Alliance negotiation as a predictor of early treatment outcome.

AIM: The therapeutic alliance is a robust predictor of treatment outcome. However, little is known about the way alliance negotiation contributes to psychotherapy outcome. The aim of the present study was to analyze the effects of alliance negotiation on treatment outcome in the first four sessions of psychotherapy. METHODS: Ninety-six patients diagnosed with emotional disorders received weekly Solution-Focused Brief Therapy. Each patient completed both the Alliance Negotiation Scale (ANS) and the Outcome Questionnaire 45 (OQ.45) after each of the first four sessions. Both between- and within-patients effects of alliance negotiation on symptom severity were analyzed using Hierarchical Linear Models. RESULTS: Results showed significant between and within patient effects of alliance negotiation on symptom severity. Patients with higher levels of alliance negotiation across treatment showed lower levels of symptom severity (between-patient effect). Also, in a session with higher alliance negotiation compared to the average session of this patient, symptom severity was lower than in the average session (within-patient effect). DISCUSSION: The results indicate that therapies characterized by higher alliance negotiation and sessions with higher alliance negotiation are beneficial for early outcome. CONCLUSION: From a clinical point of view, the results suggest that alliance negotiation is a meaningful factor for therapy outcome and that therapists may benefit from training and monitoring alliance negotiation during the early stages of treatment.

The Good, The Bad, The Uncertain: Diverse Provider Experiences with Telemental Health During COVID-19.

This study assessed mental health provider attitudes and perceptions of telemental health (TMH) prior to and during the COVID-19 Pandemic. The study expands on earlier work by providing a more detailed qualitative analysis of provider perceptions of TMH, including its efficacy, advantages, and limitations. The current study is part of a larger mixed methods project utilizing a repeated cross-sectional design. An online survey was administered to a sample of 1,448 mental health providers. Of the survey participants, 934 offered narrative responses to open-ended questions and were included in the present study. Qualitative data was analyzed using a coding team and the Consensual Qualitative Research paradigm. Providers described both positive and negative feelings about using TMH during the COVID-19 Pandemic. Several advantages were identified, with providers clearly appreciating the role of TMH in allowing them to work continuously and safely during the public health emergency. An array of negative views and concerns were also expressed, including that TMH may not be optimal or effective in certain settings or situations. A portion of respondents also indicated a preference for face-to-face care and illuminated ways they found TMH lacking or limited.

Psychometric properties of the Alliance and Negotiation Scale-Supervision Version.

OBJECTIVE: This study examines the psychometric properties of the Alliance Negotiation Scale-Supervision Version (ANS-S) for clinical trainees. Analyses were designed to evaluate the relationship between the ANS-S and other measures of supervision process and outcome. METHOD: Online surveys included items from established measures in addition to questions about supervisor and supervisee training experiences. The survey was administered to a sample of mental health clinicians practicing under a licensed supervisor (N = 113). RESULTS: The ANS-S (a 12-item unidimensional scale) demonstrated sound psychometric properties, including evidence of reliability as well as content and construct validity. CONCLUSIONS: The ANS-S was associated with several related supervision measures and outcome variables in the expected directions. These results extend previous findings on the ANS' psychometric integrity and offer a validated measure that can be used in further research on supervision.

The Impact of COVID-19 on Provider Perceptions of Telemental Health.

The present study was designed to assess mental health provider attitudes and perceptions of telemental health (TMH) prior to and during the COVID-19 Pandemic, as well as the nature of their TMH utilization. The study aimed to gather information about positive and negative attitudes towards TMH, perceptions and correlates based on the modality of care, and beliefs about the overall effectiveness of TMH as compared to face-to-face care. The current study is part of a larger mixed methods project utilizing a repeated cross-sectional design. An online survey was administered to a sample of 1448 mental health providers and included demographic and professional information, experiences with and perceptions of TMH prior to and during the COVID-19 Pandemic, as well as a brief measure of pandemic-related stress. The COVID-19 Pandemic resulted in an increased use of TMH in the study sample. During COVID-19, providers reported increased agreement with TMH being necessary, important, and effective for care delivery. Providers who primarily used video, compared with telephone, reported that TMH was more useful, satisfying, and effective. While negative attitude towards TMH was predicted only by prior attitudes and belief in TMH effectiveness, positive attitude towards TMH was also predicted by female sex and current level of pandemic related stress. TMH use during the pandemic was predicted by primary use of video platform and previous TMH use. The 2020 COVID-19 Pandemic resulted in increased use of TMH and significantly increased positive perceptions about TMH among mental health providers.

