The Revised Pathogenic Beliefs Scale: A Transtheoretical Measure of Maladaptive Beliefs That Are Associated with Psychological Distress.

Pathogenic beliefs are maladaptive cognitive schema that may obstruct a person's ability to achieve meaningful goals in their life. This study sought to revise a previously existing measure of pathogenic beliefs (the Pathogenic Beliefs Scale) by improving the quality of items and separating the ratings of the presence of a pathogenic belief from the distress associated with it. In Study 1 (n = 272), we used item-response theory to identify 21 items from an initial pool of 44 items. In Study 2 (n = 422), we tested the items from Study 1 using confirmatory factor analysis. Study 3 used the combined samples from Study 1 and Study 2 (total n = 528) to compare the revised measure to the Experiences in Close Relationships and the Measure of Parental Style. Results indicate that the revised 21-item PBS has good reliability and convergent validity with related measures, consistent with previous studies of the longer version of the PBS. The 21-item revised PBS is included as supplemental material, and freely available to clinicians and researchers.

Development of a psychotherapy process prototype for the Real Relationship.

OBJECTIVE: The Real Relationship (RR) describes the aspect of the psychotherapy relationship that is based on a genuine connection and a realistic view between patient and therapist. In the current study, we aimed to develop a Psychotherapy Process Q-set (PQS) prototype of the RR to facilitate post-hoc assessment of the RR in psychotherapy session recordings. We also aimed to measure the association between the RR-PQS and current PQS measures of theoretical treatment principles and the working alliance. METHOD: We developed an RR-PQS prototype based on ratings of an ideal RR session by eight RR experts. We assessed the associations between the RR-PQS and existing cognitive behavioral and psychodynamic process prototypes, and seven PQS items known to predict the working alliance. RESULTS: RR experts agreed on the ideal RR session ratings to a high degree (ICC = 0.89). The RR-PQS was moderately related to both cognitive behavioral (r = 0.66, p < 0.01), and psychodynamic prototypes (r = 0.56, p < 0.01). PQS items predictive of the working alliance were characteristic of the RR-PQS. CONCLUSION: The RR-PQS prototype appears to behave in theoretically predicted ways and may be a valid measure of the RR.

Development of a new observer-rated measure to assess the real relationship in psychotherapy sessions.

OBJECTIVES: Real relationship (RR) refers to a genuine human relationship between client and therapist, that has been found to be positively related to treatment outcome, and to predict unique variance in outcome over and above the working alliance. However, thus far, the measurement of RR has been limited to self-report. We aimed to develop an observer-rated version of the RR measure (RR-O) to assess RR in therapy sessions. METHODS: We adapted items from the self-report measures to an observer rated measure, which was reviewed by RR experts. The final 24-item RR-O was rated in 540 session transcripts from 27 psychoanalytic treatments that already had existing process and outcome scores. RESULTS: The RR-O showed good internal consistency and good interrater reliability. In hierarchical EFA, items clustered into a general RR factor, and client realism, client genuineness, therapist genuineness, and therapist realism group factors. In addition, the RR-O was positively related to another RR measure and to the therapeutic alliance. CONCLUSION: The RR-O shows initial reliability and validity as an observer-rated measure of the RR to be used in post-hoc psychotherapy research. Future research should clarify the relation between RR-O and treatment outcome.

Implicit relational aspects of the therapeutic relationship in psychoanalytic treatments: an examination of linguistic style entrainment over time.

