Change motivation and mindfulness in individual psychotherapy: Examining a sample of adult outpatients with depression and/or anxiety.

OBJECTIVES: Existing literature has demonstrated that both motivation to change and mindfulness are associated with therapy outcomes in samples with mental disorders. Between the constructs of mindfulness and motivation to change occurs some theoretical-related and empirical overlap. However, it is still little known about the association of these two constructs. For this reason, we investigated the relationship of motivation to change and mindfulness in a sample of 116 adult outpatients with a primary diagnosis of depression or anxiety. METHODS: An outpatient sample of 116 depressive and/or anxious patients filled in the German short version of the University of Rhode Island Change Assessment (URICA-S) and the German version of the Kentucky Inventory of Mindfulness Skills (KIMS) before the start of cognitive-behavioral therapy (pre) and after the 25th cognitive-behavioral therapy session (post). To assess the association between change motivation and mindfulness, we calculated correlations, hierarchical regressions and cross-lagged panel models (CLPM). RESULTS: Several positive and negative significant correlations at the premeasurement time point, at the postmeasurement time point, and over time (from pre to postmeasurement time point) demonstrated a relation between the KIMS and the URICA-S. Hierarchical regression analyses and CLPM pointed towards relations between mindfulness and change motivation over time and in both directions for some subscales of the KIMS and the URICA-S. CONCLUSION: A bidirectional relation between motivation to change and mindfulness was supported in our naturalistic psychotherapy setting for several subscales. For a better understanding of the interconnection between the two constructs, future research should focus on the application of interventions to improve either mindfulness or motivation to change in psychotherapy. Additionally, the interactional effects of mindfulness and change motivation on therapy outcomes should be investigated.

Integrative systemic and family therapy for social anxiety disorder: Manual and practice in a pilot randomized controlled trial (SOPHO-CBT/ST).

Social anxiety disorders (SAD) are among the most prevalent mental disorders (lifetime prevalence: 7-12%), with high impact on the life of an affected social system and its individual social system members. We developed a manualized disorder-specific integrative systemic and family therapy (ISFT) for SAD, and evaluated its feasibility in a pilot randomized controlled trial (RCT). The ISFT is inspired by Helm Stierlin's concept of related individuation developed during the early 1980s, which has since continued to be refined. It integrates solution-focused language, social network diagnostics, and genogram work, as well as resource- and problem orientation for both case conceptualization and therapy planning. Post-Milan symptom prescription to fluidize the presented symptoms is one of the core interventions in the ISFT. Theoretically, the IFST is grounded in radical constructivism and "Cybern-Ethics," multi-directional partiality, and a both/and attitude toward a disorder-specific vs. non-disorder-specific therapy approach. SAD is understood from the viewpoint of social systems theory, especially in adaptation to a socio-psycho-biological explanatory model of social anxiety. In a prospective multicenter, assessor-blind pilot RCT, we included 38 clients with SAD (ICD F40.1; Liebowitz Social Anxiety Scale, LSAS-SR > 30): 18 patients participated in the ISFT, and 20 patients in Cognitive Behavioral Therapy (CBT; age: M = 36 years, SD = 14). Within-group, simple-effect intention-to-treat analyses showed significant reduction in social anxiety (LSAS-SR; ISFT: d = 1.67; CBT: d = 1.04), while intention-to-treat mixed-design ANOVA demonstrated the advantage of ISFT (d = 0.81). Per-protocol analyses supported these results. The remission rate based on blind diagnosticians' ratings was good to satisfactory (Structured Clinical Interview, SCID; 78% in ST, 45% in CBT, p = 0.083); this has yet to be verified in a subsequent confirmatory RCT. The article will present the ISFT rationale and manual, including a special focus on multi-person settings, and the central findings from our pilot RCT.

Change Mechanism of Cognitively-Based Compassion Training for Couples with Depression: An Exploratory Empirical Investigation of Process Variables.

