Symptom Change during Waitlist for Medicated and Nonmedicated Patients with Chronic Depression.

INTRODUCTION: Patients seeking psychotherapy often spend time on waitlist (WL), the effect of which is largely unknown. WL patients may forego alternative non-psychotherapeutic assistance and thus do more poorly than had they not been placed on a WL. The course of symptoms might also be influenced by use of antidepressant medication (ADM), an issue that remains unexplored in the literature. OBJECTIVE: In a naturalistic setting, WL symptom change before inpatient psychotherapy (mean weeks of waiting = 22.6) was assessed in a sample (N = 313) of chronically depressed patients. METHODS: Using the Beck Depression Inventory-II, patients' symptoms were tracked at assessment, when admitted to treatment (i.e., after WL), at posttreatment and 1-year follow-up. Multilevel growth curve analysis was used to examine waitlist change for the whole sample as well as for ADM users and nonmedicated patients. RESULTS: Symptoms were reduced significantly from assessment to admittance (Cohen's d = 0.47). Symptoms reduced less for ADM users (d = 0.39) than for nonmedicated patients (d = 0.65). CONCLUSION: The findings indicate that chronically depressed patients experience a decrease in symptoms during WL, quite likely due to treatment expectations. We discuss whether less symptom improvement for ADM users could be attributed to iatrogenic comorbidity and a higher degree of demoralization in this group.

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

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

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

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

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

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

Confidence in the therapist and confidence in the treatment predict symptomatic improvement week by week in therapy: A latent curve modeling approach.

Previous research suggests that common relationship factors are composed of two overarching factors, "Confidence in the therapist" and "Confidence in the treatment." The aim of this naturalistic process-outcome study was to investigate the reciprocal relationships between these two constructs and patients' symptom level across treatment. The sample consisted of 587 patients who were admitted to an inpatient program and treated with psychotherapy for a range of mental health disorders, such as chronic depression, anxiety disorders, and eating disorders. Our data consisted of weekly measures of symptomatic distress (Patient Health Questionnaire) and the common relationship factors were measured weekly using a newly developed scale. Latent curve modeling with structured residuals was used to investigate the between- and within effects of week-to-week changes in the two components as predictors of subsequent symptom level. An increase in both relationship factors predicted a decrease in subsequent levels of symptoms at the within-patient level, and the other way around, but the two relationship factors did not systematically relate to one another at the within-patient level over the course of treatment. Our findings indicate that patients' perceptions of the therapist as a person and their appraisal of the treatment, are important, different predictors of therapeutic change. Furthermore, they support prior research demonstrating a reciprocal relationship between common relationship factors and symptomatic distress and add to existing common factor theory by exploring the role of two central relationship dimensions and using a method which examines reciprocal relationships and within-patient effects simultaneously. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

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

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

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

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

Psychotherapy racial/ethnic disparities in treatment outcomes: The role of university racial/ethnic composition.

OBJECTIVE: Mental health disparities between racial/ethnic minorities (REM) and White individuals are well documented. These disparities extend into psychotherapy and have been observed among clients receiving care at university/college counseling centers. However, less is known about if campus RE composition affects outcomes from psychotherapy for REM and White clients. METHOD: This study examined psychotherapy outcomes from 16,011 clients who engaged in services at 33 university/college counseling centers. Each of these clients completed the Behavioral Health Measure as a of part routine practice. Campus RE composition was coded from publicly available data. RESULTS: The results demonstrated that White clients had better therapy outcomes than REM clients when they were at campuses where there were more White students. For universities 1 SD below the mean percentage of White students, the average difference in therapy outcomes for White and REM clients was Cohen's d = .21 (with White students experiencing more improvement); however, for universities 1 SD above the mean, the between group outcome disparity was greater (Cohen's d = .38). CONCLUSION: Therapists and higher education professionals should consider environmental impacts on counseling services. Implications for higher education, counseling centers, and mental health disparities are provided. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Depression and mentalizing: A psychodynamic therapy process study.

