Participant factors as correlates of patients' psychotherapy outcome expectation: A meta-analytic and box-count review.

OBJECTIVE: More positive pre- or early therapy patient outcome expectation (OE) has consistently correlated with better treatment outcomes. Thus, it is important to identify factors that contribute to patients' OE, which can inform therapist responsivity to such risk or facilitative markers. With growing research on OE correlates-centered primarily on patient characteristics/treatment factors and, to a lesser extent, therapist factors-a comprehensive synthesis is warranted to elucidate replicated and mixed associations and stimulate further research. Accordingly, we set a pragmatic cutoff of k ≥ 5 for meaningful empirical aggregation of participant factor-OE associations; otherwise, we conducted box counts. METHOD: We searched for articles published through March 2022 that included a clinical sample, a measure of patient's pre- or early treatment OE, and an explicit test of the factor-OE association. RESULTS: Patient problem severity, problem chronicity, education, age, and quality of life were meta-analyzed. Greater severity correlated with lower/less optimistic OE (r = -0.13, p < .001) and higher QOL correlated with higher/more optimistic OE (r = 0.18, p < .001). Box counts revealed that few variables had consistent associations with OE. CONCLUSIONS: Some factors can help forecast patient OE, though additional research is needed to enhance confidence and clinical meaning.

Symptom severity in daily life, early response and posttreatment changes in anxiety and depressive symptoms in generalized anxiety disorder.

BACKGROUND: Meta-analytic research shows early response to psychotherapy to predict depression and anxiety outcomes posttreatment. However, little is known about which variables explain differences in early response. Moreover, for patients with generalized anxiety disorder (GAD), there is limited research on whether early response predicts longer-term changes in symptoms. In this study, we used anxiety and controllability beliefs assessed in daily life at intake to predict early response to treatment (until session 5), and we further examined if early response predicts longer-term changes in symptoms (until posttreatment, when adjusting for intake symptom severity) in patients with GAD. METHODS: Forty-nine individuals with GAD reported their anxiety and controllability beliefs using event-based (participant-initiated) ecological momentary assessment (EMA) for 7 days at intake. Symptoms were measured at pretreatment, session 5, session 10, and posttreatment. RESULTS: Results show anxiety levels reported during EMA to be associated with a higher reduction in both anxiety and depressive symptoms early in treatment. Moreover, higher controllability beliefs during EMA were associated with less early response. When predicting change in symptoms until posttreatment, results showed an early change to significantly predict change in symptoms until posttreatment. CONCLUSIONS: Given that we found early response to psychotherapy in patients with GAD to be a prognostic factor for long-term response, it is recommended to monitor response early in treatment and pay special attention to those patients showing less early response.

Within- and between-patients associations between self-efficacy, outcome expectation, and symptom change in cognitive behavioral therapy for generalized anxiety disorder.

OBJECTIVES: There is limited information on how a change in patients' expectations over time results in symptom change in psychotherapy. This study aimed to investigate the changes in patients' expectations and symptoms during treatment and across follow-up as well as to determine the within- and between-patient relationships between two types of patient expectations, that is, self-efficacy and outcome expectation, and symptom change. METHODS: Participants (80 participants × 6 repeated measures; 480 observations) with generalized anxiety disorder were treated using cognitive behavioral therapy and the within- and between-patient scores of self-efficacy and outcome expectation were evaluated in multilevel models as predictors of symptom change. RESULTS: Patients' self-efficacy and outcome expectation increased, whereas severity of their symptoms reduced during and after treatment. At the within-patient (WP) level, an increase in self-efficacy was associated with a decrease in worry and depressive symptoms, and an increase in outcome expectation was associated with a decrease in depressive symptoms. The between-patient (BP) effect, however, was contrary to the WP effect, that is, self-efficacy was positively correlated with worry and outcome expectation was positively correlated with depressive symptoms CONCLUSION: These results highlight the importance of disaggregating the WP variability from BP variability in psychotherapy process-outcome research as they exhibit different associations at the within- and between-patient levels. Clinical Trial Registration: ClinicalTrial.gov (NCT03079336).

Patients' symptoms and strengths as predictors of long-term outcomes of CBT for generalized anxiety disorder - A three-level, multi-predictor analysis.

