Recommendations for Dynamic Treatment of Identity-Based Trauma: Opening the "I" to Reflection.

Current treatments for trauma are ineffective for many patients. For traumas involving violence that targets aspects of patients' identities, treatments that do not address systemic factors involved in the trauma (e.g., past and ongoing experiences of identity-based oppression and marginalization, developmental sequelae of invalidation or policing of identity, and identity-related patterns of transference and countertransference) may be ineffective. Psychodynamic approaches can flexibly address the identity-related dynamics between therapist and patient and incorporate patients' experiences of their various identities, in the context of trauma, into clinical formulation and treatment. The authors present concepts relevant to the dynamics of intersectional identities that may arise between therapist and patient and provide a case study illustrating how a patient's various identities affect their symptom manifestation and treatment course. The authors advocate for cultural humility and self-exploration of biases and assumptions among clinicians, because therapists do not hold expert knowledge of their patients' cultural experiences.

A Meta-Analysis of Interpersonal and Psychodynamic Psychotherapies for Posttraumatic Stress Disorder.

OBJECTIVE: Established trauma-focused cognitive-behavioral therapies for posttraumatic stress disorder (PTSD) have remission rates of approximately 30%-40%. Alternatively, interpersonal psychotherapy (IPT) and psychodynamic psychotherapy (PDT) focus on disrupted attachment, mentalization, and social connection in PTSD and may help some patients. The authors conducted a meta-analysis on these interpersonal and affect-oriented approaches to treating PTSD. METHODS: Building on a prior meta-analysis, the authors searched for randomized controlled trials (RCTs) comparing IPT or PDT with other established PTSD treatments or control conditions for adults diagnosed as having PTSD. Random-effects meta-analyses were conducted to assess outcome effect sizes and dropout rates. RCTs were rated via the Randomized Controlled Trial Psychotherapy Quality Rating Scale. RESULTS: Ten RCTs (eight of IPT) comparing IPT or PDT with control (k=7) or active treatment (k=4) conditions were identified, nine of which were of adequate quality. IPT (k=5) and PDT (k=2), when analyzed together, were superior to control conditions overall (g=-1.14, p=0.011 [as was IPT alone: g=-0.88, p=0.034]) and to waitlist (g=-1.49) and treatment-as-usual (g=-0.70) groups. Effect sizes, however, may have been inflated by outliers or publication bias. IPT (k=3) and PDT (k=1), when analyzed together, were equally efficacious compared with other active PTSD treatments (primarily exposure-based psychotherapies), as was IPT alone, and had lower dropout rates (relative risk=0.63, p=0.049 for IPT and PDT analyzed together; relative risk=0.61, p=0.098 for IPT alone). CONCLUSIONS: Affect-focused therapies hold promise in the treatment of PTSD. IPT has demonstrated efficacy in multiple trials, whereas the evidence base for PDT is sparse.

Childhood Trauma and Panic Disorder: The Impact of History of Child Abuse on Illness Severity and Treatment Response.

OBJECTIVE: Patients who have experienced child abuse often have complex clinical presentations; whether a history of child abuse (HCA) affects psychotherapy outcomes is unclear. The authors examined relationships between HCA, clinical baseline variables, and change in these variables after three different psychotherapies for panic disorder (PD). METHODS: Two hundred adults with PD (with or without agoraphobia) were randomly assigned to one of three treatments across two sites: panic-focused psychodynamic psychotherapy (PFPP), cognitive-behavioral therapy (CBT), or applied relaxation training (ART). Differences in demographic and clinical variables between those with and without HCA were compared. The primary analysis addressed odds of meeting clinical response criteria on the Panic Disorder Severity Scale (PDSS) between treatments, as moderated by HCA. This effect was examined via continuous outcomes on the PDSS and psychosocial functioning (Sheehan Disability Scale). RESULTS: Compared with patients without HCA (N=154), patients with HCA (N=46) experienced significantly more severe symptoms of PD (d=0.60), agoraphobia (d=0.47), and comorbid depression (d=0.46); significantly worse psychosocial impairment (d=0.63) and anxiety sensitivity (d=0.75); greater personality disorder burden (d=0.45)-particularly with cluster C disorders (d=0.47)-and more severe interpersonal problems (d=0.54). HCA significantly moderated the likelihood of clinical response, predicting nonresponse to ART (B=-2.05, 95% CI=-4.17 to -0.30, OR=0.13, z=-2.14, p=0.032) but not CBT or PFPP. HCA did not interact with treatment condition to predict slopes of PDSS change. CONCLUSIONS: The results of this study highlight the importance of HCA in formulating treatment recommendations. Increased awareness of HCA's effects on severity of PD and treatment responsiveness among patients with PD may improve outcomes.