The present study aimed to explore the relationship between changes in depressive symptoms and the capacity to mentalize over the course of a 3-month inpatient psychodynamic therapy in a sample of 56 patients with depression. Depressive symptoms and mentalizing were assessed weekly during treatment and at 1-year follow-up with the Beck Depression Inventory and the Reflective Functioning Questionnaire (RFQ). Data were analyzed using Latent Growth Curve (LGC) modeling with structured residuals. In the total sample, depressive symptoms improved on average from baseline to the end of treatment, while mentalizing skills did not. However, individual variations were observed in mentalizing skills, with some patients improving while others did not. Within-patient residual changes in mentalizing skills did not predict residual changes in depressive symptoms. Accordingly, the results did not support mentalizing as a mechanism of change at this level. Nonetheless, between-patient effects were found, showing that patients with higher levels of mentalizing at baseline and patients whose mentalizing skills improved over the course of therapy also had greater reductions in depressive symptoms. We suggest that the presence of relatively higher mentalizing skills might be a factor contributing to moderately depressed individuals' ability to benefit from treatment, while relatively poor or absent mentalizing capacity might be part of the dynamics underlying treatment resistance in individuals with severe depression. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Comparing outcomes in chronic depression following inpatient psychotherapy for patients continuing versus discontinuing antidepressant medication.

Research indicates that combination of psychotherapy and antidepressant medication (ADM) provides cumulative effects and thus outperforms monotherapy in treating chronic depression. In this quasi-experimental study, we explored symptom change for patients with chronic depression treated with ADM when presenting for a 12-week psychotherapeutic inpatient treatment programme. We compared outcomes through treatment and follow-up of patients who continued medication with those who discontinued. We also tested possible moderator effects of initial depression severity on change between the groups. Based on prior research, we hypothesized that combination treatment would yield better results (i.e., more reduction in depression). Patients (N = 112) were referred from general practitioners or local secondary health care. Outcome was measured by Beck Depression Inventory-II (BDI-II), and comparisons were carried out using multilevel modelling. Although 35 patients discontinued ADM during treatment, 77 continued. Both continuers and discontinuers had a significant treatment effect that was maintained at 1-year follow-up. There was no difference in outcome between continuers and discontinuers of ADM. Patients with severe depression had significantly more symptom improvement than patients with moderate depression, but depression severity did not affect outcomes across continuers and discontinuers of ADM differently. The results could indicate that patients had developed resistance and/or tolerance to the prophylactic effects of medication and that ADM did not contribute to the reduction of depressive symptoms. The findings may also indicate that psychotherapy alone in some instances can be a viable alternative to continued combined treatment. Clinicians should carefully assess benefits of patients' ongoing use of antidepressant medication when entering psychotherapy.

Predicting change through individual symptoms and relationship distress: A study of within- and between-person processes in couple therapy.

OBJECTIVE: In couple therapy clients often suffer from a blend of individual psychiatric symptoms as well as severe relational distress. However, research is inconclusive on whether relational change predicts symptom change or vice versa. Because answers to this question could have important clinical implications on what to focus on in couple therapy at which time in treatment, more research is recommended. METHOD: In this study, data collected before every therapy session were used to test whether changes in relational functioning predicted symptom functioning or vice versa. The study used a multilevel modelling approach, and the variables of interest were disaggregated into within- and between-person effects. RESULTS: The results indicated that if an individual improved more than expected on relational functioning, this predicted more improvement than expected on individual symptoms. No significant reciprocal relationship was found between these variables. CONCLUSIONS: The clinical implication is discussed, suggesting that an emphasis on relational improvement seems to be an important mechanism during couple therapy that may facilitate the change on individual symptoms in the long run.

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.

The influence of extra-therapeutic social support on the association between therapeutic bond and treatment outcome.

Objective: Both good therapeutic bond as well as extra-therapeutic social support seem to enhance treatment outcomes. Some features of the therapeutic bond are similar to experiences in extra-therapeutic relationships (e.g., feelings of trust or belongingness). Patients with a lack of social support might benefit particularly from a good therapeutic bond, because a well-formed bond can partly substitute relationship needs. This study replicates former research (main effects of bond and social support) and investigates the hypothesized interaction between both constructs. Method: Data from 1206 adult patients receiving cognitive-behavioral outpatient therapy were analyzed. Patients rated early therapeutic bond, their impairment, as well as their social support. Multilevel regression analyses were applied to test for main effects and interactions between bond and social support predicting therapy outcome post treatment. Results: Consistent with prior research, both therapeutic bond and social support predicted therapy outcome. Among patients with high social support, the impact of the therapeutic bond was minimal, while patients with low social support benefited most from a good therapeutic bond. Conclusions: Results suggest that both the therapeutic bond and social support play a role in therapy outcomes and that good therapeutic bond quality might be especially important if a patient lacks social support.