Objective: Compassion training seems to be a promising intervention for couples to improve individual psychopathology and relationship quality. Beyond studying the efficacy of training such as Cognitively-Based Compassion Training for Couples (CBCT-fC), it is important to gain insights into the putative mechanisms along the process. Methods: Theoretically derived presumed mechanisms of compassion training (clarification of values, self-regulation, decentering, and exposure) and additional therapeutic factors (emotional bond, social learning, and clarification of meaning) were studied over the course of a 10-session-long group-based CBCT-fC among women with depressive disorders. Results: Dyadic growth curve models indicated that emotional bond, social learning, and clarification of meaning increase over time in both partners. In decentering and clarification of values, women who suffered from depression showed a larger increase than men, while men had higher values at the start of the training. Conclusions: Women with depression seem to benefit from CBCT-fC in terms of an increase in decentering and value clarification, important mechanisms of compassion training. This study is the first to show that theoretically derived mechanisms of compassion and additional therapeutic factors can describe the process along secular contemplative training sessions, which are increasingly implemented in the health care system. Future studies should explore the relationship of mechanisms and the outcome along the process of the training. Study Registration: Trial registration number NCT03080025.

The impact of session-introducing mindfulness and relaxation interventions in individual psychotherapy for children and adolescents: a randomized controlled trial (MARS-CA).

BACKGROUND: The investigation of mindfulness-based interventions (MBIs) in cognitive-behavioral therapy has greatly increased over the past years. However, most MBI research with youth focuses on structured, manualized group programs, conducted in school settings. Knowledge about the implementation and effects of MBIs in individual psychotherapy with children and adolescents is scarce. To fill this research gap, the "Mindfulness and Relaxation Study - Children and Adolescents" (MARS-CA) is designed. It aims to assess the effects of short session-introducing interventions with mindfulness elements on juvenile patients' symptomatic outcome and therapeutic alliance in individual child and adolescent psychotherapy. METHODS: MARS-CA is conducted at a university outpatient training center for cognitive-behavior therapy. Short session-introducing interventions with mindfulness elements will be compared to short session-introducing relaxation interventions and no session-introducing intervention to explore their effects on symptomatic outcome and therapeutic alliance. The session-introducing interventions will take place at the beginning of 24 subsequent therapy sessions. We hypothesize that patients' symptomatic outcome and therapeutic alliance improve more strongly in the mindfulness condition than in the other two conditions and that the mindfulness condition moderates the relationship between therapeutic alliance and symptomatic outcome. Patients and their trainee therapists will be randomized to one of the three treatment arms. Participants aged between 11 and 19 years and having a primary diagnosis of either a depressive disorder, an anxiety disorder, or a hyperkinetic disorder will be included. Therapeutic alliance will be assessed after every therapy session (therapy session 1 to therapy session 24), symptomatic outcome will be assessed before the start of treatment (pre), after the 3rd, the 10th, and the 17th therapy sessions, at the end of treatment (24th therapy session, post), and at a 6-month follow-up. Additionally, mindfulness and mindfulness-related measures as well as demographic data, adherence, allegiance, and therapeutic techniques will be assessed. It is our aim to assess a sample of 135 patients. We will conduct multilevel modeling to address the nested data structure. DISCUSSION: The study can provide information about how add-on MBIs, conducted by trainee therapists, influence therapeutic alliance and symptomatic outcome in individual psychotherapy in children and adolescents. TRIAL REGISTRATION: ClinicalTrials.gov NCT04034576. Registered on July 17, 2019.

[Mindfulness in Trainee Psychotherapies with Children and Adolescents]. / Achtsamkeit in Ausbildungspsychotherapien bei Kindern und Jugendlichen.