OBJECTIVE: In an attempt to operationalize an implicit aspect of the therapeutic relationship, this study assesses reciprocal linguistic style entrainment (rLSM) between the patient and therapist. rLSM is defined as the dynamic adjustment of function word usage to synchronize or to be in rhythm with another person as they change over time. METHOD: In this exploratory study, levels of rLSM per talk turn were analyzed for 540 sessions of 27 long-term psychoanalytic treatments in relation to treatment outcomes. RESULTS: Within sessions, rLSM appeared to decrease by the end of sessions and followed a negative linear trajectory, ßlinear = -0.0002, SE < .001, t = -13.04, p < .001. Between sessions, rLSM showed significant variability such that neither a linear, nor a quadratic, nor a cubic trend line fit the session-by-session change over treatment. On average, therapist talk turns had significantly lower rLSM than patient talk turns, while accounting for the nested nature of the data using multilevel models ßSpeakerT = -0.033, SE = 0.009, t = -3.65, p < .001. Levels of rLSM did not relate to treatment outcome. CONCLUSION: Most of the rLSM variance was at the within-patient and within-session level. rLSM was no indicator of psychoanalytic treatment outcomes.

"It Felt Like I Was Being Tailored to the Treatment Rather Than the Treatment Being Tailored to Me": Patient Experiences of Helpful and Unhelpful Psychotherapy.

OBJECTIVE: This qualitative study explores patients' experiences of psychotherapy, focusing on elements perceived as helpful or unhelpful and suggestions for improvement in the context of public mental health care. METHODS: A total of 148 adults (Mean age = 32.24, SD = 9.92) who had been or are currently receiving psychological treatment from the National Health Service (NHS) responded to an online survey. The survey included open-ended questions regarding their experiences of psychotherapy, asking them to identify helpful or unhelpful aspects, and suggestions for improvement. Using thematic analysis, key themes were identified. RESULTS: The analysis highlighted the patient's preference for personalized treatment, the importance of therapeutic alliance, the demand for depth in therapy, and life skills and agency as therapeutic outcomes. Participants suggested improvements such as more tailored approaches and stronger therapist-patient relationships, supporting an adaptable, patient-centered model. CONCLUSION: The study highlights challenges in public mental health services where patients might feel their specific needs are not being recognized and met and underscores the importance of personalized treatment plans that satisfy and evolve with patient needs, suggesting that therapists must be attentive and responsive to individual desires to enhance the patient experience.

Measures of trauma exposure and trauma response: A scoping review.

BACKGROUND: In contrast to the vast clinical, theoretical, and empirical literature on the impact of trauma, relatively few studies have reviewed the trauma measures that researchers and clinicians can choose to use in their work. This scoping review aimed to catalog all trauma measures (trauma exposure and its subjective responses) that have been published in the peer-reviewed literature, developed for use with adult populations. METHOD: Through a systematic search of the literature and the screening of 19,631 abstracts, a total of 363 unique trauma measures were identified. RESULT: Most of these measures were developed for assessment purposes rather than for clinical screening or diagnostic purposes. Most of these measures are patient-self-report measures that assess trauma exposure in the patients' lifetime, or subsequent symptoms, particularly cognitive impairments. DISCUSSION: Complications in the trauma literature are highlighted, including the use of very similar abbreviations of measures, substantial discrepancies regarding the definition of trauma, and the general assumption that a potentially traumatic event inevitably leads to traumatic distress rather than a path of resilience.

Adjusting to a new reality: Consensual qualitative research on therapists' experiences with teletherapy.

OBJECTIVE: In the wake of the COVID-19 pandemic, the use of teletherapy has become more pervasive than ever. Many therapists faced this move to a remote setting with little experience or training. We aimed to qualitatively examine therapists' subjective experience of providing teletherapy, including changes in technique, the therapeutic relationship, and the therapeutic process. METHODS: Thirty-one psychotherapists participated in semistructured interviews. Interviews were recorded, then transcribed and analyzed using the Consensual Qualitative Research method. RESULTS: Therapists typically reported a change in the therapeutic relationship in terms of an increased sense of disconnection as well as shifts in various aspects of the relational dynamics, and they also typically experienced differences in the therapy process due to changes in patient and therapist engagement in the therapeutic work. Additionally, some therapists also reported that they became more active and directive in sessions, took a more informal, personal, or relaxed approach to interacting with patients, and while the emotional connection changed and they missed the energy and intimacy of in-person sessions, the relationship in telesessions felt more authentic and human for some, and teletherapy also provided a way to discuss new dimensions in the process. CONCLUSION: Overall, these results suggest great variability in therapists' subjective experiences with teletherapy, and present teletherapy as a distinct therapy format in many aspects. Further process-level research and subsequent training is needed to better equip therapists to navigate teletherapy's challenges and harness its unique opportunities.