Assessing the alliance-outcome association adjusted for patient characteristics and treatment processes: A meta-analytic summary of direct comparisons.

The alliance is widely recognized as a robust predictor of posttreatment outcomes. However, there is a debate regarding whether the alliance is an epiphenomenon of intake characteristics and/or treatment processes occurring over the course of treatment. This meta-analysis aimed to synthesize the evidence on this issue. We identified 125 effect sizes in 60 independent samples (6,061 participants) of studies that reported alliance-outcome correlations as well as parallel intake or process characteristics. We examined the impact of these potential confounds on the alliance-outcome correlations. We meta-analyzed the studies estimates by computing omnibus effects models as well as multivariate models. We identified 3 variable types that were used to adjust the alliance-outcome correlations: (a) intake characteristics (k = 35); (b) simultaneous processes, such as adherence or competence (k = 13); and (c) both intake and simultaneous processes (k = 24). We found moderate alliance-outcome correlations with or without adjustments for intake and simultaneous processes (range from r = .23 to r = .31). Our results provide robust empirical evidence for the assertion that the alliance-outcome association is an independent process-based factor. Findings suggest that alliance is positively related to outcome above and beyond the studied patient intake characteristics and treatment processes. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Feedback in Couple and Family Therapy: A Randomized Clinical Trial.

Routine Outcome Monitoring (ROM) is recommended as a psychotherapy procedure to serve as clinical feedback in order to improve client treatment outcomes. ROM can work as a warning signal to the therapist if the client shows signs of no change or deterioration. This study has investigated whether any difference in outcome could be detected between those clients in couple and family therapy who used the Systemic Therapy Inventory of Change (STIC) feedback system (ROM condition) versus those who were offered treatment without the use of STIC ("treatment as usual" or TAU condition). A sample of 328 adults seeking couple and family therapy in Norway was randomly assigned to ROM versus TAU conditions. Outcome measures were The Outcome Questionnaire-45 and The Revised Dyadic Adjustment Scale. The results demonstrated no significant differences in outcomes between the ROM and TAU. Possible explanations of this result related to design and implementation issues are discussed.

Cytokine concentrations are related to level of mental distress in inpatients not using anti-inflammatory drugs.

OBJECTIVE: Cross-sectional data show elevated levels of circulating cytokines in psychiatric patients. The literature is divided concerning anti-inflammatory drugs' ability to relieve symptoms, questioning a causal link between inflammatory pathways and psychiatric conditions. We hypothesised that the development of circulating cytokine levels is related to mental distress, and that this relationship is affected by the use of anti-inflammatory drugs. METHODS: The study was a longitudinal assessment of 12-week inpatient treatment at Modum Bad Psychiatric Center, Norway. Sera and self-reported Global Severity Index (GSI) scores, which measure psychological distress, were collected at admission (T0), halfway (T1) and before discharge (T2). Other variables known to distort the neuroimmune interplay were included. These were age, gender, diagnosis of PTSD, antidepressants and anti-inflammatory drugs. A total of 128 patients (92 women and 36 men) were included, and 28 were using anti-inflammatory medication. Multilevel modelling was used for data analysis. RESULTS: Patients with higher levels of IL-1RA and MCP-1 had higher GSI scores (p = 0.005 and p = 0.020). PTSD patients scored higher on GSI than non-PTSD patients (p = 0.002). These relationships were mostly present among those not using anti-inflammatory drugs (n = 99), with higher levels of IL-1RA and MCP-1 being related to higher GSI score (p = 0.023 and 0.018, respectively). Again, PTSD patients showed higher GSI levels than non-PTSD patients (p = 0.014). CONCLUSIONS: Cytokine levels were associated with level of mental distress as measured by the GSI scores, but this relationship was not present among those using anti-inflammatory drugs. We found no association between cytokine levels and development of GSI score over time.

Individual distress and dyadic adjustment over the course of couple therapy and three-year follow-up: A replication study.

