Applying precision methods to treatment selection for moderate/severe depression in person-centered experiential therapy or cognitive behavioral therapy.

OBJECTIVE: To develop two prediction algorithms recommending person-centered experiential therapy (PCET) or cognitive-behavioral therapy (CBT) for patients with depression: (1) a full data model using multiple trial-based and routine variables, and (2) a routine data model using only variables available in the English NHS Talking Therapies program. METHOD: Data was used from the PRaCTICED trial comparing PCET vs. CBT for 255 patients meeting a diagnosis of moderate or severe depression. Separate full and routine data models were derived and the latter tested in an external data sample. RESULTS: The full data model provided the better prediction, yielding a significant difference in outcome between patients receiving their optimal vs. non-optimal treatment at 6- (Cohen's d = .65 [.40, .91]) and 12 months (d = .85 [.59, 1.10]) post-randomization. The routine data model performed similarly in the training and test samples with non-significant effect sizes, d = .19 [-.05, .44] and d = .21 [-.00, .43], respectively. For patients with the strongest treatment matching (d ≥ 0.3), the resulting effect size was significant, d = .38 [.11, 64]. CONCLUSION: A treatment selection algorithm might be used to recommend PCET or CBT. Although the overall effects were small, targeted matching yielded somewhat larger effects.

Person-centred experiential therapy versus cognitive behavioural therapy delivered in the English Improving Access to Psychological Therapies service for the treatment of moderate or severe depression (PRaCTICED): a pragmatic, randomised, non-inferiority trial.