Although cognitive behavioral therapy (CBT) is an effective treatment for generalized anxiety disorder (GAD), GAD often shows a chronic clinical course and common deterioration after treatment. Many trials have examined the efficacy of treatments in GAD, but little is known about intake predictors of long-term treatment outcomes. This study examined potential predictors of long-term treatment outcomes based on the individual's symptom severity and strengths (behavioral, cognitive, interpersonal) at intake. Long-term outcomes were defined as worry at six-month follow-up (six-m FU) and worry decrease from intake and post-treatment to six-m FU. Data from 137 CBT outpatients with a GAD diagnosis from two randomized clinical trials were analyzed using three-level hierarchical linear modeling. Results revealed that worrying decreased up to the six-m FU. In single-predictor models, intake symptom severity and strength measures predicted worry at the six-m FU. In multi-predictor models, only behavioral strengths remained a significant predictor. Worry decrease from intake to the six-m FU was only predicted by behavioral strengths. These findings provide relevant information about intake predictors of long-term outcomes after CBT for GAD and underscore the potential relevance of assessing patients' strengths for clinical practice.

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

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

Worry and Positive Episodes in the Daily Lives of Individuals With Generalized Anxiety Disorder: An Ecological Momentary Assessment Study.

Worry is a central feature of generalized anxiety disorder (GAD). Although worry is related to anxiety and maintained by beliefs that worry is uncontrollable, there is scarce research on how individuals with GAD react to worry episodes in their daily life and how their positive experiences might impact reactions to worry episodes. The current study examined the level and variability of anxiety and controllability during high worry periods and positive experiences in GAD. Moreover, it investigated the influence of worry and positive experiences on later anxiety and perceived controllability within-persons. Finally, it examined change in anxiety level from previous to current episodes depending on previous episodes type. In the current study, 49 individuals with GAD (514 observations) registered their worry and positive episodes (i.e., episodes in which they had positive experiences) and reported on several variables during these episodes (i.e., anxiety and controllability of episodes and episode duration) using smartphone-based ecological momentary assessment for 7days. Results show anxiety and controllability differed by episode type (higher anxiety, lower controllability in worry episodes, and the opposite in positive episodes), and notable within-person variability in anxiety and controllability in both episode types. The time-lagged multilevel models showed episode type did not predict later anxiety during either episode type, although previous anxiety predicted current anxiety in worry episodes (but not positive episodes). Moreover, worry episodes did predict later controllability in worry episodes (but not positive episodes) and previous controllability predicted current controllability in both episode types. Furthermore, we obtained the increase in anxiety from t 0-1 to t 0 in a current worry episode to be significantly smaller when preceded by a worry (vs. positive) episode. Likewise, the reduction in anxiety from t 0-1 to t 0 in a current positive episode was significantly larger when preceded by a worry (vs. positive) episode. The novel findings in the current study that perceptions of controllability and anxiety vary within individuals with GAD, that greater controllability is experienced in positive episodes than worry episodes, and that worry may confer a sense of controllability at a later time could be seen as important contributions to the GAD literature.

Examining Working Memory Performance in Adult Psychosomatic Inpatients.

BACKGROUND: There is cumulating evidence that working memory (WM) processing is impaired in individuals suffering from a psychosomatic and a psychological disorder. However, it is unclear how repetitive negative thinking (RNT), depressive symptoms, and patient characteristics (i.e., age and incapability to work) contribute to WM impairments. The present study examines how these factors affect WM performance in highly distressed adult psychosomatic inpatients. METHODS: Seventy-six inpatients (M age = 52.7, SD = 8.4) from a psychosomatic rehabilitation clinic performed a two-block WM updating task, with accuracy and reaction time as indicators of WM functioning. RESULTS: Multivariate mixed effect model results show that accuracy and reaction time significantly decreased from WM Block 1 to WM Block 2. Higher levels of RNT, more severe depressive symptoms and higher age were associated with worse WM accuracy in Block 1. None of these variables were significantly associated with WM reaction time (in Block 1). CONCLUSION: From a clinical perspective, the results suggest that screening for the presence of high RNT levels, severe depressive symptoms or higher age may help to identify patients with impaired WM functioning and to intervene on these important patient characteristics early in the rehabilitation process.

Predictors of change in patient treatment outcome expectation during cognitive-behavioral psychotherapy for generalized anxiety disorder.