In Their Own Words: Veteran Experiences with Evidence-Based Treatments for PTSD in the Veterans Health Administration.

The aim of the present study was to increase the understanding of veteran experiences with receiving an evidence-based psychotherapy (EBPs) for PTSD (Cognitive Processing Therapy and Prolonged Exposure therapy) in the Veterans Affairs Healthcare System (VA). Eighteen veterans who participated in the study were being seen in the outpatient PTSD clinic at a New England VA and had elected to participate in an EBP. The study assessed veteran experiences with, and outcomes from, treatment through the use of both quantitative and qualitative assessment tools. A rigorous data analytic approach, Consensual Qualitative Research, was applied to narrative data. Results fell into seven domains: Previous EBP & Outcome, Barriers to Treatment, Treatment Process, Treatment Outcome, Treatment Drop Out, and Feelings about Treatment. Overall, veterans reported diverse reactions to the EBPs for PTSD and identified both positive and negative aspects of the treatments. They identified multiple barriers to treatment completion and provided insight into their thoughts and feelings during the treatment protocol. Veterans who chose to drop out of treatment prematurely identified the factors that contributed to this decision. In this way, the study offers an initial but important look at veteran perceptions of and experiences with EBPs for PTSD.

In Their Own Words: Clinician Experiences and Challenges in Administering Evidence-Based Treatments for PTSD in the Veterans Health Administration.

The aim of the present study was to increase the understanding of clinician experiences with administering two evidence-based psychotherapies (EBPs) for PTSD (Cognitive Processing Therapy and Prolonged Exposure therapy) in the Veterans Affairs Healthcare System (VA). The study assessed clinician perceptions through the use of two, one-hour focus groups and employed a rigorous data analysis approach, Consensual Qualitative Research. Clinicians who work in an outpatient PTSD clinic at a New England VA, and who routinely administer EPBs for PTSD, participated in the study. Results were categorized into seven domains by the coding team, including 1) EBP Strengths, 2) EBP Weaknesses, 3) Challenges Specific to the Veteran Population, 4) Perceived EBP Effectiveness, 5) Active Ingredients for Treating PTSD, 6) Treatment Structure and Process, and 7) Suggested Changes/Improvements to EBPs. These domains are discussed in detail, with several core ideas falling under each domain. Operational definitions and representative quotes are provided. Overall, clinicians provided a balanced perspective and identified both strengths and weaknesses of the EBPs for PTSD. They identified several challenges in applying these treatments to veteran populations, and shared their beliefs about treatment effectiveness, how they use these treatments in their clinical practice, and how they would change the treatments if given an opportunity to do so. In this way, the study offers a small but important step in attempting to address the science-practice gap related to EBP for PTSD implementation efforts in the VA.

A therapist version of the Alliance Negotiation Scale.

The aim of the current study was to design and evaluate a therapist version of the Alliance Negotiation Scale (ANS). The ANS was created in order to operationalize the construct of dyadic negotiation in psychotherapy and to augment existing conceptualizations of the working alliance. The ANS has existed only as a client self-report form since its inception and has demonstrated promise as a psychotherapy process measure. This research intended to develop a complementary therapist self-report version of the measure. The scale creation process is discussed in detail, and the results of a preliminary psychometric investigation are reported. The ANS-Therapist version (ANS-T) was developed using a sample of therapists (n = 114) through a principal components analysis procedure. The ANS-T contains 9 unidimensional items and was moderately correlated with therapist-reported working alliance (r = .468). The results of the study support the composition of the ANS-T and provide initial support for the reliability and validity of the measure.

An Investigation of the Relationship Between the Alliance Negotiation Scale and Psychotherapy Process and Outcome.

OBJECTIVE: This study examines the validity of the Alliance Negotiation Scale (ANS) in a psychotherapy research program. Analyses were designed to evaluate the relationship between the ANS and psychotherapy process and outcome variables. METHOD: Data were collected in a metropolitan psychotherapy research program. Participants completed 30 sessions of therapy, postsession assessments, and a battery of measures at intake and termination. RESULTS: Relationships were found between the ANS and session outcome, working alliance, and the presence of ruptures and their resolution. Relationships emerged between the ANS and treatment outcome on measures of psychiatric distress and interpersonal problems. CONCLUSIONS: The ANS demonstrated relationships with several psychotherapy process and outcome variables. The ANS was the most differentiated from the working alliance on measures of interpersonal functioning and in discriminating personality disorder pathology. These results extend previous findings on the ANS' psychometric integrity, and offer new data on the relationship between negotiation and treatment outcome.