Open Trial of Trauma-Focused Psychodynamic Psychotherapy for Posttraumatic Stress Disorder Among LGBTQ Individuals.

OBJECTIVE: Lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals report higher rates of exposure to traumatic events and posttraumatic stress disorder (PTSD) compared with heterosexual and cisgender individuals. No treatment outcomes research has focused on PTSD in the LGBTQ population. Trauma-focused psychodynamic psychotherapy (TFPP) is a brief, manualized, attachment- and affect-focused psychotherapy for PTSD. TFPP explicitly incorporates broad identity-related and societal factors into its conceptualization of trauma and its consequences, which may be especially helpful for LGBTQ patients with minority stress who seek affirmative care. METHODS: Fourteen LGBTQ patients with PTSD, assessed with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), received 24 sessions of twice-weekly (12 weeks) TFPP via teletherapy provided by supervised early-career therapists inexperienced in the modality. Sessions were videotaped to monitor therapists' treatment adherence. Patients were assessed at baseline, week 5, termination (week 12), and 3 months posttreatment for PTSD symptoms (assessed with the CAPS-5) and secondary outcomes. RESULTS: TFPP was well tolerated by patients, with 12 (86%) completing the intervention. CAPS-5-measured PTSD symptoms, including dissociation, significantly improved during treatment (mean decrease=-21.8, d=-1.98), and treatment gains were maintained at follow-up. Most patients experienced PTSD clinical response (N=10, 71%) or diagnostic remission (N=7, 50%). Patients generally experienced significant, concomitant improvements in complex PTSD symptoms, general anxiety, depression, and psychosocial functioning. Adherence to the intervention among therapists was high, with 93% of rated sessions meeting adherence standards. CONCLUSIONS: TFPP shows promise in the treatment of PTSD among sexual and gender minority patients seeking LGBTQ-affirmative PTSD care.

Changes in Attachment Representation and Personality Organization in Transference-Focused Psychotherapy.

OBJECTIVE: The aim of this article was to construct an empirical bridge between object relations theory and attachment theory by investigating how researchers in both traditions have contributed to understanding and assessing identity diffusion (a keystone of personality pathology) and object relations in patients with borderline personality disorder during 1 year of transference-focused psychotherapy (TFP). METHODS: The Adult Attachment Interview (AAI) and the Structured Interview of Personality Organization (STIPO) were administered to patients (N=104, all women) before and after 1 year of treatment. This study was part of a randomized controlled trial in which 104 patients with borderline personality disorder were randomly assigned to receive either TFP (a manualized, structured psychodynamic treatment approach) or treatment by experienced community psychotherapists. Changes on the AAI in attachment representations, narrative coherence, and reflective function were examined for their associations with changes on the STIPO in identity, object relations, and aggression. RESULTS: Patients who shifted from disorganized (unresolved) to organized attachment on the AAI after 1 year of TFP (but not treatment by experienced community psychotherapists) showed hypothesized improvements in domains of personality organization on the STIPO, including identity, object relations, and aggression. Those who did not change from disorganized (unresolved) to organized attachment improved only in the domain of aggression. CONCLUSIONS: These findings highlight the centrality of identity diffusion to borderline personality disorder pathology and the importance of targeting it in treatment. Furthermore, the results suggest that identity may be indexed by measures of attachment security, narrative coherence, and personality organization.

Elucidating behavioral and functional connectivity markers of aberrant threat discrimination in PTSD.