Positive patient-rated psychotherapy outcome expectation at pre- or early treatment is associated with posttreatment improvement. However, there is limited research on patients' change in outcome expectation across therapy and participant factors that predict both pretreatment outcome expectation and expectation change. The present study aimed to examine (a) the overall trajectory of change in patients' outcome expectation from pretreatment through treatment's end; (b) baseline patient characteristics as predictors of their pretreatment outcome expectation; (c) early change in general self-efficacy (controlling for baseline patient characteristics, early change in symptoms, and treatment condition) as predictor of expectation change; and (d) therapist effects on patients' outcome expectation change. For patients with generalized anxiety disorder (N = 80) receiving variants of cognitive-behavioral therapy, outcome expectation was assessed at pretreatment, Session 5, Session 10, and posttreatment. Using multilevel models with repeated assessments, we found outcome expectation to linearly increase from pre- to posttreatment. When controlling for other patient characteristics at intake, higher depression severity was associated with lower pretreatment outcome expectation. When controlling for baseline patient characteristics, early reduction in generalized anxiety disorder-symptoms and global severity, and treatment condition, an increase in early general self-efficacy was associated with a less steep increase in outcome expectation over the therapy. We also found between-therapist differences in their patients' average outcome expectation change. Results shed additional light on various participant characteristics that influence patients' pretreatment outcome expectation and expectation change through therapy. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Exploring change in cognitive-behavioral therapy for generalized anxiety disorder-A two-arms ABAB crossed-therapist randomized clinical implementation trial.

OBJECTIVE: There is little evidence-based knowledge of how psychotherapists should handle both sudden gains and more gradual session-by-session changes, either in general or in individuals suffering from generalized anxiety disorder. METHODS: Using an ABAB crossed-therapist randomized clinical implementation trial design (N = 80 patients and 20 therapists), we contrasted a Prolonged Focus on Change (PFC, N = 40) implementation with a State-Of-The-Art (SOTA, N = 40) implementation. Both implementations were based on a widely used cognitive behavioral therapy approach (Mastery of your Anxiety and Worry package) with the only difference that in the PFC implementation, the therapists were instructed to systematically explore eventual changes at the beginning of the therapy sessions. RESULTS: Based on a 3-level hierarchical linear model, PFC implementation showed faster symptom reduction in worry over therapy (i.e., linear change) and a decelerated (quadratic) change until 12-month follow-up in comparison to the SOTA implementation. CONCLUSION: These findings provide clinically useful information about potential short-term and long-term effects of exploring occurring change in GAD populations. Randomized clinical implementation trial designs are a step forward allowing to experimentally investigate basic psychotherapeutic strategies in process-based psychotherapy. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Heart rate variability change during a stressful cognitive task in individuals with anxiety and control participants.

BACKGROUND: Individuals suffering from an anxiety disorder are characterized by chronically low heart rate variability (HRV) compared to healthy individuals during resting state conditions. However, when examining HRV and HR in response to a stressor, mixed results have been obtained when comparing anxious and non-anxious groups. METHODS: The primary aim of the present study was to investigate HRV and HR responding in 26 clinically anxious and 14 control individuals before, during and after a stressful working memory task. RESULTS: Results indicate no between-group differences in HRV and HR at baseline. When starting the working memory task, the control group decreased significantly in HRV and the anxious group did not differ substantially in their change pattern from baseline to the start of the stressor. Finally, during the recovery phase of the working memory task, the clinically anxious and control individuals did not differ in their HFV or HR response compared to baseline. CONCLUSIONS: From a clinical perspective, the results suggest that screening for the presence of anxiety disorders may help to identify patients with impaired HRV and HR functioning and to intervene on these important patient characteristics early in the treatment process.

Assessing interpersonal skills-A comparison of trainee therapists' and students' interpersonal skills assessed with two established assessments for interpersonal skills.

Therapist differences in psychotherapy outcomes have been consistently found. Therefore, therapists' characteristics such as interpersonal skills are of particular interest. Two assessments of interpersonal skills for the selection of trainees have recently been developed. To extend current knowledge, this study compares trainee therapist's and psychology student's interpersonal skills in both assessments simultaneously and also investigates the potential influence of clinical experience and age on interpersonal skills. Furthermore, the psychometric properties of these assessments are examined. A total of 19 trainee therapists and 17 undergraduate students (N = 36) participated in both assessments and provided information on their prior clinical experience. Trainee therapists had significantly better interpersonal skills than the students in both assessments. However, different indicators of clinical experience (e.g., years in practice, patients treated, and supervision) did not influence their performance in either assessment. The good psychometric properties of both assessments could be replicated. Conceptual and practical considerations on the assessment of interpersonal skills are discussed.

Indirect effect of patient outcome expectation on improvement through alliance quality: A meta-analysis.

