilevel meta-analysis.

OBJECTIVE: This meta-analysis examined the relative efficacy of bona fide psychotherapy conditions in generalized anxiety disorder (GAD) from posttreatment to follow-up in adults. METHODS: Omnibus tests of relative efficacy across bona fide psychotherapies for primary and secondary outcomes were conducted. Longitudinal multilevel subgroup analyses investigated, (a) applied relaxation versus cognitive behavioral therapy (CBT) without applied relaxation and (b) well-established CBT versus augmented integrative CBT. RESULTS: In total, 54 repeated effect sizes nested in 23 studies were included in this meta-analysis. Omnibus test of relative efficacy indicated no significant differences among the bona fide psychotherapy contrasts in primary and some differences in secondary outcomes. When contrasting applied relaxation with CBT without applied relaxation, negligible relative efficacy differences were found at each assessment time. There were small efficacy differences in favor of augmented integrative CBT in comparison to well-established CBT. CONCLUSION: Small relative efficacy differences were found between bona fide psychotherapies in GAD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The efficacy and optimal matching of an Internet-based acceptance and commitment therapy intervention for depressive symptoms among university students: A randomized controlled trial in China.

OBJECTIVE: The present study tested the efficacy of an unguided internet-based Acceptance and Commitment Therapy (iACT) program for depression, and identified the psychological characteristics of participants who benefitted the most from the program. METHOD: Undergraduate students with mild to severe symptoms of depression were randomized to the iACT group (n = 95) or the waiting-list group (WLC group; n = 87). Depressive symptoms and positive mental health were assessed at baseline (T0 ), at the end of the 6-week program (T1 ), and at a 3-month follow-up (T2 ). RESULTS: Compared with the WLC group, the iACT group showed significantly more improvement in depressive symptoms (d = 1.27) and positive mental health (d = 0.59), both at T1 and T2 . Latent Profile Analysis identified three classes of participants: Sensitive-to-Relationship, Low-Reactive-Depression, and Endogenous-Depression group. In general, the treatment was particularly suitable for the Sensitive-to-Relationship class. CONCLUSION: The iACT was effective in treating the depressive symptoms of undergraduates, especially suitable for the clients with high baseline depression, high externality, high resistance, and high sensitivity to relationships.

A latent trajectory analysis of inpatient depression treatment.

Patients seeking psychotherapy may progress through treatment in varying ways. Modeling multiple treatment trajectories through growth mixture modeling provides a comprehensive way of understanding a patient population. Multiple trajectories may additionally help researchers describe complexities within a patient population, such as those with severe and persistent disorders and comorbid symptoms, to understand characteristics of patients that may be struggling during treatment. We analyzed the depression symptom outcome measures (PHQ-9) for 246 patients receiving inpatient depression treatment. We constructed a growth mixture model of depression symptom changes, allowing the number of treatment trajectories to emerge through the data, and utilized goodness-of-fit indices to select the superior model. Results indicated three classes was the best fitting model, with patients either (a) patients started above the clinical cutoff score for depression and had significant linear change over time, ending therapy just above the clinical cutoff-"Improvement-leveling off-improvement"; (b) patients started therapy well above the clinical cutoff, showed symptom alleviation at the beginning of therapy before the trajectory started to level off-"High symptom pressure"; or (c) patients started therapy just below the clinical cutoff, had steady change throughout therapy, ending well below the clinical cutoff-"continuous improvement." Implications of the study may include altering the length of treatment based on patient presenting symptoms in order to best serve patients and utilize hospital resources. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Goal setting and monitoring with alcohol and other drug use disorders: Principles and practices.

INTRODUCTION: This work builds on a small body of literature that explores core processes in psychotherapy, behavior change, and evidence-based alcohol or other drug (AOD) therapies. Here, this paper discusses two separate but dependent processes. The research team defines goal setting and goal monitoring as collaborative processes where clinicians and clients identify and formulate therapeutic goals; actionable objectives; and revisit, measure, and renegotiate these plans via a standardized procedure over time. METHOD: Study methods included a literature review and qualitative content analysis to derive a set of principles and practices of goal setting and monitoring. The research team used source documents (i.e., literature reviews, therapy manuals, and government-issued practice guidelines) and videos (i.e., therapy demonstration videos), and we performed analyses in NVIVO. RESULTS: The study identified ten principles and 32 practices. The principles suggest that goal setting and monitoring can be characterized as a collaborative, explicit, and standardized approach to engaging in goal-directed therapeutic work. The term goal-directed therapeutic work connotes a shift toward a more accountable frame for care than has been previously emphasized in the literature. The identified practices were organized into five sub-themes related to goal setting (10 practices), goal monitoring (10 practices), as well as practices specific to mechanisms of goal pursuit and behavior change. These practices involved ways to attend to client self-determination (4 practices), motivation (4 practices), and self-efficacy (4 practices). CONCLUSIONS: Goal setting and monitoring are a collaborative means of mapping and tracking a course of mutually accountable treatment. The current work is a novel resource for trainees, clinicians, and clinical supervisors interested in care based on evidence-based principles and practices of AOD and other behavior change therapies.