BACKGROUND: Patients with posttraumatic stress disorder (PTSD) tend to overgeneralize threat to safe stimuli, potentially reflecting aberrant stimuli discrimination. Yet, it is not clear whether threat overgeneralization reflects general discrimination deficits, or rather a specific bias related to aversive stimuli. Here we tested this question and characterized the neural correlates of threat discrimination. METHODS: One-hundred and eight participants (33 PTSD; 43 trauma-exposed controls; 32 healthy controls) completed an emotionally neutral complex shape discrimination task involving identifying in 42 similar pairs the previously observed shape; and an emotionally aversive discrimination task, involving providing risk ratings for an aversive conditioned stimulus (CS+), and for several stimuli gradually differing in size from the original CS+. Resting state functional connectivity (rsFC) was collected before completing the tasks. RESULTS: No group differences emerged on the emotionally neutral task. Conversely, on the emotionally aversive task, individuals with PTSD had steeper linear risk rating slopes as the stimuli more resembled the conditioned stimulus. Finally, lower rsFC of amygdala-default mode network (DMN) and DMN-salience network (SN) were associated with steeper risk slopes, while for hippocampus-SN, lower rsFC was found only among participants with PTSD. CONCLUSIONS: Individuals with PTSD show deficits in discrimination only when presented with aversive stimuli. Dysregulated discrimination pattern may relate to a lack of input from regulatory brain areas (e.g., DMN/hippocampus) to threat-related brain areas (e.g., SN/amygdala).

Treatment selection in borderline personality disorder between dialectical behavior therapy and psychodynamic psychiatric management.

BACKGROUND: No evidence-based therapy for borderline personality disorder (BPD) exhibits a clear superiority. However, BPD is highly heterogeneous, and different patients may specifically benefit from the interventions of a particular treatment. METHODS: From a randomized trial comparing a year of dialectical behavior therapy (DBT) to general psychiatric management (GPM) for BPD, long-term (2-year-post) outcome data and patient baseline variables (n = 156) were used to examine individual and combined patient-level moderators of differential treatment response. A two-step bootstrapped and partially cross-validated moderator identification process was employed for 20 baseline variables. For identified moderators, 10-fold bootstrapped cross-validated models estimated response to each therapy, and long-term outcomes were compared for patients randomized to their model-predicted optimal v. non-optimal treatment. RESULTS: Significant moderators surviving the two-step process included psychiatric symptom severity, BPD impulsivity symptoms (both GPM > DBT), dependent personality traits, childhood emotional abuse, and social adjustment (all DBT > GPM). Patients randomized to their model-predicted optimal treatment had significantly better long-term outcomes (d = 0.36, p = 0.028), especially if the model had a relatively stronger (top 60%) prediction for that patient (d = 0.61, p = 0.004). Among patients with a stronger prediction, this advantage held even when applying a conservative statistical check (d = 0.46, p = 0.043). CONCLUSIONS: Patient characteristics influence the degree to which they respond to two treatments for BPD. Combining information from multiple moderators may help inform providers and patients as to which treatment is the most likely to lead to long-term symptom relief. Further research on personalized medicine in BPD is needed.

Precision medicine for long-term depression outcomes using the Personalized Advantage Index approach: cognitive therapy or interpersonal psychotherapy?

BACKGROUND: Psychotherapies for depression are equally effective on average, but individual responses vary widely. Outcomes can be improved by optimizing treatment selection using multivariate prediction models. A promising approach is the Personalized Advantage Index (PAI) that predicts the optimal treatment for a given individual and the magnitude of the advantage. The current study aimed to extend the PAI to long-term depression outcomes after acute-phase psychotherapy. METHODS: Data come from a randomized trial comparing cognitive therapy (CT, n = 76) and interpersonal psychotherapy (IPT, n = 75) for major depressive disorder (MDD). Primary outcome was depression severity, as assessed by the BDI-II, during 17-month follow-up. First, predictors and moderators were selected from 38 pre-treatment variables using a two-step machine learning approach. Second, predictors and moderators were combined into a final model, from which PAI predictions were computed with cross-validation. Long-term PAI predictions were then compared to actual follow-up outcomes and post-treatment PAI predictions. RESULTS: One predictor (parental alcohol abuse) and two moderators (recent life events; childhood maltreatment) were identified. Individuals assigned to their PAI-indicated treatment had lower follow-up depression severity compared to those assigned to their PAI-non-indicated treatment. This difference was significant in two subsets of the overall sample: those whose PAI score was in the upper 60%, and those whose PAI indicated CT, irrespective of magnitude. Long-term predictions did not overlap substantially with predictions for acute benefit. CONCLUSIONS: If replicated, long-term PAI predictions could enhance precision medicine by selecting the optimal treatment for a given depressed individual over the long term.