Objective: A meta-analysis revealed a positive correlation between patients' optimistic baseline, or early treatment, outcome expectation (OE) and posttreatment improvement (Constantino, Vîsla, et al., [2018]. A meta-analysis of the association between patients' early treatment outcome expectation and their posttreatment outcomes. Psychotherapy, 55(4), 473-485. https://doi.org/10.1037/pst0000169). However, little is known about mechanisms through which OE operates. Increasingly, several individual studies have pointed to higher therapeutic alliance quality as a promising mediator (candidate mechanism) of the positive OE-improvement link. In this study, we conducted the first meta-analysis of this indirect effect, hypothesizing that alliance would partially mediate the OE-outcome link.Method: We included published articles involving a clinical sample; therapist-led treatment of at least 3 sessions; pre- or early treatment patient OE measures; during-treatment patient-rated alliance measures; posttreatment outcome measures; and statistical tests of mediation. This meta-analysis included 10 independent samples and over 1,000 patients.Results: As expected, better alliance quality partially mediated the association between more optimistic OE and improvement; that is, although both were significant, a multivariate analysis revealed that the direct effect was significantly lower than the total effect (standardized difference = -.12, p < .001, 95% CI [-.20, -.05]). Publication bias was low, as was heterogeneity except for the alliance-outcome path.Conclusions: Better alliance may be one process that helps transmit the therapeutic influence of early patient OE.

The reciprocal relationship between alliance and early treatment symptoms: A two-stage individual participant data meta-analysis.

OBJECTIVE: Even though the early alliance has been shown to robustly predict posttreatment outcomes, the question whether alliance leads to symptom reduction or symptom reduction leads to a better alliance remains unresolved. To better understand the relation between alliance and symptoms early in therapy, we meta-analyzed the lagged session-by-session within-patient effects of alliance and symptoms from Sessions 1 to 7. METHOD: We applied a 2-stage individual participant data meta-analytic approach. Based on the data sets of 17 primary studies from 9 countries that comprised 5,350 participants, we first calculated standardized session-by-session within-patient coefficients. Second, we meta-analyzed these coefficients by using random-effects models to calculate omnibus effects across the studies. RESULTS: In line with previous meta-analyses, we found that early alliance predicted posttreatment outcome. We identified significant reciprocal within-patient effects between alliance and symptoms within the first 7 sessions. Cross-level interactions indicated that higher alliances and lower symptoms positively impacted the relation between alliance and symptoms in the subsequent session. CONCLUSION: The findings provide empirical evidence that in the early phase of therapy, symptoms and alliance were reciprocally related to one other, often resulting in a positive upward spiral of higher alliance/lower symptoms that predicted higher alliances/lower symptoms in the subsequent sessions. Two-stage individual participant data meta-analyses have the potential to move the field forward by generating and interlinking well-replicable process-based knowledge. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

How do worry and clinical status impact working memory performance? An experimental investigation.

BACKGROUND: Previous research has suggested that worry is negatively associated with working memory performance. However, it is unclear whether these findings would replicate across different worry levels and in individuals with anxiety and depressive disorders (i.e. clinical statuses). METHOD: One-hundred-thirty-eight participants performed a two-block working memory task (150 trials per block). Based on participants` current clinical status, four groups were considered (generalised anxiety disorder group: n = 36; clinical group with another anxiety or mood disorders: n = 33; subclinical group: n = 27; control group: n = 42). Trait worry levels were collected from all of the participants. Working memory performance was measured as accuracy and reaction time. RESULTS: During the first block, higher worry scores were significantly associated with longer reaction times. Moreover, the generalised anxiety disorder group, clinical group, and subclinical groups demonstrated significantly longer reaction times compared to the control group in Block 1, when age was controlled for. From Block 1 to Block 2, all of the participants demonstrated a significant decrease in accuracy and reaction time, regardless of worry level or clinical status. CONCLUSION: The results indicate that higher worry levels negatively impact WM processing efficiency. Moreover, when age was controlled for, we found participants` clinical status to be linked with WM impairments. The results highlight the relevance of investigating the impact of different worry levels on cognitive processes across clinical and non-clinical populations.

Is there a sleeper effect of exposure-based vs. cognitive-only intervention for anxiety disorders? A longitudinal multilevel meta-analysis.

There is a longstanding debate in the cognitive behavioral literature whether exposure-based methods produce more sustainable outcomes relative to cognitive methods or vice versa. This debate concerns particularly the time after treatment termination (at follow-up assessments), also referred to as the sleeper effect. Therefore, the aim of the current meta-analysis was to examine the enduring efficacy of Exposure Therapy (ET) in comparison to Cognitive Therapy (CT) from treatment termination to follow-up in anxiety disorders. Available literature also allowed for the assessment of their long-term additive benefits relative to ET only. Traditional random effects analyses with restricted maximum likelihood estimators and multilevel longitudinal analyses were conducted on 39 randomized controlled trials (N = 1878). Traditional analyses revealed no differential efficacy at post-treatment or follow-up. Similarly, the multilevel longitudinal analyses identified no differential growth in efficacy from treatment termination to follow-up. The majority of the variables investigated did not moderate the results. However, there was evidence suggesting that CT was superior to ET when treatment was delivered individually, while ET was superior to CT when delivered as group therapy. Overall, the findings did not validate a number of assumptions, such as the existence of a sleeper effect. Several strengths and limitations are further discussed in the paper.