Mindfulness in Trainee Psychotherapies with Children and Adolescents The implementation of mindfulness-based interventions (MBIs) in cognitive-behavioral therapy has greatly increased over the past few years. However, there is little research about the implementation of MBIs in individual child and adolescent psychotherapy. The present paper gives an overview of current MBIs and their efficacy in children and adolescents. A depiction of the implementation of MBIs in individual therapy and a description of the "Mindfulness and Relaxation Study - Children and Adolescents" (MARS-CA) is given. The study aims to examine the effects of short session-introducing interventions with mindfulness elements on juvenile patients' psychopathological symptomatology and therapeutic alliance. For this reason, the authors compare session-introducing interventions with mindfulness elements with session-introducing relaxation interventions and no session-introducing intervention. Qualitative results of the pre-study show that both interventions with mindfulness elements and relaxation interventions work well with juvenile patients.

Development and Initial Validation of a Brief Questionnaire on the Patients' View of the In-Session Realization of the Six Core Components of Acceptance and Commitment Therapy.

Background: Assessing in-session processes is important in psychotherapy research. The aim of the present study was to create and evaluate a short questionnaire capturing the patients' view of the in-session realization of the six core components of Acceptance and Commitment Therapy (ACT). Method: In two studies, psychotherapy patients receiving ACT (Study 1: n = 87) or Cognitive-Behavioral Therapy (CBT) (Study 2, Sample 1: n = 115; Sample 2: n = 156) completed the ACT session questionnaire (ACT-SQ). Therapists were n = 9 ACT therapists (Study 1) and n = 77 CBT trainee therapists (Study 2). Results: Factor structure: Exploratory factor analyses suggested a one-factor solution for the ACT-SQ. Reliability: Cronbach's alpha of the ACT-SQ was good (Study 1: α = .81; Study 2, Sample 1: α = .84; Sample 2: α = .88). Convergent validity: The ACT-SQ was positively correlated with validated psychotherapeutic change mechanisms (p < .05). Criterion validity: Higher ACT-SQ scores were associated with better treatment outcomes (p < .05). Conclusion: The study provides preliminary evidence for the reliability and validity of the ACT-SQ to assess the in-session realization of the six core components of ACT in the patients' view. Further validation studies and ACT-SQ versions for therapists and observers are necessary.

[Change Mechanisms in Group Therapy: A Questionnaire to Measure Therapeutic Perspectives]. / Wirkfaktoren in der Gruppentherapie: Fragebogen zur Messung der therapeutischen Perspektive.

Group therapy was shown to be an effective and economic intervention. To date few instruments exist to empirically assess mechanisms of therapeutic change in group therapy. The Group Therapy Process Questionnaire for Therapists (FEPiG-T) measuring change mechanisms in group therapy as viewed from the perspectives of therapists was developed and validated in this study based on the conceptualizations of Grawe,Yalom and Bordin and in reference to the previously developed measure for patients. The FEPiG-T subscales show good internal consistencies and small to large correlations with convergent measures. Subscales at beginning of therapy correlated with improvement of interpersonal problems over time. Further associations with symptom scales remained more vague. However, intersections with the established version for patients allow routinely implemented evaluation of the 2 perspectives in clinical practice, but inevitably need careful interpretation where the instruments differ in their factor structure.

Comparing Cognitive Behavioral Therapy and Systemic Therapy for Social Anxiety Disorder: Randomized Controlled Pilot Trial (SOPHO-CBT/ST).

This randomized controlled trial (RCT) aimed to pilot the newly developed manualized and monitored systemic therapy (ST) for social anxiety disorder (SAD), as compared to manualized and monitored cognitive behavioral therapy (CBT). We conducted a prospective multicenter, assessor-blind pilot RCT on 38 outpatients (ICD F40.1; Structured Clinical Interview for DSM (SCID); Liebowitz Social Anxiety Scale, LSAS-SR >30). The primary outcome was level of social anxiety (LSAS-SR) at the end of treatment. A total of 252 persons were screened, and 38 patients were randomized and started therapy (CBT: 20 patients; ST: 18 patients; age: M = 36 years, SD = 14). Within-group, simple-effect intent-to-treat analyses (ITT) showed significant reduction in LSAS-SR (CBT:d = 1.04; ST:d = 1.67), while ITT mixed-design ANOVA demonstrated the advantage of ST (d = 0.81). Per-protocol analyses supported these results. Remission based on reliable change indices also demonstrated significant difference (LSAS-SR: 15% in CBT; 39% in ST;h: 0.550), supported by blind diagnosticians' ratings of those who completed therapy (SCID; 45% in CBT, 78% in ST,p = .083). No adverse events were reported. CBT and ST both reduced social anxiety, supporting patient improvement with the newly developed ST for SAD; this has yet to be verified in a subsequent confirmatory RCT.