Predictors and moderators of treatment dropout in cognitive-behavioral and psychodynamic therapies for panic disorder.

Introduction: Panic disorder patients who drop out of treatment typically do not remit from their disorder. How patient-level moderators influence dropping out of one panic-focused treatment over another has never been examined, nor in non-CBT treatments. Method: 200 patients with panic disorder with or without agoraphobia were randomized to receive cognitive-behavioral therapy (CBT), panic-focused psychodynamic psychotherapy (PFPP), or applied relaxation training (ART) across two sites. Therapy was twice a week for 12 weeks. A two-step variable search method was applied to identify potential prognostic predictors and moderators of patient dropout. Survival models predicting hazard of session-by-session dropout tested the resulting variables. Results: Across treatments, unemployment and higher psychosocial disability on the Sheehan Disability Scale predicted increased risk of dropout, while patients with higher anxiety sensitivity were more likely to complete treatment. Patients who reported experiencing childhood abuse had heightened dropout in ART, but not CBT or PFPP. Men were especially likely to complete PFPP. Session 2 expectancies and patient-rated alliance predicted lower dropout only in CBT. Conclusions: Patient-level factors may influence both whether patients will complete any treatment, and whether they continue in a particular panic-focused therapy. Moderators of dropout (e.g., abuse history) may inform treatment decisions for specific patients.Trial registration: ClinicalTrials.gov identifier: NCT00353470.

Separation anxiety in PTSD: A pilot study of mechanisms in patients undergoing IPT.

INTRODUCTION: Separation anxiety disorder (SAD) comprises one aspect of attachment dysregulation or insecurity. Although SAD aggravates posttraumatic stress disorder (PTSD) risk, no clinical research has tracked how many patients with PTSD have SAD, its clinical associations, or its response to PTSD treatment. Our open trial of interpersonal psychotherapy (IPT) for veterans with PTSD assessed these SAD domains. METHODS: Twenty-nine veterans diagnosed with chronic PTSD on the Clinician-Administered PTSD Scale were assessed for SAD using the Structured Clinical Interview for Separation Anxiety Symptoms (SCI-SAS), and for Symptom-Specific Reflective Function (SSRF), another dysregulated-attachment marker capturing patients' emotional understanding of their symptoms. Patients received 14 IPT sessions for PTSD with assessments at baseline, Week 4 (SCI-SAS and SSRF), and termination for SAD, PTSD, and depression. RESULTS: At baseline, 69% of patients met SAD criteria. Separation anxiety did not correlate with baseline PTSD severity, depressive severity, or age when traumatized; patients with and without SAD had comparable PTSD and depression severity. Patients with baseline comorbid SAD who completed IPT (N = 17) reported significantly improved adult separation anxiety (p = .009). Adult SAD improvements predicted depressive improvement (p = .049). Patients with SAD showed a stronger relationship between early SSRF gains and subsequent adult SAD improvement (p = .021) compared with patients without SAD. DISCUSSION: This first exploration of dysregulated/insecure attachment features among patients with PTSD found high SAD comorbidity and adult SAD improvement among patients with SAD following IPT. Highly impaired attachment patients normalized attachment posttreatment: 14-session IPT improved attachment dysregulation. This small study requires replication but begins to broaden clinical understanding of separation anxiety, attachment dysregulation, and PTSD.

A prognostic index for long-term outcome after successful acute phase cognitive therapy and interpersonal psychotherapy for major depressive disorder.

