Patient attachment and reflective functioning as predictors for therapist in-session feelings.

Therapists' in-session feelings in psychotherapy can be seen as indications of the development of the therapeutic relationship and the therapeutic process. To manage them appropriately, it is important to know to what extent they may be influenced by patients' pretreatment characteristics. This study aims to improve the understanding of therapists' emotional reactions in the psychotherapeutic setting by investigating if patients' pretreatment mentalization ability and attachment style predicted therapist in-session feelings. In a sample of 87 therapy dyads treated with interpersonal psychotherapy and cognitive behavioral therapy for depression, patient attachment was measured using self-reported Experiences in Close Relationships (ECR) and mentalization using Reflective Functioning (RF). ECR and RF were hypothesized to predict therapist feelings measured by the Feeling Word Checklist-24 at different treatment phases over the full course of treatment. Treatment method, patient age, gender, and pretreatment depression were evaluated as potential confounders. Multilevel modeling was used to analyze the data. Lower RF in patients predicted more negative therapist feelings in the mid- to late-treatment phases and less positive feelings in the late-treatment phase. Self-reported attachment anxiety or avoidance did not predict therapist feelings. Findings indicate that patients' ability to mentalize is important to consider when conducting psychotherapy, as it can influence therapists' feelings in the therapeutic process. Limitations of the present study's approach are discussed, and directions for future research are considered. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Change in reflective functioning in interpersonal psychotherapy and cognitive behavioral therapy for major depressive disorder.

BACKGROUND: Patients with Major Depressive Disorder (MDD) have been found to have restricted capacity for mentalization, and it is possible that this constitutes a vulnerability factor for developing depression. Due to its focus on linking depressive symptomatology to emotions and interpersonal relations, it was hypothesized that Interpersonal Psychotherapy (IPT) would improve mentalization more than Cognitive Behavioral Therapy (CBT). METHODS: In a randomized controlled trial of 90 patients undergoing IPT and CBT for MDD, Reflective Functioning (RF) was rated from Adult Attachment and from Depression-Specific Reflective Functioning (DSRF) Interviews before and after therapy. Treatment outcome was assessed using the Beck Depression Inventory-II. RESULTS: The interaction between time and treatment approach was statistically significant, with RF improving significantly more in IPT than in CBT. Change in RF was not correlated with change in depression. The difference in DSRF ratings before and after therapy was not statistically significant for any of the treatments. CONCLUSIONS: IPT may improve mentalization more than CBT. However, although RF increased significantly in IPT, the mean level was still low after therapy. A limitation of the study is the large amount of post-treatment missing data. More research is needed to understand the potential role of mentalization in symptom reduction.

Session-to-session effects of therapist adherence and facilitative conditions on symptom change in CBT and IPT for depression.

OBJECTIVE: The objective of this study was to analyze the effect of adherence to both specific technique factors and facilitative condition variables (e.g., therapists' involvement, understanding and support) in Cognitive Behavior Therapy (CBT) and Interpersonal Psychotherapy (IPT). In addition, we were interested in whether the effect of therapist adherence would depend on the level of the working alliance. METHOD: Three sessions each from 74 patients diagnosed with Major Depressive Disorder who were randomized to 14 sessions of IPT or CBT were rated for adherence using a modified version of The Collaborative Study Psychotherapy Rating Scale-6 (CSPRS-6). Data was analyzed using Multilevel Modeling. RESULTS: No effects of adherence to specific factors on outcome were found in neither CBT nor IPT. Facilitative conditions were associated with better outcome in CBT but not in IPT, even after adjustment for the quality of the working alliance. No interaction effects were found. CONCLUSIONS: Our findings highlight the importance of relational factors in CBT, but do not support the need for specific adherence to any of the two treatments. Possible explanations of the findings and directions for future research are discussed.Trial registration: ClinicalTrials.gov identifier: NCT01851915.

Therapist in-session feelings predict change in depressive symptoms in interpersonal and brief relational psychotherapy.