Interpersonal guilt and the working alliance in psychotherapy: The moderating role of childhood experience.

Interpersonal guilt often encompasses pathogenic beliefs that imply omnipotent responsibility for others and concerns about abandoning, humiliating or threatening others. This study sought to examine how interpersonal guilt may influence patients' and therapists' ratings of early working alliance and the potential moderating effect of perceived adverse parenting in childhood. Ninety-five patients and their 19 therapists in an outpatient psychotherapy clinic rated their early working alliance after the first and the fifth session in treatment. We conducted separate moderation analyses for patient and therapist-reported working alliance and controlled for psychological distress at baseline. Results suggest that perceived adverse parenting in childhood significantly moderated the effect of interpersonal guilt on the working alliance in such a way that for patients reporting very low levels of perceived adverse experiences, the interpersonal guilt beliefs had a positive effect on working alliance, whereas for those with very high levels of perceived adverse experiences, interpersonal guilt had a negative effect on working alliance. This same pattern of moderation was found for patient- and therapist-reported working alliance at session 1 and therapist-reported working alliance at session 5. Thus, although the effect of interpersonal guilt on the working alliance depends somewhat on the perspective of the working alliance rating (patient or therapist), it mainly depends on developmental experiences of the patient.

Therapist self-disclosure in teletherapy early in the COVID-19 pandemic: Associations with real relationship and traumatic distress.

The usefulness of therapists' self-disclosure (TSD) in psychotherapy remains controversial, and little is known regarding the potential risks and benefits of TSD in times of global crisis such as the COVID-19 pandemic and in teletherapy. We examined two independent samples of therapists (N = 1705; Study 1) and patients (N = 772; Study 2) on their perceptions of increases in TSD during the transition to teletherapy early in the COVID-19 pandemic (spring 2020). Approximately 20% of therapists and 14% of patients reported perceptions of definite increases in TSD. Therapists' top reasons for increased TSD were therapists' heightened distress and an effort to connect with patients in teletherapy. Importantly, therapist perceptions of their increased TSD were positively related to subjective vicarious trauma, real relationship, psychodynamic theoretical orientation and negatively with humanistic orientation, but not with age, race/ethnicity, length of clinical experience, working alliance, or professional self-doubt. Patients' perceptions of increased TSD were positively related with patient pandemic-related traumatic distress and their own self-disclosure, but not with patient-reported therapeutic relationship variables. Longitudinally, patients' perceptions of TSD increases predicted higher pandemic-related traumatic distress at 3-month follow-up, after controlling for their baseline traumatic distress and other variables. These results highlighted that increased TSD in teletherapy may be a potential marker for heightened distress in both patients and therapists during a global crisis and a transition to teletherapy. The findings also contrasted the literature and emphasized that therapists, but perhaps not patients, may have considered increased TSD as a reflection of genuine therapeutic connection.

Therapists' perception of the working alliance, real relationship and therapeutic presence in in-person therapy versus tele-therapy.

Although teletherapy is increasingly common, very little is known about its impact on therapeutic relationships. We aimed to examine differences between therapists' experiences of teletherapy and in-person therapy post-pandemic with regard to three variables pertinent to the therapeutic relationship: working alliance, real relationship, and therapeutic presence. METHODS: In a sample of 826 practicing therapists, we examined these relationship variables, as well as potential moderators of these perceived differences including professional and patient characteristics and covid-related variables. RESULTS: Therapists reported feeling significantly less present in teletherapy and their perceptions of the real relationship were somewhat impacted, but there were no average effects on their perceived quality of the working alliance. Perceived differences in the real relationship did not persist with clinical experience controlled. The relative reduction in therapeutic presence in teletherapy was driven by the ratings of process-oriented therapists and therapists conducting mostly individual therapy. Evidence for moderation by covid-related issues was also found, with larger perceived differences in the working alliance reported by therapists who used teletherapy because it was mandated and/or not by choice. CONCLUSION: Our findings might have important implications for generating awareness around the therapists' lowered sense of presence in teletherapy compared to in-person teletherapy.

