The Impact of Mental Imagery Instructions on Patients' and Therapists' Positive Affect and Strength-Based Behaviours Within Psychotherapy Sessions: A Randomized Controlled Process Study.

OBJECTIVE: Increased attention has recently been paid to the well-being and flourishing of patients in psychotherapy. This study investigated the occurrence of positive affect (PA) and strength-based behaviours within psychotherapy sessions contrasting positive versus neutral imagery instructions. METHODS: This is a secondary analysis of a randomized controlled trial. Seventy-eight sessions of cognitive behavioural therapy involving 26 patients (69.23% female; Mage = 40.31) treated by 13 therapists were selected. PA and strength-based behaviours of patients and therapists were coded on a minute-by-minute basis with the Resource-Oriented Microprocess Analysis. Each session started with a brief mental imagery instruction. Data were analysed using multilevel modelling. RESULTS: Mild levels of PA were very common, whereas stronger expressions were occasional, especially at the beginning and end of sessions. Strength-based behaviours were employed in one-fifth of the videos analysed. Therapists in the positive imagery instruction showed more strength-based behaviours in the beginning phase of sessions, p < 0.05. The two imagery instructions significantly differed in the session trajectories of PA, p < 0.05. A quadratic trend with higher initial values and a sharper decline in PA were found in the positive instruction, whereas the neutral instruction showed a flatter trend. CONCLUSION: Patients and therapists experience PA and discuss strengths in psychotherapy sessions despite patients' distress. The positive imagery instructions potentially induced a positive focus at baseline for therapists but had a negligible effect on the subsequent session progression. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03767101 (registered December 6, 2018).

Association of patients' pre-therapy strengths and alliance in outpatient psychotherapy: A multilevel growth curve analysis.

OBJECTIVE: Meta-analytic evidence showed robust associations between the alliance in psychotherapeutic dyads and treatment outcomes. Recent studies have indicated that facets of positive mental health are additionally relevant predictors of both the alliance and success of psychotherapy. However, the impact of patients' pre-therapy strengths on the alliance at the beginning and during treatment has been scarcely examined. METHOD: 428 patients (62.4% female, Mage = 40.79), treated by 41 therapists, underwent cognitive behavioral therapy in a German outpatient training and research center. Alliance from patients' perspectives was assessed at the beginning and during treatment. Data were analyzed with multilevel growth curve modeling. RESULTS: Alliance increased during psychotherapy, with a quadratic trajectory best representing this trend on average, p < .001. Pre-therapy strengths were positively related to alliance intercept, b = 0.0537, p < .001. No interaction was found between the included time variables and pre-therapy strengths in the prediction of the alliance slope. CONCLUSION: Positive mental health facets should be considered in psychotherapy research and practice. Future studies may focus on the parallel development of patients' strengths with other process factors in treatment.

Patients' self-perceived strengths increase during treatment and predict outcome in outpatient cognitive behavioral therapy.

OBJECTIVE: Modern conceptualizations suggest the independence of positive and negative mental health constructs. Research of positive constructs in psychotherapy is scarce. This study analyzed the development of patients' strengths during psychotherapy and whether pre-therapy strengths incrementally predict treatment outcome. METHODS: Two hundred and two patients (56.44% female, mean age = 42.49) treated by 54 therapists underwent cognitive behavioral therapy. Patients' strengths in different contexts as well as psychopathology, interpersonal problems, and self-esteem were assessed at the beginning and end of therapy. RESULTS: Strengths increased in the contexts of everyday life (EvdayS; d = 0.44, p < 0.001) and current problems (ProbS; d = 0.70, p < 0.001). Strengths in the context of previous crises that were managed successfully (CrisesS) did not change. However, baseline scores of CrisesS were a significant incremental predictor of all outcomes. CONCLUSION: A differentiated assessment of positive constructs is useful for outcome prediction and the implementation of strength-based interventions.

Multidimensional Assessment of Strengths and Their Association With Mental Health in Psychotherapy Patients at the Beginning of Treatment.

Background: Modern concepts assume that mental health is not just the absence of mental illness but is also characterized by positive well-being. Recent findings indicated a less pronounced distinction of positive and negative mental health dimensions in clinical samples. Self-perceived strengths were associated with markers of mental health in healthy individuals. However, analyses of strengths and their association with different mental health variables in clinical populations are scarce. Method: A cross-sectional design was conducted at a German outpatient training and research center. 274 patients before treatment (female: 66.4%, mean age = 42.53, SD = 13.34, range = 18-79) filled out the Witten Strengths and Resource Form (WIRF), a multidimensional self-report of strengths, as well as other instruments assessing positive and negative mental health variables. Data was analyzed with structural equation modeling and latent regression analyses. Results: Confirmatory factor analysis of the WIRF showed good model fit for the assumed three-subscale solution. Regarding mental health, a one-factor model with positive and negative variables as opposite poles showed acceptable fit. A correlated dual-factor model was not appropriate for the data. All WIRF subscales significantly predicted unique parts of variance of the latent mental illness factor (p = .035 - p < .001). Conclusion: The context-specific assessment of patients' strengths was confirmed and led to an information gain in the prediction of mental health. Results suggest that positive and negative facets of mental health are highly entwined in people with pronounced symptoms. The scientific and practical implications of these findings are discussed.

A Mental Imagery Micro-Intervention to Increase Positive Affect in Outpatient CBT Sessions (PACIfIC): Study Protocol of a Randomized Controlled Implementation Trial.

Background: Recent findings indicated that mental disorders are associated with both an up-regulation of negative affect and a down-regulation of positive affect (PA) as distinct processes. Established treatment approaches focus on the modification of problems and negative affect only. Experimental paradigms in healthy samples and research on strengths-based approaches showed that fostering PA may improve psychotherapy process and outcome. Specific and easily implementable interventions targeting PA in treatment sessions are scarce. Mental imagery was shown to be a promising strategy for boosting positive emotional experiences. Method: The PACIfIC-study is planned as a longitudinal randomized-controlled trial in the context of cognitive behavioral therapy, implemented at a German outpatient training and research center. In the process analysis, trajectories of PA over the first twelve treatment sessions will be examined with weekly questionnaires. In the intervention analysis, a six-minute positive mental imagery intervention to enhance PA will be developed and tested. The intervention is implemented with loudspeakers at the beginning of each session for a standardized induction of PA. The experimental group will be compared to an active control group (neutral mental imagery) and treatment as usual. Procedures in all treatment arms are parallelized. Main outcomes after twelve sessions of psychotherapy will be psychosocial resources, resilience and self-esteem (theory-driven), as well as psychopathology and working alliance (secondary outcome). Multilevel modeling will be conducted to address the nested data structure. Conclusion: Study results may have implications on the consideration of positive constructs in mental disorders and the implementation of strengths-based interventions in psychotherapy.