Objective: Brief Relational Therapy (BRT) includes the idea that the therapists use their in-session feelings in meta-communications about the therapy relationship to facilitate resolution of alliance ruptures. The current study aimed to explore the effect of therapist feelings on patient depressive symptoms in BRT compared to Interpersonal Psychotherapy (IPT).Methods: The effects of therapist feelings were studied in 40 patients randomized to 16 sessions of IPT or BRT, using the Feeling Word Checklist-24, the Patient Health Questionnaire-9 and the Working Alliance Inventory. Data was analyzed using dynamic structural equation modeling.Results: Negative therapist feelings predicted increase and positive feelings decrease in next-session PHQ-9 via the alliance and the patients' engaged feelings, in both treatments. The direct effect of negative therapist feelings on PHQ-9 differed significantly between BRT and IPT, with more negative feelings predicting a decrease in PHQ-9 in BRT but not in IPT.Conclusion: Negative therapist feelings may cause increase/less decrease and positive feelings more decrease in depressive symptoms via disruptions in the alliance. In BRT, if the alliance is unaffected by negative therapist feelings, the patient's depressive symptoms may improve. Findings need replication in a larger sample.

The role of the working alliance in psychological treatment of substance use disorder outpatients.

Objective: The main objective of this study was to explore the relationship between alliance and treatment outcome of substance use disorder (SUD) outpatients in routine care. Attachment, type of substance use, and treatment orientation were analyzed as potential moderators of this relationship.Method: Ninety-nine SUD outpatients rated their psychological distress before every session. Patients and therapists rated the alliance after every session. At treatment start and end, the patient completed the Alcohol Use Disorders Identification Test (AUDIT), the Drug Use Disorders Identification Test (DUDIT), and the Experiences in Close Relationships (ECR-S). Data were analyzed using multilevel growth curve modeling and Dynamic Structural Equation Modeling (DSEM).Results: The associations between alliance and outcome on psychological distress and substance use were, on average, weak. Within-patient associations between patient-rated alliance and outcome were moderated by self-rated attachment. Type of abuse moderated associations between therapist-rated alliance and psychological distress. No moderating effect was found for treatment orientation.Conclusions: Patients' attachment style and type of abuse may have influenced the association between alliance and problem reduction. A larger sample size is needed to confirm these findings.

Does it make a difference to be more "on the same page"? Investigating the role of alliance convergence for outcomes in two different samples.

Objective: To better understand the complexity of dyadic processes, such as the mechanisms of the working alliance, researchers recommend taking advantage of innovations in data analytic procedures when studying the interactions between therapists and patients that are associated with favorable therapeutic outcomes. Inspired by a recent line of alliance research using dyadic multilevel modeling, the present study investigated the hypothesis that convergence in the patient-therapist working alliance (i.e., increased similarity in ratings of the alliance across treatment) would be associated with better outcomes. Method: Data were retrieved from two samples: 1. A randomized controlled trial for treatment resistant depression (N = 96 dyads), and 2. An archival dataset of naturalistic psychotherapies from public health care (N = 139 dyads). Multilevel growth curve analysis was employed to investigate the degree of change in session-to-session agreement of global WAI ratings between therapists and patients (i.e., alliance convergence) as a predictor of symptom reduction in the BDI-II and the SCL-90R. Results: Contrary to our expectations, alliance convergence did not predict outcome in either sample, but was negatively associated with symptom severity in Study 2. Implications for understanding the complexity of dyadic processes and alliance work in psychotherapy are discussed.

Psychoform and somatoform dissociation among individuals with eating disorders.