Este ensayo controlado aleatorizado tuvo como finalidad probar la terapia sistémica (TS) estandarizada y monitoreada recientemente desarrollada para el trastorno de ansiedad social en comparación con la terapia cognitivo-conductual (TCC) estandarizada y monitoreada. Realizamos un ensayo controlado aleatorizado prospectivo, multicentro y con enmascaramiento para el evaluador en 38 pacientes ambulatorios (CIE F40.1; Entrevista Clínica Estructurada para los trastornos del DSM (SCID); Escala de Ansiedad Social de Liebowitz, LSAS-SR > 30). El resultado principal fue el nivel de ansiedad social (LSAS-SR) al final del tratamiento. Se evaluó a un total de 252 personas, 38 pacientes fueron aleatorizados y comenzaron la terapia (TCC: 20 pacientes; TS: 18 pacientes; edad: promedio= 36 años, desviación estándar = 14). Los análisis intragrupales, de efecto simple, con intención de tratar demostraron una reducción significativa del LSAS-SR (TCC: d = 1.04; TS: d = 1.67), mientras que el análisis de varianza de diseño mixto con intención de tratar demostró la ventaja de la TS (d = 0.81). Los análisis por protocolo respaldaron estos resultados. La remisión basada en los índices de cambio fiable también demostró una diferencia significativa (LSAS-SR: 15% en la TCC; 39% en la TS; h: 0.550), respaldada por diferencias casi significativas en las valoraciones con enmascaramiento para los evaluadores de aquellos que completaron la terapia (SCID; 45% en la TCC, 78% en la TS, p = 0.083). No se informaron efectos adversos. Tanto la TCC como la TS reducen la ansiedad social y respaldan la mejora de los pacientes con la terapia sistémica recientemente desarrollada para los trastornos de ansiedad social; esto aun debe verificarse en un ensayo controlado aleatorizado confirmatorio posterior.

Targeting parental motivation for change in childhood obesity: development and validation of the PURICA-S scale.

BACKGROUND: The high prevalence of overweight and obesity in childhood and adolescence call for effective and sustainable intervention strategies. Parental motivation for change may be a key factor in sustained behavioral improvement towards a healthy weight status of their offspring. In this study, we developed a new short instrument to assess parental motivation for change to facilitate motivation-tailored family interventions that promise improved effectiveness. METHODS: The preexisting gold-standard instrument to assess motivational stages for change was adapted from the self to the parental perspective in a structured multistep Delphi procedure. The new instrument to assess parental motivation for change related to a health problem of their children was psychometrically evaluated in a sample (N = 193) of parents of children or adolescents with overweight or obesity. Confirmatory factor analysis, internal consistency, construct, and criteria validity were analyzed to test the psychometric properties of the new instrument. RESULTS: As a result of the Delphi procedures, all 16 items were successfully transferred to the parental perspective. The hypothesized four-factor structure of the new instrument was approved, and internal consistency and criteria validity were good to very good (albeit with inconsistent findings for the subscale precontemplation). DISCUSSION: In our investigated target group of parents with children with overweight or obesity, the new instrument to assess parental motivation for change proved to be a practicable, valid, and time-efficient short measure. The new instrument will enable more specific motivational stage-directed interventions that promise higher effectiveness of family-based interventions to fight childhood obesity. However, the subscale precontemplation seemed not fully suitable for the population investigated here and needs to be applied very carefully in future studies.

Heart Rate Variability in Individual Psychotherapy: Associations With Alliance and Outcome.