This replication study examined the change over time and the relationship between depressive symptoms and dyadic adjustment during residential couple therapy and at one- and three-year follow-up. Mixed models were used in the analyses, and a disaggregation procedure was applied to examine the results on a between-person as well as on a within-person level. Overall, the results of the previous study were replicated. Significant improvement (p < .001) occurred on measures assessing relationship satisfaction and depressive symptoms from admission to discharge (effect sizes .47 to.72) and from admission to three-year follow-up (effect sizes .59 to .66). The within-person finding implies that when a person experiences more depressive symptoms than usual for him/her, subsequent dyadic adjustment is poorer than usual. Thus, our previous clinical implication suggestion is reinforced in this study: When treating couples suffering from co-existing relational and symptomatic distress, couple therapy should include the aim of lowering individual depressive symptoms.

Does the working alliance mediate the effect of routine outcome monitoring (ROM) and alliance feedback on psychotherapy outcomes? A secondary analysis from a randomized clinical trial.

Little is known about the mechanisms through which routine outcome monitoring (ROM) influences psychotherapy outcomes. In this secondary analysis of data from a randomized clinical trial (Brattland et al., 2018), we investigated whether the working alliance mediated the effect of the Partners for Change Outcome Monitoring System (PCOMS), a ROM system that provides session-by-session feedback on clients' well-being and the alliance. Adult individuals (N = 170) referred for hospital-based outpatient mental health treatment were randomized to individual psychotherapy either with the PCOMS ROM system, or without (treatment as usual [TAU]). Treatment was provided by the same therapists (N = 20) in both conditions. A multilevel mediation model was developed to test if there was a significant indirect effect of ROM on client impairment at posttreatment through the alliance at 2 months' treatment controlled for first-session alliance. Alliance ratings increased more from session 1 to 2 months' treatment in the ROM than TAU condition, and alliance increase was associated with less posttreatment impairment. A significant indirect effect of ROM on treatment outcomes through alliance increase (p = .043) explained an estimated 23.0% of the effect of ROM on outcomes. The results were consistent with a theory of the alliance as one mechanism through which ROM works. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Let's Distinguish Relative and Absolute Efficacy to Move Psychotherapy Research Forward.

Objective: Background regarding a recent debate between Cuijpers et al. (2019a, b) and the authors (Munder et al. 2019) about the efficacy of psychotherapy for depression is given. Method: A main reason for the discrepancy in Cuijpers et al.'s and our conclusions is discussed. Results: In our view the discrepancy is due, among other things, to a blurred distinction between questions of relative and absolute efficacy of psychotherapy. Although the efficacy of psychotherapy vis-à-vis alternative treatments may be ambiguous, there can be little doubt about the benefits of psychotherapy relative to no treatment. Conclusion: We do not think that raising fundamental concerns about the value of psychotherapy is a service to the field. We argue that moving the field forward requires a focus on how psychotherapy works and how the access to psychotherapy can be increased.

Vom Sinn des Verfahrenskonzepts und der Verfahrensvielfalt ­ und warum das Baukasten-System in der Psychotherapie nicht funktioniert.

Why the concept of distinct psychotherapeutic approaches is indispensable - and why the tool box concept of psychotherapy cannot work Background: In Germany, the official psychotherapy guidelines are oriented towards the model of distinct psychotherapeutic approaches. Within the German health care system this also applies to the training in psychotherapy. Some critics, however, are presently pleading in favour of abolishing the model of distinct psychotherapeutic approaches, which also implies to abolish the concept of the so called "Richtlinienverfahren" in Germany - approaches of psychotherapy which proved to be efficacious and whose costs are reimbursed by the insurance companies. Objective: The arguments put forward such as the heterogeneity of the approaches as well as the proposed alternatives, for example, an "integrative" model of both mental disorders and psychotherapeutic treatment are critically discussed. Results: Both the arguments and proposed alternatives are found to be not convincing, neither from a scientific nor from a psychotherapeutic perspective. From a scientific perspective, there is no evidence for efficacy of a "general" or "integrative" model of psychotherapy - which is in contrast to the Richtlinienverfahren for which evidence for efficacy exists. From a psychotherapeutic perspective psychotherapy cannot be taught, learnt and applied by use of tools or modules without a theoretical orientation. Conclusions: The concept of distinct psychotherapeutic approaches proves to be an in dispensable principal for orientation in psychotherapy, for both therapists and patients.