BACKGROUND: The UK Government's implementation in 2008 of the Improving Access to Psychological Therapies (IAPT) initiative in England has hugely increased the availability of cognitive behavioural therapy (CBT) for the treatment of depression and anxiety in primary care. Counselling for depression-a form of person-centred experiential therapy (PCET)-has since been included as an IAPT-approved therapy, but there is no evidence of its efficacy from randomised controlled trials (RCTs), as required for recommendations by the National Institute for Health and Care Excellence. Therefore, we aimed to examine whether PCET is cost effective and non-inferior to CBT in the treatment of moderate and severe depression within the IAPT service. METHODS: This pragmatic, randomised, non-inferiority trial was done in the Sheffield IAPT service in England and recruited participants aged 18 years or older with moderate or severe depression on the Clinical Interview Schedule-Revised. We excluded participants presenting with an organic condition, a previous diagnosis of personality disorder, bipolar disorder, or schizophrenia, drug or alcohol dependency, an elevated clinical risk of suicide, or a long-term physical condition. Eligible participants were randomly assigned (1:1), independently of the research team, and stratified by site with permuted block sizes of two, four, or six, to receive either PCET or CBT by use of a remote, web-based system that revealed therapy after patient details were entered. Those assessing outcomes were masked to treatment allocation. Participants were seen by appropriately trained PCET counsellors and CBT therapists in accordance with the IAPT service delivery model. Depression severity and symptomatology measured by the Patient Health Questionnaire-9 (PHQ-9) at 6 months post-randomisation was the primary outcome, with the PHQ-9 score at 12 months post-randomisation being a key secondary outcome. These outcomes were analysed in the modified intention-to-treat population, which comprised all randomly assigned patients with complete data, and the per-protocol population, which comprised all participants who did not switch from their randomised treatment and received between four and 20 sessions. Safety was analysed in all randomly assigned patients. The non-inferiority margin was set a priori at 2 PHQ-9 points. Patient safety was monitored throughout the course of therapy, adhering to service risk procedures for monitoring serious adverse events. This trial is registered at the ISRCTN Registry, ISRCTN06461651, and is complete. FINDINGS: From Nov 11, 2014, to Aug 3, 2018, 9898 patients were referred to step three treatments in the Sheffield IAPT service for common mental health problems, of whom 761 (7·7%) were referred to the trial. Of these, we recruited and randomly assigned 510 participants to receive either PCET (n=254) or CBT (n=256). In the PCET group, 138 (54%) participants were female and 116 (46%) were male, and 225 (89%) were White, 16 (6%) were non-White, and 13 (5%) had missing ethnicity data. In the CBT group, 155 (61%) participants were female and 101 (39%) were male, and 226 (88%) were White, 17 (7%) were non-White, and 13 (5%) had missing ethnicity data. The 6-month modified intention-to-treat analysis comprised 401 (79%) of the enrolled participants (201 in the PCET group; 200 in the CBT group) and the 12-month modified intention-to-treat analysis comprised 319 participants (167 in the PCET group; 152 in the CBT group). The 6-month per-protocol analysis comprised 298 participants (154 in the PCET group; 144 in the CBT group). At 6 months post-randomisation, PCET was non-inferior to CBT in the intention-to-treat population (mean PHQ-9 score 12·74 [SD 6·54] in the PCET group and 13·25 [6·35] in the CBT group; adjusted mean difference -0·35 [95% CI -1·53 to 0·84]) and in the per-protocol population (12·73 [SD 6·57] in the PCET group and 12·71 [6·33] in the CBT group; 0·27 [95% CI -1·08 to 1·62]). At 12 months post-randomisation, there was a significant adjusted between-group difference in mean PHQ-9 score in favour of CBT (1·73 [95% CI 0·26-3·19]), with a 95% CI exceeding the 2-point non-inferiority margin. There were two deaths, one death by suicide in the PCET group and one due to chronic obstructive pulmonary disease in the CBT group. Both were assessed by the responsible clinician to be unrelated to the trial. In terms of using emergency departments for depression-related events, four people (three in the PCET group; one in the CBT group) made more than a single use and six people (three in the PCET group; three in the CBT group) made a single use. One patient in the PCET group had inpatient treatment for a depression-related event. INTERPRETATION: This trial is the first to examine the two most frequently administered psychological therapies in the IAPT service. The finding of non-inferiority of PCET to CBT at 6 months supports the results from large, routine, non-randomised datasets from the IAPT programme. Given the high demand for psychological therapies and the need for patient choice, our findings suggest the need for continued investment in the training and delivery of PCET for improving short-term outcomes, but suggest that PCET might be inferior to CBT at 12 months. FUNDING: British Association for Counselling and Psychotherapy Research Foundation.

Assessing and promoting the use of implementation intentions in clinical practice.

RATIONALE: Striving for goals is a key part of psychological therapy, but people often struggle to translate their goals into action. Prior evidence has found that forming if then plans (or 'implementation intentions') is an effective way to bridge the gap between goals and action. However, it is unclear if therapists naturally prompt their clients to form implementation intentions and, if not, whether training would be feasible. METHOD AND RESULTS STUDY 1: Researchers coded the behavior change techniques used in 40 sessions of therapy for depression using a Cognitive Behavioral Therapy approach and a Person-Centered Experiential Therapy approach and found that therapists do not typically prompt their clients to form implementation intentions in either therapeutic approach. METHOD AND RESULTS STUDIES 2 AND 3: The aim was to develop and evaluate a training program for therapists on implementation intentions. Training was delivered face-to-face to 69 cognitive-behavioral therapists (Study 2), and online to 87 therapists working across models (Study 3) and therapists completed self-report measures of their use and knowledge of implementation intentions before training, post-training, and follow-up. The training significantly increased therapists' use and knowledge of implementation intentions. CONCLUSIONS: Taken together, these findings suggest therapists can be trained in the use of implementation intentions and that appropriate content might be integrated into training programs.

Acceptability and Effectiveness of NHS-Recommended e-Therapies for Depression, Anxiety, and Stress: Meta-Analysis.