Heart rate variability (HRV) can be conceptualized as a marker of an individual's capability to adaptively respond to its environment and has been linked with mental health. Although conceptually and empirically linked to social behavior and thus relevant in the therapeutic setting, HRV is seldom investigated directly within therapy sessions. In the present examination, we aimed at addressing this research gap by assessing patients' and therapists' HRVs both ambulatory within therapy sessions and under resting conditions. Drawing on polyvagal theory, we hypothesized that higher in-session HRV is accompanied with higher therapeutic alliance ratings. Further, we expected baseline HRV to predict symptomatic outcome and to increase over the course of therapy. In a sample of 53 outpatients receiving 25 sessions of cognitive behavioral therapy, we measured HRV, therapeutic alliance and depressive symptoms on four occasions. Multilevel modeling analyses demonstrated that patients with higher in-session high-frequency HRV rated the therapeutic alliance higher. Baseline HRV predicted symptomatic outcome and increased over the course of therapy. Possible explanations involve a link between in-session HRV and in-session behavior and should be investigated in future studies. The results highlight the usefulness of in-session HRV as a promising process variable in psychotherapy research.

Therapeutic Agency Inventory: Development and psychometric validation of a patient self-report.

Objectives: Therapeutic agency is defined as a patient's intentional influence over the process of psychotherapeutic change. However, there is a lack of conceptually sound self-report measures with adequate psychometric properties. The aim of this study was to develop and psychometrically evaluate the patient-rated Therapeutic Agency Inventory (TAI).Method: Based on the literature, we developed items related to therapeutic agency and investigated their psychometric properties in a naturalistic study with a sample of 334 psychotherapy participants. We assessed changes in TAI scores in a subsample of 58 patients over the course of inpatient psychotherapy and related TAI scores to therapeutic improvement.Results: The TAI consists of 15 items. We performed exploratory factor analyses, and the following three factors were extracted: In-session activity, therapy-related processing, and therapist-oriented passivity. Internal consistency was .84 for the total score and ranged between .73 and .80 for each of the factors. The TAI was significantly associated with other psychotherapy process factors, self-efficacy expectations, control beliefs, lower overall psychological distress, and lower depression scores. Changes in agency during psychotherapy predicted therapy outcome, even after controlling for baseline distress.Conclusions: The TAI is a reliable, valid, and change-sensitive self-report instrument that can be used to assess agency in psychotherapy.

Mindfulness and progressive muscle relaxation as standardized session-introduction in individual therapy: A randomized controlled trial.

OBJECTIVE: There is scarce research on the effects of mindfulness in individual therapy. As many practitioners integrate mindfulness exercises into individual therapy, empirical evidence is of high clinical relevance. METHOD: We investigated the effects of a session-introducing intervention with mindfulness elements (SIIME) in a randomized, controlled design. The effects of SIIME on therapeutic alliance and symptomatic outcome were compared with progressive muscle relaxation (PMR) and treatment-as-usual (TAU) control conditions. The sample comprised 162 patients with anxiety and depression. RESULTS: Multilevel modeling revealed a significant symptom reduction and significant increase of alliance over the course of therapy. There were no significant time-condition interactions on outcome and alliance, indicating the comparable efficiency of all three treatment conditions. CONCLUSIONS: We found no advantage of SIIME versus PMR and TAU. Add-on mindfulness might not improve individual therapy related to alliance and outcome.

[Questionnaire on the Experience of the Art Therapy Group in Psychosomatics from Patient View (FEKTP) - Construction and Validation of a Measuring Instrument]. / Fragebogen zum Erleben der Kunsttherapiegruppe in der Psychosomatik aus Patientensicht (FEKTP).

