"The early bird catches the worm"-Prediction of early response and its importance for treatment outcome in a naturalistic setting of cognitive behaviour therapy.

OBJECTIVE: Knowledge about predictors of early response (ER) remains limited. This study examined patient, process, and therapist variables to predict ER in a naturalistic setting. RESEARCH DESIGN AND METHODS: Data from 493 psychotherapy outpatients were analysed. ER was defined by a ≥25% reduction in general psychological distress (ER percent) and by the reliable change index (ER RCI) within the first 10 sessions measured by the Brief Symptom Inventory-18. ER prediction was determined using logistic regression. General psychological distress (GSI) throughout treatment in patients with and without ER was modelled using a multilevel linear model. This model aimed to predict GSI over treatment using repeated measurements, considering group affiliation (ER percent vs. no ER percent), controlled for other predictors. RESULTS: The prevalence of ER percent and ER RCI were 63.6% and 47.5%, respectively. GSI and therapeutic relationship significantly predicted ER (ER percent: χ2 (6) 70.32, p < .001, Nagelkerkes R2 = .19; ER RCI: χ2 (6) 134.71, p < .001, Nagelkerkes R2 = .35). Patients who rated the therapeutic relationship more positively were more likely to achieve ER (OR = 1.10). Difference in outcomes between patients with and without ER during treatment was influenced by factors such as therapeutic relationship, GSI, therapist experience, and mental comorbidities. Including these variables improved the predictive model from AIC = 17,042.98 to AIC = 16,730.24. CONCLUSION: The therapeutic relationship is a crucial predictor of ER. Patients achieving ER tend to have better outcome than those without ER. The early phase of therapy warrants particular attention to enhance psychotherapy outcomes.

Lessons from ten years of psychotherapy process research.

Objective: The aim of this review is to systematize and interpret results produced over one decade of Psychotherapy Process Research (2009-2019) in eight journals. Method: It is a Mixed Studies Review of quantitative as well as qualitative primary studies. The analysis of the results of these studies included a descriptive quantitative part and a qualitative part that followed the logic of Qualitative Meta Analysis, categorizing the main results of both types of studies in a bottom-up procedure that generates specific content categories that are synthesized in further steps of a higher level of abstraction, leading to an "interpretive synthesis" presented in a narrative way. Results: The review shows that psychotherapy process research uses a variety of qualitative and quantitative methods, often creating new procedures. Furthermore, the review indicates that the most commonly assessed macroprocess variables are ongoing change, therapeutic relationship (predominantly therapeutic alliance), and therapeutic intervention; while the most extensively studied microprocess variables are change events, difficult episodes (mainly ruptures), and therapeutic intervention. Macrolevel results reveal that the main contents of ongoing change are the building of new meanings and progressive psychological integration; underscore the association of the therapeutic alliance with ongoing change and outcome; and show the complexity of associating intervention with outcome, because different phases of therapy (and problems) need different assessments. Microlevel results indicate that change events impact on ongoing change and outcome; that for ruptures the key fact is their repair; and that therapist communication has an immediate influence on patient communication. Conclusion: Our knowledge regarding relevant aspects of psychotherapy is very fragmented; robust and replicated results are still scarce. Only a few variables have been found to consistently predict outcome across most therapies. Only in the field of alliance research it has been possible to perform meta-analyses that clearly demonstrate the impact of this factor on final outcomes. Despite these limitations, psychotherapy process research is a powerful tool for uncovering change mechanisms and is at present widely implemented. Our conclusion is that, in order to generate useful future knowledge, change mechanisms need to be linked to ongoing change; this, in turn, requires models of change, hopefully of a transtheoretical nature.

Pretreatment insight as a predictor of alliance strengthening in supportive vs. supportive-expressive treatment.