Beyond treatment modalities: Clinical decisions and relational dynamics that facilitate change in group treatments.

This commentary on six articles comprising this Journal of Clinical Psychology: In Session issue on the therapeutic process in group psychotherapy brings together relevant clinical challenges and opportunities concerning the unique processes of change in group treatments. As illustrated by these six inspiring group therapy cases, therapy groups may vary widely in content and context. To balance the rich clinical illustrations of successful group treatments and the different theoretical formulations offered in these case studies, we highlight the processes that these treatments appear to have in common. Specifically, we describe the clinical considerations about the group format and the group members. We also reflect on the relational dynamics as they play out within the complex interplay between group leaders and group members; the facilitation of the corrective emotional experience as a change mechanism in group therapy, as well as the relational challenges and opportunities inherent in group treatments more generally. It is hoped that in this issue, clinicians will not only be inspired by the clinical description of successful change processes in group treatments but will also be reminded of the therapeutic nuances and opportunities of this multilayered treatment format.

How to make the most of routine outcome monitoring (ROM): A multitude of clinical decisions and nuances to consider.

Routine outcome monitoring (ROM) involves the use of patient-reported standardized outcome measures to monitor progress throughout the course of treatment, followed by feedback of the patient's scores to the therapist. The potential benefits of ROM have been established, however, from our own experiences, we know that the implementation in clinical practice can be challenging. We therefore wanted to explore in more detail exactly how we might be able to apply ROM in difficult clinical contexts. The inspiring case illustrations in this issue of Journal of Clinical Psychology: In Session highlight the heterogeneity in ROM systems, and the way in which ROM can be used in treatment. Just as there are many ways of interpreting a survey data-point, there are also many ways in which ROM may be used to complement the treatment and supervision. Whether or not ROM is implemented may partly be determined by clinic policies and routines, but there remain a multitude of clinical decisions that require careful consideration by the individual therapist. To complement the evidence supporting the benefits of using ROM, further empirical support and clinical guidance is needed on how exactly therapists are to use ROM in their work and how ROM may be used in evidence-based practice. We make suggestions for additional uses of ROM for deliberate practice, and teletherapy practice, and look toward novel ways of assessing progress in the near future.

Routine outcome monitoring: The need for case examples.

Routine outcome monitoring (ROM) involves measuring an outcome variable (e.g., symptoms and alliance) at a regular interval over time (e.g., before each session), using a standardized patient self-report measure. Several computerized ROM system exists that also provide the therapist with benchmarks for these measures based on expected treatment responses (ETRs) for a patient, and clinical support tools (CSTs) to help the therapists in making clinician decisions in the treatment. When implementing ROM into clinical practice, a therapist needs to decide what patient-self report measure to use as well as what ROM system might be most clinically helpful and cost-effective. Although the use of ROM has shown to be effective, especially in reducing dropout and reducing deterioration of patients, the implementation of ROM can be challenging. The use of ROM always requires the active involvement of the therapist, but the implementation in treatment may look different for each patient. It is thus helpful to see case illustration of exactly how ROM might be useful or not so useful in clinical practice.

The development of a self-report scale to assess therapists' acceptance of telepsychotherapy.