Objective: This study analyzed the prevalence of psychoform and somatoform dissociation among individuals with the whole spectrum of eating disorder diagnoses and compared it with ratings from a non-clinical group. The relationship between dissociation and severity of eating disturbance was examined as well as differences between the eating disorder diagnosis groups in extent of dissociation. The validity of a new structural dissociation interview suitable for eating disorder patients was analyzed.Method: Sixty individuals with eating disorder completed three self-report questionnaires: Dissociation Questionnaire Sweden, Somatoform Dissociation Questionnaire and Eating Disorder Examination Questionnaire. The ratings were compared with the scores in a female non-clinical group (N = 245). Twenty patients with eating disorder diagnoses were interviewed with the Interview for Dissociative Disorders and Trauma Related Symptoms. The validity of the interview was tested by comparing the ratings on the interview subscales with the scores on the Dissociation questionnaires and the Somatoform Dissociation Questionnaire.Results: Participants with eating disorders reported a higher extent of both psychoform and somatoform dissociation compared with the non-clinical individuals. Analyses also showed a correlation between degree of dissociation and severity of eating disorder symptoms. No differences in dissociation were found between the ED subgroups. Participants reporting more dissociation got higher ratings on the interview, indicating convergent validity.Discussion: Eating disorders seem to be associated with presence and severity of dissociative symptoms. The extent of dissociation needs to be assessed for these individuals as treatment may benefit from a focus on such symptoms in order to increase its effect.

A relational perspective on the association between working alliance and treatment outcome.

Objective: Evidence is inconclusive on whether variability in alliance ratings within or between therapists is a better predictor of treatment outcome. The objective of the present study was to explore between and within patient and therapist variability in alliance ratings, reciprocity among them, and their significance for treatment outcome. Method: A large primary care psychotherapy sample was used. Patient and therapist ratings of the working alliance at session three and patient ratings of psychological distress pre-post were used for analyses. A one-with-many analytical design was used in order to address problems associated with nonindependence. Results: Within-therapist variation in alliance ratings accounted for larger shares of the total variance than between-therapist variation in both therapist and patient ratings. Associations between averaged patient and therapist ratings of the alliance for the individual therapists and their average treatment outcome were weak but the associations between specific alliance ratings and treatment outcome within therapies were strong. Conclusions: The results indicated a substantial dyadic reciprocity in alliance ratings. Within-therapist variation in alliance was a better predictor of treatment outcome than between-therapist variation in alliance ratings.

Prediction of treatment outcome in psychotherapy by patient initial symptom distress profiles.

Understanding how different groups of patients change at different rates is important for treatment selection, planning and evaluation. This study aimed to assess whether an approach to classifying patients on the basis of initial symptom distress profiles (ISDPs) derived from a self-rated questionnaire measuring psychological distress may be useful in predicting treatment response. The Clinical Outcome in Routine Evaluation-Outcome Measure were collected from 1,095 first line mental health service patients (M [SD] age = 37.3 [14.3] years; 74% female) prior to every session. Latent profile analysis was performed on the questionnaires from the first session to classify participants into subtypes, which were then used to predict change rates. The best-fitting model identified 4 ISDP subtypes with significantly different treatment responses. Profile 1 predicted very slow change rate and indicated low initial distress coupled with low deviations among problem areas. Profile 2 predicted slow change rate with average initial distress and low emphasis on questions relating to risk of harming oneself and/or others. Profile 3 predicted fast improvement rate and showed high initial distress combined with low emphasis on the risk area. Profile 4 predicted moderate change rate and displayed very high initial distress accompanied with more emphasis on the risk area. Findings support the potential utility of ISDP subtypes to predict treatment response, suggesting that intake data that is easily collected by the clinician contain reliable information about treatment prognosis. The study is exploratory and needs to be replicated before stable conclusions can be drawn. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The Alliance and Rupture Observation Scale (AROS): Development and validation of an alliance and rupture measure for repeated observations within psychotherapy sessions.