OBJECTIVE: The available literature points to the potential therapeutic benefits of alliance strengthening during treatment. Both supportive and expressive techniques have been suggested to be associated with strengthening of the alliance. The present study investigates whether patients may show different effects of supportive vs. expressive techniques in improving alliance as a function of their pretreatment insight levels. METHOD: Fifty-five patients were randomly assigned to either supportive treatment (ST) or supportive-expressive treatment (SET), as part of a larger randomized controlled trial. Clinical interviews were administered at pretreatment to evaluate the patients' level of insight. The working alliance was measured after each of the 16 sessions. A multilevel model, including a 3-way interaction of pretreatment insight by treatment condition (ST vs. SET) by time, was used to predict alliance strengthening. RESULTS: The findings suggest that, for individuals receiving ST, those with higher levels of insight show greater alliance strengthening. For individuals receiving SET, those with lower levels of insight show greater alliance strengthening. CONCLUSION: The current study suggests that one size may not fit all and, whereas some individuals may benefit more from ST to achieve alliance strengthening, others may benefit more from SET.

Good-Enough Therapy: A Review of the Empirical Basis of Good Psychiatric Management.

In this review, the question of whether good psychiatric management (GPM) has a sufficient, or good-enough, evidence base is examined from two complementary perspectives. First, the author reviews research that has investigated whether GPM reduces symptoms of borderline personality disorder. Analyses at the group and individual levels have indicated that symptoms may decrease among patients receiving GPM. Second, the author reviews research that has investigated the processes through which change occurs in GPM. Studies that have shown process changes toward emotional balance, interpersonally effective functioning, and a more coherent and reality-based autobiographical narrative are discussed. To fully answer the question of whether GPM is good enough, more controlled trials are needed to demonstrate effectiveness, mechanisms of change, and broad implementation in culturally diverse populations.

An Active Inference Agent for Modeling Human Translation Processes.

This paper develops an outline for a hierarchically embedded architecture of an artificial agent that models human translation processes based on principles of active inference (AIF) and predictive processing (PP). AIF and PP posit that the mind constructs a model of the environment which guides behavior by continually generating and integrating predictions and sensory input. The proposed model of the translation agent consists of three processing strata: a sensorimotor layer, a cognitive layer, and a phenomenal layer. Each layer consists of a network of states and transitions that interact on different time scales. Following the AIF framework, states are conditioned on observations which may originate from the environment and/or the embedded processing layer, while transitions between states are conditioned on actions that implement plans to optimize goal-oriented behavior. The AIF agent aims at simulating the variation in translational behavior under various conditions and to facilitate investigating the underlying mental mechanisms. It provides a novel framework for generating and testing new hypotheses of the translating mind.

Technical and relational process in MI sessions with a sample of Hispanic/Latinx adults who engage in heavy drinking: A latent growth mediation model.

The current study tests the Motivational Interviewing (MI) technical and relational hypotheses in a sample of Hispanic/Latinx adults (N = 276) who engage in heavy alcohol consumption. MI causal theory hypothesizes that therapist use of MI consistent skills (i.e., technical hypothesis) and embodiment of the MI Spirit (i.e., relational hypothesis) will elicit client change talk, which is a putative mechanism of positive client outcome after the session. We tested these associations in a rigorous parallel process latent growth curve mediation modeling framework. The data are from a completed randomized clinical trial of a culturally-adapted (CAMI) versus un-adapted MI targeting hazardous alcohol use and consequences. Results. The unconditional growth models for the mediator (i.e., proportion of change talk relative to sustain talk) and two study outcomes (i.e., percent of heavy drinking days; alcohol-related consequences) showed a linear effect over a 12-month period with a slower rate of growth at later timepoints. Contrary to expectations, the latent growth mediation models did not show relationships between MI-consistent skills (i.e., technical predictor) or latent MI Spirit (i.e., relational indicator) and the slope factor for proportion change talk. The slope factor for proportion change talk was also not associated with the slope factors for percent heavy drinking and consequences over follow-up. Conclusions. In this novel population for MI process analysis, the technical and relational hypotheses were not supported. Studies that are exploratory may be needed to further investigate the causal model in populations that are not often represented in MI process research.