OBJECTIVE: We aimed to develop a self-report measure of therapist acceptance of telepsychotherapy based on the Unified Theory of Acceptance and Use of Technology (UTAUT) framework. METHODS: Using a cross-sectional survey design, 1265 therapists completed the UTAUT-T, as well as additional questions. RESULTS: Confirmatory analysis indicated that the original UTAUT model did not fit the therapist context well. Exploratory factor analysis specified a better-fitting five-factor model, which showed good internal validity fit (χ2 = 17,753.36, RMSEA = 0.063, TLI = 0.886, SRMSR = 0.04). The five UTAUT-T subscales showed high internal consistency (Cronbach's α = 0.86) and together predicted the intention to use online therapy in the future (R2 = 0.42, F(5, 1259) = 181.9, p < 0.001). CONCLUSION: The 21-item UTAUT-T offers a promising self-report measure of therapist acceptance of telepsychotherapy and intention towards using it in the future. Future studies on the convergent and predictive validity of the UTAUT-T are warranted.

Within-patient perceptions of alliance and attunement: Associations with progress in psychotherapy.

The most frequently examined aspect of the therapeutic relationship is the working alliance, which reflects the conscious collaborative bond, and agreement on task and goal. In addition to the established importance of the working alliance, the therapists' attunement and responsiveness might reflect another important aspect of the therapeutic relationship that can be considered in relation to session-by-session progress over treatments. Emerging research suggests that the quality of the working alliance not only differs between patients but also within patients over time. However, little is known about the quality of the therapeutic relationship between and within patients in relation to progress in psychotherapy. We examined fluctuations of the working alliance measure (WAI) and the newly developed measure of the Patients' Experiences of Attunement and Responsiveness (PEAR) during treatment in a naturalistic sample of patients in an outpatient psychotherapy clinic. Multilevel modelling was used to examine the respective contribution of these measures to subsequent improvement in psychological functioning longitudinally. Results suggest that the within-patient effect, instead of between-patient effect, was significant for WAI (and did not reach significance for PEAR), indicating that the fluctuation of WAI was predictive of psychological functioning in the subsequent month. Based on these findings, therapists and their patients might benefit from regular tracking of the patient-reported working alliance. The findings underscore the importance of the alliance, specifically at the within-patient level. It also highlights the challenge for research to tap into other aspects of the therapeutic relationship that can help explain progress in therapy. Given the breadth and accessibility of the working alliance construct, more work is needed for researchers to examine the construct of attunement and responsiveness.

Assessing internalized beliefs: Development of the Pathogenic Belief Scale.

The way that people internalize adverse experiences plays an important role in the development of psychopathology. The Pathogenic Belief Scale (PBS) is intended to operationalize a transtheoretical understanding of repetitive patterns of emotion-laden beliefs that develop in childhood and continue to influence people's current experience. Using a cross-sectional survey design, we recruited a large heterogeneous sample of 246 clinic outpatients and 732 adults in the community. Besides the PBS, measures of adverse parenting experiences and common psychopathology were administered. An exploratory factor analysis of the total sample of 978 participants was conducted followed by a convergent validity analysis for the 246 clinic outpatients. The three-factor solution included "cannot rely on others," "undeserving," and "interpersonal guilt," and it showed good psychometric properties, including convergent validity with the measures of adverse parenting experiences and psychopathology. The 34-item PBS offers a promising self-report measure that could help delineate and understand the pathogenic beliefs that heterogeneous samples of patients may hold. Pathogenic beliefs may be relevant to the psychotherapy process, regardless of model or theoretical context.

Interpersonal and Social Functioning Among Psychotherapy Patients: The Indirect Effect of Childhood Adversity.

ABSTRACT: This study examined the mediating role of pathogenic beliefs on the relationship between patients' recollections of experienced adverse parenting in childhood and adult interpersonal and social problems. A total of 210 psychotherapy outpatients rated their experiences of perceived adverse parenting in childhood and completed measures of psychological distress, interpersonal problems and social impairment, and internalized beliefs about self and others. Significant mediation effects were observed for two of the three belief domains: "cannot rely on others" and "undeserving." Although both were significant mediators between adverse parenting and symptom distress, only "cannot rely on others" was a significant mediator predicting interpersonal problems, and only "undeserving" was a significant mediator predicting impaired social functioning. Thus, patients' underlying convictions regarding their self-worth seem to play a role in the ability to develop social roles, whereas the beliefs about the steadfastness of others play an important role in the capacity for interpersonal relating.