BACKGROUND: There is a disconnect between the ability to swiftly develop e-therapies for the treatment of depression, anxiety, and stress, and the scrupulous evaluation of their clinical utility. This creates a risk that the e-therapies routinely provided within publicly funded psychological health care have evaded appropriate rigorous evaluation in their development. OBJECTIVE: This study aims to conduct a meta-analytic review of the gold standard evidence of the acceptability and clinical effectiveness of e-therapies recommended for use in the National Health Service (NHS) in the United Kingdom. METHODS: Systematic searches identified appropriate randomized controlled trials (RCTs). Depression, anxiety, and stress outcomes at the end of treatment and follow-up were synthesized using a random-effects meta-analysis. The grading of recommendations assessment, development, and evaluation approach was used to assess the quality of each meta-analytic comparison. Moderators of treatment effect were examined using subgroup and meta-regression analysis. Dropout rates for e-therapies (as a proxy for acceptability) were compared against controls. RESULTS: A total of 24 studies evaluating 7 of 48 NHS-recommended e-therapies were qualitatively and quantitatively synthesized. Depression, anxiety, and stress outcomes for e-therapies were superior to controls (depression: standardized mean difference [SMD] 0.38, 95% CI 0.24 to 0.52, N=7075; anxiety and stress: SMD 0.43, 95% CI 0.24 to 0.63, n=4863), and these small effects were maintained at follow-up. Average dropout rates for e-therapies (31%, SD 17.35) were significantly higher than those of controls (17%, SD 13.31). Limited moderators of the treatment effect were found. CONCLUSIONS: Many NHS-recommended e-therapies have not been through an RCT-style evaluation. The e-therapies that have been appropriately evaluated generate small but significant, durable, beneficial treatment effects. TRIAL REGISTRATION: International Prospective Register of Systematic Reviews (PROSPERO) registration CRD42019130184; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=130184.

Usability, Acceptability, and Effectiveness of Web-Based Conversational Agents to Facilitate Problem Solving in Older Adults: Controlled Study.

BACKGROUND: The usability and effectiveness of conversational agents (chatbots) that deliver psychological therapies is under-researched. OBJECTIVE: This study aimed to compare the system usability, acceptability, and effectiveness in older adults of 2 Web-based conversational agents that differ in theoretical orientation and approach. METHODS: In a randomized study, 112 older adults were allocated to 1 of the following 2 fully automated interventions: Manage Your Life Online (MYLO; ie, a chatbot that mimics a therapist using a method of levels approach) and ELIZA (a chatbot that mimics a therapist using a humanistic counseling approach). The primary outcome was problem distress and resolution, with secondary outcome measures of system usability and clinical outcome. RESULTS: MYLO participants spent significantly longer interacting with the conversational agent. Posthoc tests indicated that MYLO participants had significantly lower problem distress at follow-up. There were no differences between MYLO and ELIZA in terms of problem resolution. MYLO was rated as significantly more helpful and likely to be used again. System usability of both the conversational agents was associated with helpfulness of the agents and the willingness of the participants to reuse. Adherence was high. A total of 12% (7/59) of the MYLO group did not carry out their conversation with the chatbot. CONCLUSIONS: Controlled studies of chatbots need to be conducted in clinical populations across different age groups. The potential integration of chatbots into psychological care in routine services is discussed.

Therapist personality traits as predictors of psychological treatment outcomes.

Aim: To investigate if therapists' personality influences their patients' treatment outcomes. Methods:N = 4,052 patients were treated by 69 therapists, including 36 Psychological Wellbeing Practitioners (PWPs) and 33 Cognitive Behavioural Therapists (CBTs). Therapists completed the NEO-PI-R personality inventory, they reported years of clinical experience, and expert assessors rated their clinical competence and reflective abilities. Their patients completed pre and post-treatment measures of depression (PHQ-9) and anxiety (GAD-7). Associations between therapist personality traits and patient treatment outcomes were examined using multilevel modelling, controlling for therapist demographics, clinical experience, technical competence and reflective ability. Results: Relative to other sources of variability, therapists accounted for 1% to 3% of overall variability in treatment outcomes. However, the magnitude of systematic heterogeneity in performance between therapists was around 6%, such that the best-performing therapists outperformed average therapists by a margin of moderate to large effects (g = .57-1.10). Clinical experience, technical competence and reflective ability were unrelated to treatment outcomes. Patients treated by PWPs with above-average agreeableness scores and CBTs with above-average openness to experience scores had poorer treatment outcomes. Conclusions: Therapist effects may be partly explained by the influence of their personality on their work with anxious and depressed patients.