Patient perspectives on working with preferences in psychotherapy: A consensual qualitative research study.

OBJECTIVE: Assessing and accommodating patient preferences is integral to evidence-based practice. This qualitative study sought to explore patient perspectives and experiences of preference work in psychotherapy. METHODS: Participants were 13 UK-based patients who had completed up to 24 sessions of a collaborative-integrative psychotherapy. Ten participants identified as female and three as male. Interviews were conducted at endpoint and analyzed using a team-based, consensual qualitative research approach. RESULTS: Three superordinate domains were developed: Preferences Themselves, Process of Working with Preferences in Psychotherapy, and Effect of Preference Work (or its Absence). Patients typically wanted leadership, challenge, and input from their psychotherapist, and an affirming style. Patients attributed the origin of their preferences to personal history, characteristics, or circumstances; the present psychotherapy; or past episodes of psychotherapy. Some preferences changed over time. Preference work was described as having positive effects on the therapeutic relationship and patients' intrapersonal worlds; however, variantly, non-accommodation of preferences was also experienced as beneficial. CONCLUSION: Our findings provide in-depth answers to a range of novel questions on preference work-potential mechanisms by which preference work impacts outcomes, factors that may facilitate preference work, and origins of preferences-as well as nuancing previously-established quantitative findings. Implications for clinical training and practice are discussed.

The therapeutic effects of the therapists' ability to pass their patients' tests in psychotherapy.

Introduction According to Control-Mastery Theory (CMT)-a cognitive-dynamic relational theory of mental functioning, psychopathology, and psychotherapy-patients come to therapy with an unconscious plan to disprove their pathogenic beliefs and achieve adaptive goals. One of the primary ways patients work to disconfirm their pathogenic beliefs is by testing them within the therapeutic relationship. Objectives: The present study aimed to replicate and expand the results of previous studies suggesting that therapists' responses that disconfirmed patient's pathogenic beliefs were predictive of patients' within-session progress. Moreover, we wanted to investigate whether these interventions correlated with the therapeutic alliance. Methods: Transcriptions of 81 sessions from five brief psychodynamic psychotherapies were assessed by 11 independent raters. For each case, the patient's plan was formulated and tests identified, the accuracy of the therapist's responses to these tests was rated, and the impact of the therapist's interventions on the patient's subsequent communications and their relationship with the therapeutic alliance was measured. Results: The results supported the central hypothesis of the CMT that when the therapist's interventions passed the patient's tests, the patient showed signs of improvement. Moreover, the ability of the therapist to pass the patient's tests correlated with the therapeutic alliance. Conclusions: The clinical implications and the limitations of these findings are discussed, together with the relevance of a good case formulation for clinicians' optimal responsiveness.

Psychotherapy with older adults: Ageism and the therapeutic process.

Objective This study explores how ageism in therapists is manifested in psychotherapy with older adults and how therapists deal with its impact on their therapeutic work. Method: Semi-structured interviews were conducted with 14 therapists and analyzed using grounded theory methodology. Results: Findings clustered around two themes: (i) maintaining openness to change while acknowledging limitations; (ii) dealing with manifestations of ageism inside therapy by going beyond relating to older patients only in terms of their chronological age. Conclusions: Our findings indicate that while therapists maintain an optimistic view regarding the possibility of therapeutic change, the therapeutic encounter with older patients triggers certain ageist therapeutic biases and behaviors in therapists, even in experienced therapists who have competency in working with older adults. Our findings also indicate that dealing with therapists' ageism in psychotherapy with older patients requires therapists not only to be aware in advance of their ageist attitudes but also to continuously engage in the management of the manifestations of ageism inside treatment. We use the conceptual framework of countertransference to suggest an understanding of the relationship between therapists' ageism and the therapeutic process. Implications for training and practice are discussed.

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.

Engaging with difficult topics and emotional experiences in psychotherapy: A study of helpful therapist acts.