BACKGROUND: Major depressive disorder (MDD) has a highly recurrent nature. After successful treatment, it is important to identify individuals who are at risk of an unfavorable long-term course. Despite extensive research, there is no consensus yet on the clinically relevant predictors of long-term outcome in MDD, and no prediction models are implemented in clinical practice. The aim of this study was to create a prognostic index (PI) to estimate long-term depression severity after successful and high quality acute treatment for MDD. METHODS: Data come from responders to cognitive therapy (CT) and interpersonal psychotherapy (IPT) in a randomized clinical trial (n = 85; CT = 45, IPT = 40). Primary outcome was depression severity, assessed with the Beck Depression Inventory II, measured throughout a 17-month follow-up phase. We examined 29 variables as potential predictors, using a model-based recursive partitioning method and bootstrap resampling in conjunction with backwards elimination. The selected predictors were combined into a PI. Individual PI scores were estimated using a cross-validation approach. RESULTS: A total of three post-treatment predictors were identified: depression severity, hopelessness, and self-esteem. Cross-validated PI scores evidenced a strong correlation (r = 0.60) with follow-up depression severity. CONCLUSION: Long-term predictions of MDD are multifactorial, involving a combination of variables that each has a small prognostic effect. If replicated and validated, the PI can be implemented to predict follow-up depression severity for each individual after acute treatment response, and to personalize long-term treatment strategies.

Changing character: A narrative review of personality change in psychotherapies for personality disorder.

Objective: Personality disorder (PD) is a negative prognostic indicator for treatment, and absolute improvements in functioning among these patients are often modest. This may be because personality features that give rise to dysfunction in PD are not targeted optimally during most treatments. Method: Attachment, mentalization, core beliefs, and personality organization/defense use were identified as personality constructs that have been pursued in treatment studies and that are proposed to underlie PD. Results: All constructs correlate with psychiatric symptoms, PD diagnosis, and functioning. Defense mechanisms and core beliefs further distinguish specific PDs, whereas personality organization separates more versus less severe PDs. Evidence from treatment and naturalistic studies indicate that maturation of defense mechanisms temporally precedes improvements in symptoms and functioning. Changes in attachment and mentalization correlate with some outcomes, but mediation of improvement has not been established. In psychodynamic therapy, transference interpretations may promote amelioration of personality dysfunction. With the exception of attachment, the experimental literature is lacking that could explicate the mechanisms by which these personality constructs maintain psychosocial dysfunction. Conclusions: Future research should aim to identify changes in these mechanisms that mediate positive outcomes in PD, as well as the specific therapeutic procedures that best promote positive change in PD.

Focus is key: Panic-focused interpretations are associated with symptomatic improvement in panic-focused psychodynamic psychotherapy.

Objective: This study examines whether, in panic-focused psychodynamic psychotherapy (PFPP), interpretations of conflicts that underlie anxiety (panic-focused or PF-interpretations) are specifically associated with subsequent panic disorder (PD) symptom improvement, over and above the provision of non-symptom-focused interpretations. Method: Technique use in Sessions 2 and 10 of a 24-session PFPP protocol was assessed for the 65 patients with complete outcome data randomized to PFPP in a two-site trial of psychotherapies for PD. Sessions were rated in 15-min segments for therapists' use of PF-interpretations, non-PF-interpretations, and PF-clarifications. Robust regressions were conducted to examine the relationship between these interventions and symptom change subsequent to the sampled session. Interpersonal problems were examined as a moderator of the relationship of PF-interpretations to symptom change. Results: At Session 10, but not at Session 2, patients who received a higher degree of PF-interpretations experienced greater subsequent improvement in panic symptoms. Non-PF-interpretations were not predictive. Patients with more interpersonal distress benefitted particularly from the use of PF-interpretations at Session 10. Conclusions: By the middle phase of PFPP, panic-focused interpretations may drive subsequent improvements in panic symptoms, especially among patients with higher interpersonal distress. Interpretations of conflict absent a panic focus may not be especially helpful.

What is the effect on comorbid personality disorder of brief panic-focused psychotherapy in patients with panic disorder?