e-Therapies in England for stress, anxiety or depression: how are apps developed? A survey of NHS e-therapy developers.

OBJECTIVE: To document the quality of web and smartphone apps used and recommended for stress, anxiety or depression by examining the manner in which they were developed. DESIGN: The study was conducted using a survey sent to developers of National Health Service (NHS) e-therapies. DATA SOURCES: Data were collected via a survey sent out to NHS e-therapy developers during October 2015 and review of development company websites during October 2015. DATA COLLECTION/EXTRACTION METHODS: Data were compiled from responses to the survey and development company websites of the NHS e-therapies developers. RESULTS: A total of 36 (76.6%) out of the 48 app developers responded. One app was excluded due to its contact details and developer website being unidentifiable. Data from the missing 10 was determined from the app developer's website. The results were that 12 out of 13 web apps and 20 out of 34 smartphone apps had clinical involvement in their development. Nine out of 13 web apps and nine out of 34 smartphone apps indicated academic involvement in their development. Twelve out of 13 web apps and nine out of 34 smartphone apps indicated published research evidence relating to their app. Ten out of 13 web apps and 10 out of 34 smartphone apps indicated having other evidence relating to their app. Nine out of 13 web apps and 19 out of 34 smartphone apps indicated having a psychological approach or theory behind their app. CONCLUSIONS: As an increasing number of developers are looking to produce e-therapies for the NHS it is essential they apply clinical and academic best practices to ensure the creation of safe and effective apps.

How Does Therapy Harm? A Model of Adverse Process Using Task Analysis in the Meta-Synthesis of Service Users' Experience.

Background: Despite repeated discussion of treatment safety, there remains little quantitative research directly addressing the potential of therapy to harm. In contrast, there are numerous sources of qualitative evidence on clients' negative experience of psychotherapy, which they report as harmful. Objective: To derive a model of process factors potentially leading to negative or harmful effects of therapy, from the clients' perspective, based on a systematic narrative synthesis of evidence on negative experiences and effects of psychotherapy from (a) qualitative research findings and (b) participants' testimony. Method: We adapted Greenberg (2007) task analysis as a discovery-oriented method for the systematic synthesis of qualitative research and service user testimony. A rational model of adverse processes in psychotherapy was empirically refined in two separate analyses, which were then compared and incorporated into a rational-empirical model. This was then validated against an independent qualitative study of negative effects. Results: Over 90% of the themes in the rational-empirical model were supported in the validation study. Contextual issues, such as lack of cultural validity and therapy options together with unmet client expectations fed into negative therapeutic processes (e.g., unresolved alliance ruptures). These involved a range of unhelpful therapist behaviors (e.g., rigidity, over-control, lack of knowledge) associated with clients feeling disempowered, silenced, or devalued. These were coupled with issues of power and blame. Conclusions: Task analysis can be adapted to extract meaning from large quantities of qualitative data, in different formats. The service user perspective reveals there are potentially harmful factors at each stage of the therapy journey which require remedial action. Implications of these findings for practice improvement are discussed.

The relationship between expected engagement and talking therapy outcome.