OBJECTIVE: The purpose of this study was to explore moments during psychotherapy sessions in which clients experience that they have an opportunity to approach and engage with difficult topics and emotional experiences, with the aim of describing therapists' acts that support clients' in-session engagement. METHODS: Two treatment sessions of 11 participants were videotaped and immediately followed by an in-depth semi-structured interview, using the interpersonal process recall (IPR) interview method. A follow-up interview was conducted 3 months after the final IPR interview. Participants' accounts were analyzed using thematic analyses. RESULTS: Five themes of engagement-supportive acts resulted from our analyses: 1. inviting the client by showing acceptance; 2. recognizing the clients' hints and try-out signs; 3. providing information on the process and evaluating clients' expectations; 4. actively helping the clients to notice and stay with difficult experience and 5. showing sensitivity to the client's needs for micropauses. We discuss these themes as acts of recognition. CONCLUSION: Clients found it was engagement-supportive when therapists implicitly and explicitly recognized the challenges of being in psychotherapy. This recognition could be achieved through the engagement-supportive acts described in the five themes. Therapists should continually make space for and seek a balance between different engagement-supportive acts.

Models of the Translation Process and the Free Energy Principle.

Translation process research (TPR) has generated a large number of models that aim at explaining human translation processes. In this paper, I suggest an extension of the monitor model to incorporate aspects of relevance theory (RT) and to adopt the free energy principle (FEP) as a generative model to elucidate translational behaviour. The FEP-and its corollary, active inference-provide a general, mathematical framework to explain how organisms resist entropic erosion so as to remain within their phenotypic bounds. It posits that organisms reduce the gap between their expectations and observations by minimising a quantity called free energy. I map these concepts on the translation process and exemplify them with behavioural data. The analysis is based on the notion of translation units (TUs) which exhibit observable traces of the translator's epistemic and pragmatic engagement with their translation environment, (i.e., the text) that can be measured in terms of translation effort and effects. Sequences of TUs cluster into translation states (steady state, orientation, and hesitation). Drawing on active inference, sequences of translation states combine into translation policies that reduce expected free energy. I show how the notion of free energy is compatible with the concept of relevance, as developed in RT, and how essential concepts of the monitor model and RT can be formalised as deep temporal generative models that can be interpreted under a representationalist view, but also support a non-representationalist account.

Two kinds of sudden gains in brief psychotherapy.

OBJECTIVE: Sudden gains (SGs) are known to predispose to good outcome in psychotherapy, especially in brief treatment. However, some SGs may be illusory, in the sense that they arise from measurement error in the context of gradual change. We examined change before, during, and after SGs that were either true or illusory. METHOD: In a sample of 1,867 university students treated with brief psychotherapy, we simulated session data as gradually changing score sequences, identified artifactual SGs therein, and utilized the simulated data to categorize actual participant SGs as either illusory or true. RESULTS: During treatment, participants with illusory SGs (N = 42) improved as much as did participants with true SGs (N = 67). Moreover, late in treatment participants with SGs and their matched controls improved at similar rates. True SGs were preceded by more distress and were larger than illusory SGs. Among participants with true SGs, very large SGs were more likely to reverse later in treatment. CONCLUSIONS: Relatively small SGs may reflect measurement error. When brief psychotherapy patients deteriorate early in treatment but then suddenly experience substantial improvement, little further change is to be expected.

[Mentalization ability and treatment success in psychosomatic rehabilitation]. / Mentalisierungsfähigkeit und Behandlungserfolg in der Psychosomatischen Rehabilitation.