It's the therapist and the treatment: The structure of common therapeutic relationship factors.

Objective: Prior research has established that common therapeutic relationship factors are potent predictors of change in psychotherapy, but such factors are typically studied one at a time and their underlying structure when studied simultaneously is not clear. We assembled empirically validated relationship factors (e.g., therapist empathy; patient expectations; agreement about goals) into a single instrument and subjected it to factor analysis. Method: The instrument was applied to patients (N = 332) undergoing intensive psychotherapy of different types for depressive disorders, anxiety disorders, eating disorders, and childhood trauma in an inpatient specialized mental health setting. In order to examine the psychometric properties of the scale, we used half the sample (N=164) to conduct exploratory factor analysis (EFA) and parallel analysis before we tested the solution using exploratory structural equation modeling (ESEM) on the second half of the sample (N=168). Measurement invariance analysis was conducted to examine the stability of the factor structure. Results: The analysis yielded two factors, which were termed 1. "Confidence in the therapist" and 2. "Confidence in the treatment." Discussion: When assessed simultaneously, patients differentiate between their evaluation of the therapist and of the treatment. The results indicate that there is substantial overlap among previously established relationship factors.Trial registration: ClinicalTrials.gov identifier: NCT03503981.

Trajectories of change in chronic depression: Differences in self-criticism and somatic symptoms between users of antidepressants and nonmedicated patients.

OBJECTIVE: Depression is typically seen as composed of several factors (i.e., cognitive, affective, somatic) which may be targeted by different interventions (i.e., pharmacotherapy, psychotherapy, or combination treatment). Successfully targeting these factors may contribute to improved treatment response in depression. A previous study identified two subfactors on Beck Depression Inventory-II (BDI-II) in a sample of chronically depressed patients: (a) self-criticism and (b) somatic symptoms (sleep disturbance, fatigue, changes in appetite). Prior research indicates that these symptoms may respond differently to psychotherapy and pharmacotherapy. In this study, we examined whether patients who were on antidepressant medication (ADM) had different outcomes on these factors than patients not using medication while undergoing intensive inpatient psychotherapeutic treatment. METHOD: After adjusting for baseline difference with propensity score matching, a total of 238 patients with chronic depression were included in the analysis of which 119 patients were using ADM during treatment while 119 were not. We analyzed whether the two groups had different trajectories of change on the factors "self-criticism" and "somatic symptoms" using multilevel growth curve modeling. RESULTS: Patients not using medication during treatment had significantly larger symptom reduction than ADM users on the self-criticism factor, while there was no difference between groups on the somatic factor. CONCLUSION: There seems to be a difference in outcomes on self-criticism depending on the use of ADM for this patient group. This may suggest that the simultaneous use of ADM while in psychotherapy could make patients less accessible to the effects of psychotherapeutic interventions on this factor. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Examining therapist effects in the alliance-outcome relationship: A multilevel meta-analysis.

OBJECTIVE: The relationship between the therapeutic alliance and outcome has been supported consistently over time. More recently, studies have examined therapist effects in the alliance-outcome relationship and came up with somewhat mixed findings. The purpose of this study was to replicate and extend previous meta-analytic work using a much larger data set, permitting not only the verification of the overall impact of the therapists' contribution but, at the same time, controlling for several potential covariates effecting this relationship. METHOD: We conducted two- and three-level mixed-effects meta-analyses (k = 152; 827 total effect sizes) to examine the significance of several potential moderators of the alliance-outcome correlation. These moderators included (a) Patient-Therapist Ratio (PTR; Patient N divided by therapist N to test therapist effects), (b) Alliance and Outcome Rater's contribution (patient, therapist, observer, and other), (c) Alliance Measures, (d) Research Design (RCT, Other) and (e) Personality Disorder. RESULTS: The PTR, an index of the therapist's contribution to the alliance, was a significant moderator of the alliance-outcome correlation in both the two- and three-level models. When several potential confounds were simultaneously tested in a three-level multipredictor metaregression, including rater of alliance and outcome, research design, alliance measure, and personality disorder, PTR remained a significant moderator of the alliance-outcome correlation. CONCLUSION: Replicating and extending previous research, this study supported the significance of therapists' impact in the alliance-outcome relationship. These results remained significant even when, using three-level metaregressions, several potential covariates were simultaneously controlled. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

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.