The aim of the study was to investigate whether client-reported expected engagement with therapy predicted therapy outcome. It was hypothesized that higher expected engagement with cognitive behavioural therapy (CBT) or person-centred experiential therapy (PCET) would predict more symptomatic improvement following therapy and higher likelihood of therapy completion. The Sheffield Expected Engagement with Therapy Scale was administered to 96 clients at pre-therapy assessment with all meeting a diagnosis of moderate or severe depression with 53 receiving CBT and 43 receiving PCET. Higher expected engagement predicted more symptomatic improvement in CBT but not PCET. Expected engagement only predicted improvement in CBT when clients rated the credibility of CBT as low or moderate. Expected engagement did not predict therapy completion in either therapy. Assessment of expected engagement could be a useful tool in prediction of symptomatic improvement in CBT.

Risk factors for negative experiences during psychotherapy.

BACKGROUND: It is estimated that between 3% and 15% of patients have a negative experience of psychotherapy, but little is understood about this. AIMS: The aim of this study was to investigate the factors associated with patients' negative therapy experiences. METHOD: The data comprised 185 patient and 304 therapist questionnaires, 20 patient and 20 therapist interviews. Patients reported on an unhelpful or harmful experience of therapy, and therapists on a therapy where they thought the patient they were working with had a poor or harmful experience. These were transcribed and analysed using thematic analysis. RESULTS: There was a Lack of fit between Patient needs, Therapist skills, and Service structures. This could result in Fault Lines, a tension between Safety and containment and Power and control. This tension led to Strain and Poor Engagement, which led to Consequences following the negative therapy experience. CONCLUSIONS: Patients require clear information, choice, involvement in decision-making, explicit contracting and clarity about sessions and progress. Opportunities for patient feedback should be the norm, where the therapist and service are vigilant for signs of deterioration and solutions considered. Clinical and methodological significance of this article: Estimates of "unwanted effects," including long-lasting effects, of psychotherapy have ranged from 3% to 15%. Few empirical studies have been conducted in this area. This study aimed to address this gap and provide clinicians with a model of risk factors for negative therapy effects. The findings of this study indicate the importance of providing patients with a supportive service structure that offers clear information, choice and involvement in decision-making. Explicit contracting at the beginning of therapy and clarity about sessions and progress are also important in managing patient expectations throughout. Opportunities for patient feedback should be provided.

How do we know what makes for "best practice" in clinical supervision for psychological therapists? A content analysis of supervisory models and approaches.

Clinical supervision for psychotherapies is widely used in clinical and research contexts. Supervision is often assumed to ensure therapy adherence and positive client outcomes, but there is little empirical research to support this contention. Regardless, there are numerous supervision models, but it is not known how consistent their recommendations are. This review aimed to identify which aspects of supervision are consistent across models, and which are not. A content analysis of 52 models revealed 71 supervisory elements. Models focus more on supervisee learning and/or development (88.46%), but less on emotional aspects of work (61.54%) or managerial or ethical responsibilities (57.69%). Most models focused on the supervisee (94.23%) and supervisor (80.77%), rather than the client (48.08%) or monitoring client outcomes (13.46%). Finally, none of the models were clearly or adequately empirically based. Although we might expect clinical supervision to contribute to positive client outcomes, the existing models have limited client focus and are inconsistent. Therefore, it is not currently recommended that one should assume that the use of such models will ensure consistent clinician practice or positive therapeutic outcomes. KEY PRACTITIONER MESSAGES: There is little evidence for the effectiveness of supervision. There is a lack of consistency in supervision models. Services need to assess whether supervision is effective for practitioners and patients.

A pragmatic randomised controlled trial assessing the non-inferiority of counselling for depression versus cognitive-behaviour therapy for patients in primary care meeting a diagnosis of moderate or severe depression (PRaCTICED): Study protocol for a randomised controlled trial.