Objectives: Psychosomatic rehabilitation clinics represent an important branch of care with good treatment results in Germany. So far, however, it is largely unclear which processes underlie the treatment successes. In the partial evaluations of the Hersfeld catamnesis study presented here, recourse is made to the construct of mentalizing ability, which has become very important in recent psychotherapy research. Methods: The mentalization ability of a large sample (N = 559) was assessed with the help of the Mentalization Questionnaire (MZQ), and psychological and somatic complaints were assessed with HEALTH-PSB scale from HEALTH-49 at three points in time, namely at admission, at discharge and in a 6-month catamnesis. Results: Both the total score of the MZQ and all subscores show significant reductions in mentalization deficits in the small effect size range, the HEALTH-PSB in the high effect size range and the catamnesis in the medium effect size range. A regression analysis shows that the reduction in mentalization deficits has a high predictive power for symptom improvement. Conclusions: The results indicate that the construct of mentalization ability is a central target variable in psychosomatic rehabilitation.

Patient motivation in group metacognitive therapy for generalized anxiety disorder.

OBJECTIVE: The aim of this study was to investigate the predictive value of motivational language (change talk [CT] and sustain talk [ST]) on treatment outcome of group metacognitive therapy (g-MCT) for generalized anxiety disorder (GAD). METHOD: Video recordings of the first, fourth, and seventh therapy sessions (55 patients) were encoded using the Motivational Interviewing Skill Code (MISC) manual. The strength of the patients' motivational utterances was encoded as CT or ST with seven subcategories. RESULTS: The strength of CT-utterances and ST-utterances differed significantly between treatment responders and non-responders as therapy progressed. The strength of ST-utterances increased significantly more among non-responders than responders, whereas CT and positive taking steps utterances increased more among treatment responders than non-responders. CT and ST in session 1 were not associated with treatment outcome. CT and ST in sessions 4 and 7 significantly predicted lower and higher worry-scores at post-treatment, respectively. This effect was particularly evident for taking steps utterances in session 7. CONCLUSION: These findings confirm the predictive value of MISC in sessions 4 and 7 of g-MCT for GAD and highlight the importance of therapists addressing patient motivation.

Addressing interpersonal patterns in patients with personality disorders partially explains psychotherapy outcome via changes in interaction patterns: A mediation analysis.

Objective Many patients with personality disorders (PDs) present with problematic interaction patterns. These may also manifest in the therapeutic relationship. For successful treatment, therapists must therefore find effective ways to address such problematic interaction patterns. Methods: A total of 382 patients with PDs were recruited within a naturalistic setting and received integrative cognitive-behavioral therapy (CBT). Two subscales of the observer-rated Process-Content-Relationship Scale were applied to sessions 15, 20, and 25 of treatment: one on patient interaction patterns and the other on therapist addressing these. Symptom severity was assessed at intake and discharge. Mediation analysis was applied. Results: We found significant main effects of (1) therapists' addressing problematic interaction patterns in session 15 on patients' changes in such patterns from session 15 to 25 and (2) patients' changes in problematic interaction patterns on symptom severity at treatment termination. Further, the effect of therapists' addressing problematic interaction patterns on outcome was mediated by changes in patients' interaction patterns. Conclusion: The results indicate that therapists' addressing of PD patients' problematic interaction patterns may be particularly important to improve such patterns and thereby treatment outcome. Future research should identify in which patients the mechanism of addressing interaction patterns works best.

Emotional processing during the therapy for complicated grief.

OBJECTIVE: Prior research, mainly conducted on depression, observed that clients' improved capability to process their emotions predicted better therapeutic outcomes. The current comparative study aimed to investigate whether emotional processing was related to therapeutic change in complicated grief. METHOD: We analyzed two contrasting cases (good or poor outcome) treated with grief constructivist therapy. In both cases we investigated the association of emotional processing (Experiencing Scale) to (1) therapeutic outcome (Inventory of Complicated Grief), and (2) change in the type of grief-related emotions (Emotions Episodes). RESULTS: The session-by-session growth of clients' emotional processing and the change of grief-related emotions were qualitatively explored throughout both cases. Compared with the poor outcome case, the good outcome case achieved more improvement in the ability to process emotions. Such improvement occurred alongside a deeper change in the type of grief-related emotions aroused, from maladaptive to more adaptive responses. CONCLUSION: Our findings suggest that a higher emotional processing capability may be associated with the transformation of grief-related maladaptive emotions and with the improvement of complicated grief condition.