OBJECTIVE: The aim of this study was to test a new observer-rated instrument, the Alliance and Rupture Observation Scale (AROS). It was designed for repeated measurements of the alliance within sessions and to detect alliance ruptures. METHOD: Videotaped therapy sessions with depressed adults were analyzed. Reliability was mainly assessed as inter-rater reliability. Convergent, predictive, and discriminant validity of the AROS was assessed by comparing the instrument with both observer-rated and patient-rated measures. RESULTS: The AROS exhibited excellent inter-rater reliability. Alliance levels measured with the AROS predicted patients' ratings of the alliance in the same session and were highly correlated with another observer-rated alliance measure. Alliance patterns (rupture; repair; and no-rupture) based on AROS scores were significantly correlated with patients' ratings of the alliance. CONCLUSIONS: Preliminary support for convergent and predictive validity was found. It is yet to be determined whether AROS scores are related to psychotherapy outcomes.

Mentalizing in Interpersonal Psychotherapy.

Mentalization-how people understand their own minds and those of others-is an attachment-based, normative, cognitive, and affective capacity important to interpersonal relations and to certain kinds of psychotherapy. Mentalization seems related to aspects of, and may hold important implications for, interpersonal psychotherapy (IPT). Weissman and colleagues' IPT manual does not explicitly describe improvement in mentalization as a targeted outcome of therapy, but IPT may utilize mentalization as an underlying process. Recent theory emphasizes the applicability of a mentalization model to many, if not all, types of psychotherapy and suggests particular value for affect-focused and socially focused psychotherapies such as IPT, despite IPT's differences in focus and diagnostic targets from mentalization-based treatments. This article reviews the overlap of these approaches and suggests the potential of mentalization to mediate IPT outcomes.

Review of organizational effects on the outcome of mental health treatments.

OBJECTIVE: As there are theoretical, clinical, and "common sense" reasons to expect a relationship between organizational factors and outcome in clinics providing psychotherapy and other mental health treatments, a review of empirical research in this area was undertaken with the aim of finding empirical evidence for organizational effects. METHODS: A structured search for studies on organizational differences in patient mental health outcomes was performed using EBSCO host, Cochrane Library Database, and the Health Systems Evidence database at McMasters University. Finished studies published in English were included if they presented data from more than one mental health service and used change in symptom, level of functioning, or quality of life as outcome. RESULTS: The search yielded not more than 19 studies fulfilling inclusion criteria. All studies showed some evidence for organization effects, and there was some evidence for organizational climate and culture explaining differences in outcome. CONCLUSION: Given that mental health treatments are likely to be especially susceptive to organizational effects, it is remarkable that not more research has been devoted to this. Clearly, more research is needed to study the consequences of work organization for the outcome of psychotherapy. Methodological issues in organizational studies are discussed.

Alliance ruptures and repairs in psychotherapy in primary care.

OBJECTIVE: The association between alliance level and outcome in psychotherapy has been extensively studied. One way to expand this knowledge is to study alliance patterns. The main aims of this study were to examine how frequent alliance patterns with ruptures or rupture-repair episodes were in a naturalistic sample of psychotherapies in primary care, and if three alliance patterns (a Rupture pattern, a Repair pattern, and a No Rupture pattern) were differentially associated with treatment outcome. METHOD: The psychotherapies (N = 605) included a wide range of different treatment orientations and patient diagnoses. Alliance patterns were studied at session-to-session level, using patient-rated alliance scores. Outcome data were analyzed using longitudinal multilevel modeling with a slopes-as-outcomes model. RESULTS: The Repair pattern accounted for 14.7% (n = 89) of the treatments, 10.7% (n = 65) exhibited a Rupture pattern, and 74.5% (n = 451) contained no ruptures. The Rupture pattern was associated with inferior treatment outcomes. The Repair pattern was, in longer treatments, associated with better outcomes than the No Rupture pattern. CONCLUSIONS: The results support theory about the importance of ruptures in the therapeutic alliance and suggest that identification of alliance ruptures is important in alliance-outcome research, for feedback purposes in clinical practice, and in training of therapists.

Responding to mentalization invitations in psychotherapy sessions-A conversation analysis approach.