BACKGROUND: NICE guidelines state cognitive behavioural therapy (CBT) is a front-line psychological treatment for people presenting with depression in primary care. Counselling for Depression (CfD), a form of Person-Centred Experiential therapy, is also offered within Improving Access to Psychological Therapies (IAPT) services for moderate depression but its effectiveness for severe depression has not been investigated. A full-scale randomised controlled trial to determine the efficacy and cost-effectiveness of CfD is required. METHODS: PRaCTICED is a two-arm, parallel group, non-inferiority randomised controlled trial comparing CfD against CBT. It is embedded within the local IAPT service using a stepped care service delivery model where CBT and CfD are routinely offered at step 3. Trial inclusion criteria comprise patients aged 18 years or over, wishing to work on their depression, judged to require a step 3 intervention, and meeting an ICD-10 diagnosis of moderate or severe depression. Patients are randomised using a centralised, web-based system to CfD or CBT with each treatment being delivered up to a maximum 20 sessions. Both interventions are manualised with treatment fidelity tested via supervision and random sampling of sessions using adherence/competency scales. The primary outcome measure is the Patient Health Questionnaire-9 collected at baseline, 6 and 12 months. Secondary outcome measures tap depression, generic psychological distress, anxiety, functioning and quality of life. Cost-effectiveness is determined by a patient service receipt questionnaire. Exit interviews are conducted with patients by research assessors blind to treatment allocation. The trial requires 500 patients (250 per arm) to test the non-inferiority hypothesis of -2 PHQ-9 points at the one-sided, 2.5% significance level with 90% power, assuming no underlying difference and a standard deviation of 6.9. The primary analysis will be undertaken on all patients randomised (intent to treat) alongside per-protocol and complier-average causal effect analyses as recommended by the extension to the CONSORT statement for non-inferiority trials. DISCUSSION: This large-scale trial utilises routinely collected outcome data as well as specific trial data to provide evidence of the comparative efficacy and cost-effectiveness of Counselling for Depression compared with Cognitive Behaviour Therapy as delivered within the UK government's Improving Access to Psychological Therapies initiative. TRIAL REGISTRATION: Controlled Trials ISRCTN Registry, ISRCTN06461651 . Registered on 14 September 2014.

Supervision for treatment of depression: An experimental study of the role of therapist gender and anxiety.

Psychological treatments for depression are not always delivered effectively or consistently. Clinical supervision of therapists is often assumed to keep therapy on track, ensuring positive patient outcomes. However, there is a lack of empirical evidence supporting this assumption. This experimental study explored the focus of supervision of depression cases, comparing guidance given to supervisees of different genders and anxiety levels. Participants were clinical supervisors who supervised therapists working with patients with depression. Supervisors indicated their supervision focus for three supervision case vignettes. Supervisee anxiety and gender was varied across vignettes. Supervisors focused calm female supervisees more on therapeutic techniques than state anxious female supervisees. Males were supervised in the same way, regardless of their anxiety. Both male and female supervisors had this pattern of focus. Findings indicate that supervision is influenced by supervisors' own biases towards their supervisees. These factors may cause supervisors to drift from prompting their supervisees to deliver best practice. Suggestions are made for ways to improve the effectiveness of clinical supervision and how these results may inform future research practice.

Does forming implementation intentions help people with mental health problems to achieve goals? A meta-analysis of experimental studies with clinical and analogue samples.

OBJECTIVE: People struggle to act on the goals that they set themselves, and this gap between intention and action is likely to be exacerbated by mental health problems. Evidence suggests that forming specific if-then plans (or 'implementation intentions') can promote goal attainment and a number of studies have applied such techniques in clinical contexts. However, to date, the extent to which planning can help people with mental health problems has not been systematically examined. METHOD: The present review used meta-analysis to investigate the effect of if-then planning on goal attainment among people with a DSM-IV/ICD-10 diagnosis (i.e., clinical samples) or scores above a relevant cut-off on clinical measures (i.e., analogue samples). In total, 29 experimental studies, from 18 records, met the inclusion criteria. RESULTS: Excluding one outlying (very large) effect, forming implementation intentions had a large-sized effect on goal attainment (d+ = 0.99, k = 28, N = 1,636). Implementation intentions proved effective across different mental health problems and goals, and in studies with different methodological approaches. CONCLUSIONS: Taken together, the findings suggest that forming implementation intentions can be a useful strategy for helping people with mental health problems to achieve various goals and might be usefully integrated into existing treatment approaches. However, further studies are needed addressing a wider range of mental health problems.