The working alliance in manualized CBT for generalized anxiety disorder: Does it lead to change and does the effect vary depending on manual implementation flexibility?

OBJECTIVE: The investigation of session-to-session effects of working alliance on symptoms and coping experiences in patients diagnosed with generalized anxiety disorder. In addition, investigating these effects dependent on whether therapists are primed to work with patients strength (resource priming) or to adhere to the treatment manual (adherence priming). METHOD: Data was drawn from a randomized controlled trial in which 57 patients were randomly assigned to either the resource priming condition or the adherence priming condition. Within- and between patient associations were disentangled using dynamic structural equation modeling. RESULTS: The total score of the working alliance, as well as all its overlapping components (i.e., goal agreement, task consensus, bond) showed significant within-patient effects on next session coping experiences. More specifically, better alliance scores in one session were followed by more coping experiences in the subsequent session. With regard to anxiety symptoms, an association was found only with the working alliance total score as well as for the bonds component, but not for the goals and task components of the working alliance. The priming condition (resource priming vs. adherence priming) had no influence on the within-patient alliance-outcome association. Between-patient alliance associations were only present with coping experiences, but not with anxiety symptoms. CONCLUSION: The findings provide further empirical evidence for the hypothesis that the working alliance may be a robust facilitative factor for change in CBT treatments for generalized anxiety disorder, which evolves irrespective of the strictness with which therapists adhere to the treatment manual. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Investigating the impact of early alliance on predicting subjective change at posttreatment: An evidence-based souvenir of overlooked clinical perspectives.

[Correction Notice: An Erratum for this article was reported in Vol 66(5) of Journal of Counseling Psychology (see record 2019-58882-002). In the article, a portion, +γ40ERit, was omitted in the Model 3 formula. The corrected formula is presented in the erratum. All versions of this article have been corrected.] Despite meta-analytic evidence showing that alliance is associated with posttreatment outcomes, several open questions still remain regarding this relation. First, we investigate whether (or not) the progressive aggregation of early alliance assessments increases the alliance-outcome relation across 2 distress and 4 subjective change measures. Second, we investigate whether the alliance-outcome relations using subjective change measures are independent from intake distress and early response. Third, we explore whether the progressive aggregation of the alliance on outcomes becomes particularly apparent between or within therapists again investigating these six outcome measures. Data were drawn from N = 430 patients treated by N = 151 therapists. Patient ratings of early alliance were assessed after Session 1 to 6. For outcome, 2 commonly used distress measures at intake and at posttreatment and 4 measures of retrospectively evaluated subjective change at posttreatment are integrated into a series of multilevel models. The proportion of variance in outcome predicted by alliance scores varied considerably depending on the number of alliance assessments which were aggregated, as well as on the type of outcome assessment (distress vs. subjective change measures) explaining up to 15% of outcome variance. Improvements in the strength of prediction with aggregated alliance assessments were most pronounced for subjective change measures for between-therapist components of the alliance. Examining associations with subjective change measures provides an additional, patient-centered perspective of the relation between early alliance and treatment outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Patient characteristics and the therapist as predictors of depressed patients' outcome expectation over time: A multilevel analysis.

Objective: Although there is an established link between patients' early positive outcome expectation for and their actual improvement from therapy, there is little research on patients' change in outcome expectation across therapy and both patient and therapist correlates of early outcome expectation level and change. The present study examined: (i) the overall trajectory of change in patients' outcome expectation through cognitive-behavioral therapy (CBT) for depression; (ii) patient characteristics as predictors of both initial outcome expectation and change in outcome expectation; and (iii) between-therapist effects in outcome expectation change. Method: Depressed patients (N = 143) received a brief course of CBT. Outcome expectation was measured at screening, pretreatment, session 7, and session 14. Results: Outcome expectation linearly increased from screening to session 14. When controlling for other patient characteristics at intake, having previous depressive episodes was negatively associated with initial outcome expectation and higher well-being was positively associated with initial outcome expectation. When controlling for early alliance and early symptom change, outcome expectation change was predicted by previous depressive episodes. Finally, therapist effects emerged in outcome expectation over time. Conclusions: Various depressed patients' characteristics predict initial outcome expectation level and change, with significant between-therapists' differences related to outcome expectation change.