Psychotherapy Utilization and Retention in a National Sample of Veterans With PTSD.

OBJECTIVE: This study examines the demographic, diagnostic, and military variables associated with psychotherapy utilization and retention in a national Veteran sample. METHOD: A large administrative VA dataset (142,620 Veterans) was utilized. Logistic regression was used to determine predictors of psychotherapy utilization and retention. RESULTS: Female gender was associat ed with increased psychotherapy utilization and retention. Geriatric age was associated with less retention in individual psychotherapy. Being a racial minority was associated with decreased utilization, but increased retention in group therapy. The majority of comorbid diagnoses were associated with longer retention in treatment. Depression was associated with decreased utilization but longer treatment duration. Dimensional symptom assessment demonstrated relationships with the dependent variables. Avoidance symptoms did not emerge as a barrier to treatment. CONCLUSION: Differences in psychotherapy utilization and retention emerged across demographic, diagnostic and military variables, suggesting that these variables should inform outreach and treatment retention efforts for Veterans with PTSD.

The working alliance: Where have we been, where are we going?

OBJECTIVE: This paper reviews the construct of the working alliance, beginning with its historical development and moving into its modern pantheoretical conceptualization. METHOD: Major research efforts on the topic are reviewed. The review includes both theoretical and empirical literature on the working alliance and related constructs, such as alliance ruptures and repair, and therapeutic negotiation. Existing measures of the working alliance are also reviewed. RESULTS: The working alliance is critiqued on both theoretical and empirical grounds, including the strengths and limitations of current approaches and assessments. Recent theoretical developments are reviewed, among them work on alliance rupture and repair and the reconceptualization of the alliance as a process of therapeutic negotiation. Emerging applications of advanced statistical techniques to measure the working alliance are also considered. CONCLUSION: The review concludes by supporting recent efforts that have attempted to increase the sophistication of measurement tools and statistical approaches, and encouraging future research in these areas.

Psychophysiological predictors of working alliance among treatment-seeking women with complex trauma exposure.

Research has established that trauma-related symptoms may impede the formation of a strong working alliance (i.e., interpersonal connection, trust, and shared goals between therapist and client). As the alliance is critical in trauma-focused therapy, we studied how clients' pretherapy factors, including symptoms and psychophysiological arousal, predict treatment alliance. We examined symptoms and physiological responses in 27 women who had exposure to extreme interpersonal violence; all of whom were enrolled in therapy. All had symptoms consistent with a diagnosis of posttraumatic stress disorder. Clients completed measures of working alliance and were assessed before and after treatment on measures of symptoms and autonomic arousal. Autonomic assessment included measures of skin conductance and respiratory sinus arrhythmia (RSA), taken during baseline, while viewing positive and then trauma-related slides, and during recovery. Higher alliance ratings were predicted by lower pretherapy skin conductance during trauma slides (r = -.41, p = .049) and recovery (r = -.44, p = .047) and higher RSA during baseline (r = .47, p = .027) and positive slides (r = .43, p = .044). Findings remained significant even after partialling pretherapy symptoms. These data on a high-need but understudied population suggest that sympathetic and parasympathetic arousal may help traumatized clients effectively engage in therapy, further supporting the role of parasympathetic activity in social engagement.

Some closure on exposure-Realigning the perspective on trauma treatment and finding a pathway forward: Reply to Brown (2024) and Najavits (2024).

We respond to commentaries by Brown (2024) and Najavits (2024) on our original work titled "To Expose or Not to Expose: A Comprehensive Perspective on Treatment for Posttraumatic Stress Disorder" (Rubenstein et al., 2024). Their work serves to augment the original argument that exposure is an important change factor in the amelioration of traumatic stress but should be viewed more broadly than traditional treatment paradigms suggest. We are grateful for this opportunity and aim to promote additional dialogue in the field about ways to improve upon existing models of trauma and its treatment. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

To expose or not to expose: A comprehensive perspective on treatment for posttraumatic stress disorder.