An investigation of client mood in the initial and final sessions of cognitive-behavioral therapy and psychodynamic-interpersonal therapy.

OBJECTIVE: Our aim was to examine client mood in the initial and final sessions of cognitive-behavioral therapy (CBT) and psychodynamic-interpersonal therapy (PIT) and to determine how client mood is related to therapy outcomes. METHODS: Hierarchical linear modeling was applied to data from a clinical trial comparing CBT with PIT. In this trial, client mood was assessed before and after sessions with the Session Evaluation Questionnaire-Positivity Subscale (SEQ-P). RESULTS: In the initial sessions, CBT clients had higher pre-session and post-session SEQ-P ratings and greater pre-to-post session mood change than did clients in PIT. In the final sessions, these pre, post, and change scores were generally equivalent across CBT and PIT. CBT outcome was predicted by pre- and post-session SEQ-P ratings from both the initial sessions and the final sessions of CBT. However, PIT outcome was predicted by pre- and post-session SEQ-P ratings from the final sessions only. Pre-to-post session mood change was unrelated to outcome in both treatments. CONCLUSIONS: These results suggest different change processes are at work in CBT and PIT.

The Content, Quality and Impact of Cognitive Behavioural Case Formulation During Treatment of Obsessive Compulsive Disorder.

BACKGROUND: Case formulation (CF) is considered a core component of cognitive behavioural therapy (CBT). Despite this, few studies have explored the content and quality of CFs in routine practice and any associated impact on treatment outcome. AIMS: This study investigated (1) the content, timing and quality of CF for patients (N = 29) with Obsessive Compulsive Disorder; (2) the impact of CF on symptoms, distress and therapeutic alliance; and (3) the relationship between CF quality and treatment outcome. METHOD: CF content and quality were assessed from audiotapes of routine CBT sessions using a validated coding manual and evaluated against treatment outcomes at different stages of therapy. RESULTS: CFs were developed early during treatment and contained strong behavioural and cognitive components, with a focus on symptoms and maintaining factors. CF quality ratings ranged from rudimentary to excellent. A significant improvement in distress and the therapeutic alliance occurred following the introduction of CF, but no significant relationship was found between CF quality and outcome at any stage of treatment. CONCLUSION: CF may be valuable in reducing patient attrition, due to its impact early in treatment. Further research is needed to explore the most important components of CF. Theoretically sound and disorder specific measurement tools for evaluating CFs are required.

Zone of proximal development (ZPD) as an ability to play in psychotherapy: a theory-building case study of very brief therapy.