OBJECTIVE: Increase in the capacity to mentalize has been proposed to be an important mechanism of change in psychotherapy. However, mentalization has primarily been studied as an individual skill that people either possess or lack, rather than as an interactional phenomenon. METHOD: In this study, excerpts from three different sessions in a therapy that aimed at increasing the patients mentalizing capacity were identified and studied using conversation analysis. RESULTS: The analysis indicated that resistance to mentalizing may not only be due to lack of capacity but also may be seen as a linguistic resource in which this resistance demonstrates precisely the ability to mentalize. CONCLUSIONS: Consequences for psychotherapy practice and process research are discussed.

Randomized Trial of Interpersonal Psychotherapy and Cognitive Behavioral Therapy for Major Depressive Disorder in a Community-Based Psychiatric Outpatient Clinic.

BACKGROUND: Interpersonal psychotherapy (IPT) and cognitive behavioral therapy (CBT) are both evidence-based treatments for major depressive disorder (MDD). Several head-to-head comparisons have been made, mostly in the United States. In this trial, we compared the two treatments in a small-town outpatient psychiatric clinic in Sweden. The patients had failed previous primary care treatment and had extensive Axis-II comorbidity. Outcome measures were reduction of depressive symptoms and attrition rate. METHODS: Ninety-six psychiatric patients with MDD (DSM-IV) were randomized to 14 sessions of CBT (n = 48) or IPT (n = 48). A noninferiority design was used with the hypothesis that IPT would be noninferior to CBT. A three-point difference on the Beck Depression Inventory-II (BDI-II) was used as noninferiority margin. RESULTS: IPT passed the noninferiority test. In the ITT group, 53.5% (23/43) of the IPT patients and 51.0% (24/47) of the CBT patients were reliably improved, and 20.9% (9/43) and 19.1% (9/47), respectively, were recovered (last BDI score <10). The dropout rate was significantly higher in CBT (40%; 19/47) compared to IPT (19%; 8/43). Statistically controlling for antidepressant medication use did not change the results. CONCLUSIONS: IPT was noninferior to CBT in a sample of depressed psychiatric patients in a community-based outpatient clinic. CBT had significantly more dropouts than IPT, indicating that CBT may be experienced as too demanding. Since about half the patients did not recover, there is a need for further treatment development for these patients. The study should be considered an effectiveness trial, with strong external validity but some limitations in internal validity.

Are therapists uniformly effective across patient outcome domains? A study on therapist effectiveness in two different treatment contexts.

As established in several studies, therapists differ in effectiveness. A vital research task now is to understand what characterizes more or less effective therapists, and investigate whether this differential effectiveness systematically depends on client factors, such as the type of mental health problem. The purpose of the current study was to examine whether therapists are universally effective across patient outcome domains reflecting different areas of mental health functioning. Data were obtained from 2 sites: the Research Consortium of Counseling and Psychological Services in Higher Education (N = 5,828) in the United States and from primary and secondary care units (N = 616) in Sweden. Outcome domains were assessed via the Outcome Questionnaire-45 (Lambert et al., 2004) and the CORE-OM (Evans et al., 2002). Multilevel models with observations nested within patients were used to derive a reliable estimate for each patient's change (which we call a multilevel growth d) based on all reported assessment points. Next, 2 multilevel confirmatory factor analytic models were fit in which these effect sizes (multilevel ds) for the 3 subscales of the OQ-45 (Study 1) and 6 subscales of CORE-OM (Study 2) were indicators of 1 common latent factor at the therapist level. In both data sets, such a model, reflecting a global therapist effectiveness factor, yielded large factor loadings and excellent model fit. Results suggest that therapists effective (or ineffective) within one outcome domain are also effective within another outcome domain. Tentatively, therapist effectiveness can thus be conceived of as a global construct. (PsycINFO Database Record

Deteriorated and unchanged patients in psychological treatment in Swedish primary care and psychiatry.