Trauma-focused psychotherapies, in particular prolonged exposure (PE) therapy, have been recognized as the "gold standard" for the treatment of posttraumatic stress disorder (PTSD). But effectiveness and implementation data show that a large proportion of patients who undergo exposure therapy retain their PTSD diagnosis, and implementation studies have shown low engagement and high dropout rates. Meanwhile, non-trauma-focused therapies have shown promise in treating PTSD. In this review, we aim to answer the question of whether exposure is necessary to treat PTSD by integrating clinical and research literature from multiple perspectives. We review the roots of exposure therapy in both psychodynamic and behavioral paradigms and their proposed mechanisms. We then review non-trauma-focused treatments and their proposed mechanisms. We conclude that the specific form of exposure required by PE is not necessary for symptom remission. Finally, common psychotherapy factors may facilitate patient self-directed exposure outside of the therapy context. These findings should alter the direction of clinical research to identify the therapy processes that most effectively promote the processing of trauma memories. With respect to clinical practice, shared decision-making should allow for increased patient autonomy in choosing either trauma-focused or non-trauma-focused treatments. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Mixed Reality Platforms in Telehealth Delivery: Scoping Review.

BACKGROUND: The distinctive features of the digital reality platforms, namely augmented reality (AR), virtual reality (VR), and mixed reality (MR) have extended to medical education, training, simulation, and patient care. Furthermore, this digital reality technology seamlessly merges with information and communication technology creating an enriched telehealth ecosystem. This review provides a composite overview of the prospects of telehealth delivered using the MR platform in clinical settings. OBJECTIVE: This review identifies various clinical applications of high-fidelity digital display technology, namely AR, VR, and MR, delivered using telehealth capabilities. Next, the review focuses on the technical characteristics, hardware, and software technologies used in the composition of AR, VR, and MR in telehealth. METHODS: We conducted a scoping review using the methodological framework and reporting design using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines. Full-length articles in English were obtained from the Embase, PubMed, and Web of Science databases. The search protocol was based on the following keywords and Medical Subject Headings to obtain relevant results: "augmented reality," "virtual reality," "mixed-reality," "telemedicine," "telehealth," and "digital health." A predefined inclusion-exclusion criterion was developed in filtering the obtained results and the final selection of the articles, followed by data extraction and construction of the review. RESULTS: We identified 4407 articles, of which 320 were eligible for full-text screening. A total of 134 full-text articles were included in the review. Telerehabilitation, telementoring, teleconsultation, telemonitoring, telepsychiatry, telesurgery, and telediagnosis were the segments of the telehealth division that explored the use of AR, VR, and MR platforms. Telerehabilitation using VR was the most commonly recurring segment in the included studies. AR and MR has been mainly used for telementoring and teleconsultation. The most important technical features of digital reality technology to emerge with telehealth were virtual environment, exergaming, 3D avatars, telepresence, anchoring annotations, and first-person viewpoint. Different arrangements of technology-3D modeling and viewing tools, communication and streaming platforms, file transfer and sharing platforms, sensors, high-fidelity displays, and controllers-formed the basis of most systems. CONCLUSIONS: This review constitutes a recent overview of the evolving digital AR and VR in various clinical applications using the telehealth setup. This combination of telehealth with AR, VR, and MR allows for remote facilitation of clinical expertise and further development of home-based treatment. This review explores the rapidly growing suite of technologies available to users within the digital health sector and examines the opportunities and challenges they present.

Therapist mindfulness, alliance and treatment outcome.

The present study investigated the association between therapist dispositional mindfulness and therapist self-affiliation, the therapeutic alliance, and treatment outcome. Total therapist mindfulness was associated with therapist self-affiliation, r=.413, p<.05. Therapist mindfulness was positively correlated with therapist ratings of the working alliance, r=.456, p<.05, though only the Act with Awareness subscale showed a relationship with patient rated alliance, r=.379. Therapist mindfulness was not associated with patient rated decreases in global symptomatology, but was associated with patient rated improvements in interpersonal functioning, r=.481, p<.05. All correlations correspond to a medium effect size. The results indicate that therapist dispositional mindfulness may be an important pre-treatment variable in psychotherapy outcome.

The alliance negotiation scale: psychometric construction and preliminary reliability and validity analysis.

Current measures of the working alliance tend to emphasize the degree of agreement or collaboration between patient and therapist about therapeutic tasks and goals. There are, however, both theoretical and empirical grounds to suggest that the degree to which patient and therapist are able to constructively negotiate disagreements about tasks and goals is another important dimension of the alliance. The present study outlines the preliminary development and evaluation of a measure to operationalize this dimension. This measure, the alliance negotiation scale (ANS), is a 12-item patient self-report instrument. Exploratory factor analysis and expert ratings informed the development of the scale, which consists of two distinct factors that demonstrate good internal consistency. Correlations between these factors and the working alliance offer preliminary support for its construct validity. A working version of the ANS is presented and the need for further validation is discussed.