BACKGROUND: No studies of psychotherapies for panic disorder (PD) have examined effects on comorbid personality disorders (PersD), yet half such patients have a PersD. METHODS: In a randomized trial for PD with and without agoraphobia comparing Cognitive-Behavioral Therapy (CBT) and Panic-Focused Psychodynamic Psychotherapy (PFPP), PersD was assessed pre-to-post treatment with the Structured Clinical Interview for the Diagnosis of Axis-II Disorders (SCID-II). For patients completing therapy (n = 118, 54 with PersD), covariance between panic and SCID-II criteria improvements was analyzed. SCID-II diagnostic remission and recovery were evaluated. Comparative efficacy of PFPP versus CBT for improving PersD was analyzed both for the average patient, and as a function of PersD severity. RESULTS: 37 and 17% of PersD patients experienced diagnostic PersD remission and recovery, respectively. Larger reductions in PersD were related to more panic improvement, with a modest effect size (r = 0.28). Although there was no difference between treatments in their ability to improve PersD for the average patient (d = 0.01), patients meeting more PersD criteria did better in PFPP compared to CBT (P = .007), with PFPP being significantly superior at 11 criteria and above (d = 0.66; 3 more criteria lost). CONCLUSIONS: PersD presenting in the context of primary PD rarely resolves during psychotherapies focused on PD, and change in PersD only moderately tracks panic improvements, indicating non-overlap of the constructs. Patients receiving panic-focused psychotherapies may require additional treatment for their PersD. PFPP may be superior at improving severe PersD, but replication of this finding is required.

In rape trauma PTSD, patient characteristics indicate which trauma-focused treatment they are most likely to complete.

BACKGROUND: Dropout rates for effective therapies for posttraumatic stress disorder (PTSD) can be high, especially in practice settings. Although clinicians have intuitions regarding what treatment patients may complete, there are few systematic data to drive those judgments. METHODS: A multivariable model of dropout risk was constructed with randomized clinical trial data (n = 160) comparing prolonged exposure (PE) and cognitive processing therapy (CPT) for rape-induced PTSD. A two-step bootstrapped variable selection algorithm was applied to identify moderators of dropout as a function of treatment condition. Employing identified moderators in a model, fivefold cross-validation yielded estimates of dropout probability for each patient in each condition. Dropout rates between patients who did and did not receive their model-indicated treatment were compared. RESULTS: Despite equivalent dropout rates across treatments, patients assigned to their model-indicated treatment were significantly less likely to drop out relative to patients who did not (relative risk = 0.49 [95% CI: 0.29-0.82]). Moderators included in the model were: childhood physical abuse, current relationship conflict, anger, and being a racial minority, all of which were associated with higher likelihood of dropout in PE than CPT. CONCLUSIONS: Individual differences among patients affect the likelihood they will complete a particular treatment, and clinicians can consider these moderators in treatment planning. In the future, treatment selection models could be used to increase the percentage of patients who will receive a full course of treatment, but replication and extension of such models, and consideration of how best to integrate them into routine practice, are needed.

The Generalizability of Randomized Controlled Trials of Self-Guided Internet-Based Cognitive Behavioral Therapy for Depressive Symptoms: Systematic Review and Meta-Regression Analysis.

BACKGROUND: Self-guided internet-based cognitive behavioral therapies (iCBTs) for depressive symptoms may substantially increase accessibility to mental health treatment. Despite this, questions remain as to the generalizability of the research on self-guided iCBT. OBJECTIVE: We sought to describe the clinical entry criteria used in studies of self-guided iCBT, explore the criteria's effects on study outcomes, and compare the frequency of use of these criteria with their use in studies of face-to-face psychotherapy and antidepressant medications. We hypothesized that self-guided iCBT studies would use more stringent criteria that would bias the sample toward those with a less complex clinical profile, thus inflating treatment outcomes. METHODS: We updated a recently published meta-analysis by conducting a systematic literature search in PubMed, MEDLINE, PsycINFO, and EMBASE. We conducted a meta-regression analysis to test the effect of the different commonly used psychiatric entry criteria on the treatment-control differences. We also compared the frequency with which exclusion criteria were used in the self-guided iCBT studies versus studies of face-to-face psychotherapy and antidepressants from a recently published review. RESULTS: Our search yielded 5 additional studies, which we added to the 16 studies identified by Karyotaki and colleagues in 2017. Few self-guided iCBT studies excluded patients with severe depressive symptoms (6/21, 29%), but self-guided iCBT studies were more likely than antidepressant (14/170, 8.2%) studies to use this criterion. However, self-guided iCBT studies did not use this criterion more frequently than face-to-face psychotherapy studies (6/16, 38%). Beyond this, we found no evidence that self-guided iCBTs used more stringent entry criteria. Strong evidence suggested that they were actually less likely to use most entry criteria, especially exclusions on the basis of substance use or personality pathology. None of the entry criteria used had an effect on outcomes. CONCLUSIONS: A conservative interpretation of our findings is that the patient population sampled in the literature on self-guided iCBT is relatively comparable with that of studies of antidepressants or face-to-face psychotherapy. Alternatively, studies of unguided cognitive behavioral therapy may sample from a more heterogeneous and representative patient population. Until evidence emerges to suggest otherwise, the patient population sampled in self-guided iCBT studies cannot be considered as less complex than the patient population from face-to-face psychotherapy or antidepressant studies.