OBJECTIVES: This theory-building case study examined the zone of proximal development (ZPD) in psychotherapy within the assimilation model. Theoretically, the ZPD is the segment of the continuum of therapeutic development within which assimilation of problematic experiences can take place. Work within a problem's current ZPD may be manifested as a Winnicottian ability to play, that is, an ability to adopt a flexible reflexive stance to the presenting problem and be involved in joint examination of possible alternatives. Play may be recognized in the client's receptivity to and creative use of the therapist's formulations of the presenting problems. DESIGN AND METHODS: A case was selected from a comparative clinical trial of two very brief psychotherapies for mild to moderate depression, the Two-Plus-One Project (Barkham, Shapiro, Hardy, & Rees, 1999, J. Consult. Clin. Psychol., 67, 201). Martha, a woman in her late forties, received two sessions of psychodynamic-interpersonal therapy 1 week apart and a follow-up ('plus one') session approximately 3 months later. Dialogical sequence analysis was used to analyse the transcripts of the three sessions. RESULTS: The analysis revealed Martha's problematic action pattern, which remained unchanged throughout the three sessions. Her ability to use and elaborate the therapist's formulations depended on the referential object that the therapist addressed; in particular, she seemed unable to play with the therapist's formulations of her more problematic experiences. CONCLUSIONS: The case helped elucidate how the ZPD is content dependent. Winnicott's conception of playing emphasizes the quality of client response as an indicator of this content sensitivity. Differing breadths of major problems' ZPD, manifested as differing abilities to play with therapists' formulations may explain why some clients improve in psychotherapy while some do not. PRACTITIONER POINTS: Accessing very problematic content may be very difficult even though the client's ability to mentalize other material appears ordinary. Mildly depressed clients who have developed powerful care-taking coping strategies may not respond to very brief therapeutic interventions. A client's minimal acknowledgements may mislead the therapist into supplementing the client's failing self-reflection rather than addressing the issue that provokes this failure.

Alliance ruptures and resolution during cognitive behaviour therapy with patients with borderline personality disorder.

OBJECTIVE: To explore the process of rupture resolution in cognitive behaviour therapy (CBT) with two good outcome clients with borderline personality disorder (BPD). METHOD: This study employed task-analytic methods to investigate whether the existing CBT rupture resolution model for depression could be validated. Quantitative analyses identified rupture-repair sequences and 41 rupture resolution attempts were systematically analysed. RESULTS: The final model shared similarities with the existing model although additional components, including an "external observer" were identified. Focus on affective experience was also hypothesized to be important. CONCLUSIONS: The final theoretical rupture resolution model may be a useful tool when working with BPD clients in CBT. It is however recognized that further research on data from larger samples is needed. Clinical implications for managing alliance ruptures with BPD clients are discussed.

Patient affect experiencing following therapist interventions in short-term dynamic psychotherapy.

The aim of this research was to examine the relationship between therapist interventions and patient affect responses in Short-Term Dynamic Psychotherapy (STDP). The Affect Experiencing subscale from the Achievement of Therapeutic Objectives Scale (ATOS) was adapted to measure individual immediate affect experiencing (I-AES) responses in relation to therapist interventions coded within the preceding speaking turn, using the Psychotherapy Interaction Coding (PIC) system. A hierarchical linear modelling procedure was used to assess the change in affect experiencing and the relationship between affect experiencing and therapist interventions within and across segments of therapy. Process data was taken from six STDP cases; in total 24 hours of video-taped sessions were examined. Therapist interventions were found to account for a statistically significant amount of variance in immediate affect experiencing. Higher levels of immediate affect experiencing followed the therapist's use of Confrontation, Clarification and Support compared to Questions, Self-disclosure and Information interventions. Therapist Confrontation interventions that attempted to direct pressure towards either the visceral experience of affect or a patient's defences against feelings led to the highest levels of immediate affect experiencing. The type of therapist intervention accounts for a small but significant amount of the variation observed in a patient's immediate emotional arousal. Empirical findings support clinical theory in STDP that suggests strategic verbal responses promote the achievement of this specific therapeutic objective.

Two short forms of the Agnew Relationship Measure: the ARM-5 and ARM-12.

This article reports the development and psychometric properties of two short forms of the 28-item Agnew Relationship Measure, the ARM-12 and ARM-5. For the ARM-12, results of previous research were used together with conceptual considerations to select three items to represent each of four ARM subscales: Bond, Partnership, Confidence, and Openness. For the ARM-5, item-analytic principles were used to select five items to represent overall alliance. In all three ARMs, client and therapist versions were constructed to contain parallel items. We drew data to assess reliability and validity from three UK trials of brief therapy for depression. Results indicated that the two short ARMs have acceptable psychometric properties and that they converged with each other and with the full ARM.