Stakeholder perspectives on current determinants of ultrasound-guided thoracentesis in resource limited settings: a qualitative study.

OBJECTIVE: Preprocedure pleural fluid localization using bedside ultrasound has been shown to reduce complications related to thoracentesis and is now considered the standard of care. However, ultrasound-guided thoracentesis (USGT) has not been broadly adopted in many low-resource settings. With increasing affordability and portability of ultrasound equipment, barriers to USGT are changing. The aim of this multisite qualitative study is to understand the current barriers to USGT in two resource-limited settings. SETTING: We studied two geographically diverse settings, Harare, Zimbabwe, and Kathmandu, Nepal. PARTICIPANTS: 19 multilevel stakeholders including clinical trainees, attendings, clinical educators and hospital administrators were interviewed. There were no exclusion criteria. PRIMARY OUTCOME: To understand the current determinants of USGT adoption in these settings. RESULTS: Three main themes emerged from these interviews: (1) stakeholders perceived multiple advantages of USGT, (2) access to equipment and training were perceived as limited and (3) while an online training approach is feasible, stakeholders expressed scepticism that this was an appropriate modality for procedural training. CONCLUSION: Our data suggests that USGT implementation is desired by local stakeholders and that the development of an educational intervention, cocreated with local stakeholders, should be explored to ensure optimal contextual fit.

Fear extinction and memory reconsolidation as critical components in behavioral treatment for posttraumatic stress disorder and potential augmentation of these processes.

Posttraumatic stress disorder (PTSD) is associated with alterations in critical brain regions such as the amygdala, hippocampus, and prefrontal cortex. This brief review has two objectives: (1) to discuss research examining extinction and reconsolidation processes as mechanisms in PTSD psychotherapy, and (2) present possibilities for augmenting extinction and reconsolidation within treatment through alterations to therapeutic interventions and novel approaches. A key component of many effective PTSD therapies is exposure, which involves intentional confrontation and processing of the traumatic memory. Our review suggests that extinction and reconsolidation processes underlie effective exposure-based treatment, but the neurobiological mechanisms of these processes in behavioral treatments for PTSD remains unclear. We argue that enhancing extinction and/or disrupting reconsolidation of a feared memory may improve the efficacy of existing treatments (e.g., increased change for limited/non-responders, faster/greater changes for responders), which can be done through multiple channels. Potential avenues for augmentation of the processes of extinction and reconsolidation in PTSD psychotherapies are reviewed, including behavioral modifications, pharmacotherapy agents, and the use of devices during therapy. We further suggest that investigations towards understanding the extent to which extinction and reconsolidation processes are necessary in effective PTSD psychotherapy is an important future direction for enhancing clinical care among PTSD populations.

Inhibitors of 15-Prostaglandin Dehydrogenase To Potentiate Tissue Repair.

The enzyme 15-prostaglandin dehydrogenase (15-PGDH) catalyzes the first step in the degradation of prostaglandins including PGE2. It is a negative regulator of tissue repair and regeneration in multiple organs. Accordingly, inhibitors of 15-PGDH are anticipated to elevate in vivo levels of PGE2 and to promote healing and tissue regeneration. The small molecule SW033291 (1) inhibits 15-PGDH with Ki = 0.1 nM in vitro, doubles PGE2 levels in vivo, and shows efficacy in mouse models of recovery from bone marrow transplantation, ulcerative colitis, and partial hepatectomy. Here we describe optimized variants of 1 with improved solubility, druglike properties, and in vivo activity.

The Alliance Negotiation Scale: A psychometric investigation.

This study investigates the utility and psychometric properties of a new measure of psychotherapy process, the Alliance Negotiation Scale (ANS; Doran, Safran, Waizmann, Bolger, & Muran, 2012). The ANS was designed to operationalize the theoretical construct of negotiation (Safran & Muran, 2000), and to extend our current understanding of the working alliance concept (Bordin, 1979). The ANS was also intended to improve upon existing measures such as the Working Alliance Inventory (WAI; Horvath & Greenberg, 1986, 1989) and its short form (WAI-S; Tracey & Kokotovic, 1989) by expanding the emphasis on negative therapy process. The present study investigates the psychometric validity of the ANS test scores and interpretation-including confirming its original factor structure and evaluating its internal consistency and construct validity. Construct validity was examined through the ANS' convergence and divergence with several existing scales that measure theoretically related constructs. The results bolster and extend previous findings about the psychometric integrity of the ANS, and begin to illuminate the relationship between negotiation and other important variables in psychotherapy research. (PsycINFO Database Record