Perceived Adverse Parenting in Childhood and Psychological Distress Among Psychotherapy Patients: The Mediating Role of Pathogenic Beliefs.

ABSTRACT: The way people derive inferences from actual adverse experiences plays an important role in the development of psychopathology. This study aims to examine the mediating role of pathogenic beliefs (i.e., emotion-laden, powerful, painful convictions about self and others) on the relation between perceived adverse parenting behaviors in childhood and subsequent adult psychopathology. Participants (mostly Caucasian and heterosexual) were 204 consecutively admitted patients with a range of psychological difficulties, including depression, anxiety, and interpersonal problems, at a low-fee outpatient clinic. Participants completed standard self-report assessments of perceived parental style, depressive and anxiety symptoms, and a clinically derived measure of pathogenic beliefs. We examined the indirect effects of adverse parenting on anxiety and depressive symptom severity through pathogenic beliefs. Pathogenic beliefs reflecting the unreliability of others significantly mediated the relationship between adverse parenting and anxiety symptoms. The other mediation model is consistent with the theory that perceived adverse parenting contributes to the severity of depressive symptoms through beliefs about not being deserving and other people being unreliable. Within the limitations of the cross-sectional, retrospective, and self-report nature of the data, our results seem to suggest that attending to intermediary subjective beliefs might be important in understanding psychopathology development in the context of childhood adversity. Aiming to modify the beliefs in therapy might modify the symptoms. However, this would remain to be demonstrated through formal intervention research.

Psychotherapists' acceptance of telepsychotherapy during the COVID-19 pandemic: A machine learning approach.

OBJECTIVE: This study aimed to develop predictive models of three aspects of psychotherapists' acceptance of telepsychotherapy (TPT) during the COVID-19 pandemic, attitudes towards TPT technology, concerns about using TPT technology and intention to use TPT technology in the future. METHOD: Therapists (n = 795) responded to a survey about their TPT experiences during the pandemic, including quality of the therapeutic relationship, professional self-doubt, vicarious trauma and TPT acceptance. Regression decision tree machine learning analyses were used to build prediction models for each of three aspects of TPT acceptance in a training subset of the data and subsequently tested in the remaining subset of the total sample. RESULTS: Attitudes towards TPT were most positive for therapists who reported a neutral or strong online working alliance with their patients, especially if they experienced little professional self-doubt and were younger than 40 years old. Therapists who were most concerned about TPT were those who reported higher levels of professional self-doubt, particularly if they also reported vicarious trauma experiences. Therapists who reported low working alliance with their patients were least likely to use TPT in the future. Performance metrics for the decision trees indicated that these three models held up well in an out-of-sample dataset. CONCLUSIONS: Therapists' professional self-doubt and the quality of their working alliance with their online patients appear to be the most pertinent factors associated with therapists' acceptance of TPT technology during COVID-19 and should be addressed in future training and research.

A scoping review of machine learning in psychotherapy research.

Machine learning (ML) offers robust statistical and probabilistic techniques that can help to make sense of large amounts of data. This scoping review paper aims to broadly explore the nature of research activity using ML in the context of psychological talk therapies, highlighting the scope of current methods and considerations for clinical practice and directions for future research. Using a systematic search methodology, fifty-one studies were identified. A narrative synthesis indicates two types of studies, those who developed and tested an ML model (k=44), and those who reported on the feasibility of a particular treatment tool that uses an ML algorithm (k=7). Most model development studies used supervised learning techniques to classify or predict labeled treatment process or outcome data, whereas others used unsupervised techniques to identify clusters in the unlabeled patient or treatment data. Overall, the current applications of ML in psychotherapy research demonstrated a range of possible benefits for indications of treatment process, adherence, therapist skills and treatment response prediction, as well as ways to accelerate research through automated behavioral or linguistic process coding. Given the novelty and potential of this research field, these proof-of-concept studies are encouraging, however, do not necessarily translate to improved clinical practice (yet).