"What shall we focus on?" - A thematic analysis of what characterizes cognitive-behavior therapy sessions with high or low quality of working alliance.

OBJECTIVE: Several studies have shown that the quality of the working alliance predicts symptomatic improvement session-by-session, including in cognitive-behavioral therapy (CBT). We wanted to explore what characterizes CBT sessions with high and low alliances further using qualitative analysis. METHOD: Ten CBT-sessions were selected from eight patients' therapies in a larger research project on psychotherapy for patients with major depression. Five sessions were chosen from high- and five from low-alliance sessions, based on therapist- and patient-reported Working Alliance Inventory scores. Transcripts of these sessions were analyzed using thematic analysis. RESULTS: The analysis yielded four themes, each structured into two sub-themes: Therapist style, Person in focus, Content focus, and Therapeutic direction. In contrast to low-alliance sessions, high-alliance sessions were characterized by a more exploring as opposed to expert therapist style; a focus on the patient's thoughts, feelings, and behavior, rather than a diffuse focus or a focus on other people's actions/external events; and a sense of moving forward rather than stagnation. CONCLUSION: Our qualitative analysis showed theoretically and clinically meaningful processes in CBT sessions of high- vs low working alliance. This method is a useful complement to quantitative within-patient analyses, to expand on the meaning of quantitative findings.

Matching research and practice: Prediction of individual patient progress and dropout risk for basic routine outcome monitoring.

OBJECTIVE: Despite evidence showing that systematic outcome monitoring can prevent treatment failure, the practical conditions that allow for implementation are seldom met in naturalistic psychological services. In the context of limited time and resources, session-by-session evaluation is rare in most clinical settings. This study aimed to validate innovative prediction methods for individual treatment progress and dropout risk based on basic outcome monitoring. METHODS: Routine data of a naturalistic psychotherapy outpatient sample were analyzed (N = 3902). Patients were treated with cognitive behavioral therapy with up to 95 sessions (M = 39.19, SD = 16.99) and assessment intervals of 5-15 sessions. Treatment progress and dropout risk were predicted in two independent analyses using the nearest neighbor method and least absolute shrinkage and selection operator regression, respectively. RESULTS: The correlation between observed and predicted patient progress was r = .46. Intrinsic treatment motivation, previous inpatient treatment, university-entrance qualification, baseline impairment, diagnosed personality disorder, and diagnosed eating disorder were identified as significant predictors of dropout, explaining 11% of variance. CONCLUSIONS: Innovative outcome prediction in naturalistic psychotherapy is not limited to elaborated progress monitoring. This study demonstrates a reasonable approach for tracking patient progress as long as session-by-session assessment is not a valid standard.

Integrating theory-based and data-driven methods to case conceptualization: A functional analysis approach with ecological momentary assessment.

Objective Ecological momentary assessment (EMA) and network analysis are promising empirical developments for psychotherapy research and practice, but they lack a therapeutic rationale that could guide case conceptualization and treatment planning. We developed an assessment strategy that aims to assess functional analysis with EMA. Method: The assessment strategy was applied to a series of three N-of-1 assessments in a proof-of-concept study. After selecting a personalized set of items, EMA was implemented with three measurement time points per day for a period of 30 days. The participants evaluated feasibility and acceptance. Practicing psychotherapists discussed clinical implications in a focus group. Results: The implementation of the assessment strategy seemed feasible and accepted; participants did not report any side effects. Principal component and network analyses indicated interpretable components (e.g., participant 1: hopelessness, procrastination, coping, avoidance). The focus group pointed out potentials (e.g., efficient profit of the waiting time, empowering patients) and challenges (e.g., prioritize and interpret all the information). Conclusion: The presented assessment strategy may enhance the scientific quality of case conceptualization empowering therapists' decision-making regarding treatment planning. At the same time, it is a concrete demonstration of the challenges that need to be addressed in future research.