BACKGROUND: Despite substantial effect sizes for psychological therapy among different diagnosis groups and in different treatment contexts, many studies show that a large proportion of patients do not attain reliable improvement and a substantial portion are worse off after treatment. Previous studies suggest that patients in psychiatry may have worse outcome than patients in primary care. AIMS: In this practice-based study of psychological treatment in Swedish primary care and adult psychiatry, the proportions of patients who did not improve and who deteriorated were assessed. METHODS: Proportions of reliably improved, unchanged, and reliably deteriorated patients among 840 patients in primary care and 317 patients in specialist psychiatry were assessed by self-ratings using the Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM). RESULTS: More than half of the patients did not change reliably. About 2% of the patients in primary care and 7% in psychiatry deteriorated. Multilevel analyses of the data from primary care indicated that there were no therapist effects. CONCLUSIONS: The results emphasize the importance of monitoring treatment continuously in order to increase results for patients who do not improve.

Client and therapist agreement about the client's problems-Associations with treatment alliance and outcome.

OBJECTIVE: A shared understanding of the patient's symptoms and problems is seen by most theories as a crucial aspect of the collaboration in therapy, presumably influencing alliance and outcome. The empirical ground for this argument is not solid, however. Several studies have found weak associations between a common view of the patient's problems and outcome. The purpose of the present study was to analyze whether agreement in the understanding of the patient's depression and anxiety problems was important for alliance and outcome. METHOD: The study used data from a practice-based study using the CORE system with 846 patients who received psychological treatment in primary care. RESULTS: The analyses indicated that although patients who were assessed by their therapists as having depression and anxiety problems scored higher on these subscales than other patients, about half of the patients reported such problems when the therapists did not, and vice versa. Agreement was not associated with better alliance or outcome. CONCLUSIONS: Productive collaboration in psychotherapy may be based on other factors than agreement about symptoms.

Somatoform dissociation among Swedish adolescents and young adults: the psychometric properties of the Swedish versions of the SDQ-20 and SDQ-5.

BACKGROUND: Somatoform dissociation is supposed to be a vital aspect of the general concept of dissociation. The Somatoform Dissociation Questionnaire-20 (SDQ-20) and the brief version SDQ-5 are self-report instruments constructed to identify somatic dissociation. AIM: In the present study, the psychometric qualities of the Swedish version of the SDQ-20 and its brief version, the SDQ-5, were examined among adolescents and young adults. Reliability and concurrent validity were investigated. METHODS: A total of 512 adolescents and young adults participated in the study: 461 adolescents from a non-clinical sample and 50 adolescents and young adults from a clinical eating disorder outpatient unit. They completed the self-report instruments the SDQ-20, the SDQ-5 (part of SDQ-20), the Linköping Youth Life Experience Scale (LYLES, a trauma history scale) and the Dissociation Questionnaire-Sweden (Dis-Q-Sweden). RESULTS: Both internal consistency and test-retest reliability of the Swedish version of SDQ-20 were good in both the non-clinical (α = 0.83) and the clinical groups (α = 0.84); the reliability for the SDQ-5 was, however, lower (non-clinical α = 0.50, clinical α = 0.64). Significant differences were found between the clinical and non-clinical groups on both somatoform and psychoform dissociation. Correlations between the Dis-Q-Sweden, SDQ-20 and SDQ-5 were generally high. The criterion and convergent validity was acceptable for both scales but somewhat better for SDQ-20 than for SDQ-5. CONCLUSION: The advantage with both the SDQ-20 and the SDQ-5 is that they are short questionnaires, but the results suggests that SDQ-20 is preferable based on the higher-quality psychometric properties of the SDQ-20.

Developing practice-based evidence: benefits, challenges, and tensions.

Attempts to regulate service delivery in line with results from randomized trials have been vigorously debated. In this paper, results from practice-based studies using the CORE System illustrate the potential to enrich knowledge about the actual outcome of psychological therapy in routine care. These studies also provide data for important questions in psychotherapy research, like orientation differences, the importance of the therapist factor, number of sessions needed for clinical effect, and the alliance-outcome question. Obstacles and challenges in making such studies are illustrated. In conclusion, arguments are put forward for introducing a common measurement system that strikes a balance between clinicians' questions and the need for comparable data, and that encompasses the complexities of patients' reasons for seeking psychological help.