Fluctuations in alliance and use of techniques over time: A bidirectional relation between use of "common factors" techniques and the development of the working alliance.

OBJECTIVE: The aim of this study was twofold: (a) Investigate whether therapists are consistent in their use of therapeutic techniques throughout supportive-expressive therapy (SET) and (b) Examine the bi-directional relation between therapists' use of therapeutic techniques and the working alliance over the course of SET. METHOD: Thirty-seven depressed patients were assigned to 16 weeks of SET as part of a larger randomized clinical trial (Barber, Barrett, Gallop, Rynn, & Rickels, ). Working Alliance Inventory-Short Form (WAI-SF) was collected at Weeks 2, 4, and 8. Use of therapeutic interventions was rated by independent observers using the Multitheoretical List of Therapeutic Interventions (MULTI). Intraclass correlation coefficients assessed therapists' consistency in use of techniques. A cross-lagged path analysis estimated the working alliance inventory- Multitheoretical List of Therapeutic Interventions bidirectional relation across time. RESULTS: Therapists were moderately consistent in their use of prescribed techniques (psychodynamic, process-experiential, and person-centred). However, they were inconsistent, or more flexible, in their use of "common factors" techniques (e.g., empathy, active listening, hope, and encouragements). A positive bidirectional relation was found between use of common factors techniques and the working alliance, such that initial high levels of common factors (but not prescribed) techniques predicted higher alliance later on and vice versa. CONCLUSION: Therapists tend to modulate their use of common factors techniques across treatment. Additionally, when a strong working alliance is developed early in treatment, therapists tend to use more common factors later on. Moreover, high use of common factors techniques is predictive of later improvement in the alliance.

Goldilocks on the couch: Moderate levels of psychodynamic and process-experiential technique predict outcome in psychodynamic therapy.

OBJECTIVES: Greater symptom change is often assumed to follow greater technique use, a "more is better" approach. We tested whether psychodynamic techniques, as well as common factors and techniques from other orientations, had a curvilinear relation to outcome (i.e., whether moderate or "just right" intervention levels predict better outcome than lower or higher levels). METHODS: For 33 patients receiving supportive-expressive psychodynamic psychotherapy for depression, interventions were assessed at Week 4 using the multitheoretical list of therapeutic interventions and symptoms were rated with the Hamilton Rating Scale for Depression. RESULTS: Moderate psychodynamic and experiential techniques predicted greater symptom change compared to lower or higher levels. CONCLUSION: This "Goldilocks effect" suggests a more complex relation of intervention use to outcome might exist.

A systematic review of the association between interpretations and immediate, intermediate, and distal outcomes.

Interpretations are a hallmark of psychodynamic treatment and a method used in other theoretical orientations as well. Therapists use interpretations to increase patients' insight concerning unconscious and preconscious elements in their lives, with the ultimate aim to reduce mental pain and suffering and improve mental health. This systematic review focuses on the association between the therapists' use and accuracy of interpretation and immediate (within-session), intermediate (between-session), and distal (end-of-treatment) outcomes. This synthesis of the research literature is based on 18 independent samples of 1,011 total patients in individual psychotherapy. The results suggest that the use and accuracy of interpretations were associated, in half the studies, with patient disclosure of emotions and increased insight at the immediate, moment-to-moment enfolding of the session. At the intermediate postsession outcome, the use of interpretations was associated with a stronger alliance and greater depth, in half the studies. At the end of treatment, however, while there is some evidence for a positive effect of the use of interpretations on treatment success, there are also neutral effects and even evidence that interpretations have the potential to be harmful in some particular situations. The article concludes with training implications and therapeutic practices based on the integration of clinical experience and research evidence. (PsycInfo Database Record (c) 2023 APA, all rights reserved).