Art therapy is a clinically accepted method of therapy, but there are still very few studies that deal with the efficacy, change factors or mode of action of art therapy. In particular, there is a dearth of research instruments and psychometrically verified research tools specially fitted for art therapy which measures the experience dimensions of the art therapy group from the patient's point of view. Hence, it provides evidence of its effectiveness, better understands the art therapy group processes and serves quality assurance. The aim of the present study was to develop and validate the questionnaire on the experience of the art therapy group from patient view (FEKTP). This questionnaire is based on Grawe's and Yalom's conceptions of change factors in group therapy. 133 patients participated in the study and completed the FEKTP directly after the 6th art therapy session. Patients additionally received established questionnaires concerning clinical symptoms and experience processes at the beginning and end of treatment. Factor analysis demonstrated a clear factor structure of the FEKTP, which corresponded to the theoretically predicted subscales to the greatest extent. The test psychometric main quality criteria of the FEKTP (reliability, validity and objectivity) can be classified as acceptable to good range. The criterion validity appear to be given, but should be examined more exactly in future studies. Thus, a valid instrument for the systemic detection of general change factors for art therapy is now available. The questionnaire can be recommended for research as well as clinical contexts.

Mind-Body Practices and the Self: Yoga and Meditation Do Not Quiet the Ego but Instead Boost Self-Enhancement.

Mind-body practices enjoy immense public and scientific interest. Yoga and meditation are highly popular. Purportedly, they foster well-being by curtailing self-enhancement bias. However, this "ego-quieting" effect contradicts an apparent psychological universal, the self-centrality principle. According to this principle, practicing any skill renders that skill self-central, and self-centrality breeds self-enhancement bias. We examined those opposing predictions in the first tests of mind-body practices' self-enhancement effects. In Experiment 1, we followed 93 yoga students over 15 weeks, assessing self-centrality and self-enhancement bias after yoga practice (yoga condition, n = 246) and without practice (control condition, n = 231). In Experiment 2, we followed 162 meditators over 4 weeks (meditation condition: n = 246; control condition: n = 245). Self-enhancement bias was higher in the yoga (Experiment 1) and meditation (Experiment 2) conditions, and those effects were mediated by greater self-centrality. Additionally, greater self-enhancement bias mediated mind-body practices' well-being benefits. Evidently, neither yoga nor meditation fully quiet the ego; to the contrary, they boost self-enhancement.

Effects of mindfulness exercises as stand-alone intervention on symptoms of anxiety and depression: Systematic review and meta-analysis.

Mindfulness-based interventions (MBIs) are currently well established in psychotherapy with meta-analyses demonstrating their efficacy. In these multifaceted interventions, the concrete performance of mindfulness exercises is typically integrated in a larger therapeutic framework. Thus, it is unclear whether stand-alone mindfulness exercises (SAMs) without such a framework are beneficial, as well. Therefore, we conducted a systematic review and meta-analysis regarding the effects of SAMs on symptoms of anxiety and depression. Systematic searching of electronic databases resulted in 18 eligible studies (n = 1150) for meta-analyses. After exclusion of one outlier SAMs had small to medium effects on anxiety (SMD = 0.39; CI: 0.22, 0.56; PI: 0.07, 0.70; p < .001, I2 = 18.90%) and on depression (SMD = 0.41; CI: 0.19, 0.64; PI: -0.05, 0.88; p < .001; I2 = 33.43%), when compared with controls. Summary effect estimates decreased, but remained significant when corrected for potential publication bias. This is the first meta-analysis to show that the mere, regular performance of mindfulness exercises is beneficial, even without being integrated in larger therapeutic frameworks.

Validation of the URICA-S in Group Therapy: Associations of Stages of Change with Therapeutic Factors and Treatment Outcome.

Stages of change could be driving forces to activate the realization of therapeutic factors and symptom change. Consequently, the aims of the present study were to investigate whether the stages of change concept is valid in group therapy settings shown by factor analysis, internal consistencies, and criterion validity. A total of 377 patients completed measures of stages of change, symptom change, and therapeutic factors. A confirmatory factor analysis replicated the stages of change factors for group therapy. Related to the criterion validity, stages of change demonstrated only low, non-significant associations with symptom change, but some stages of change were significant predictors of certain therapeutic factors. Further research is needed to explore whether a stronger focus on motivational stages of change could help to intensify the realization of therapeutic factors in group therapy.

Increasing the treatment motivation of patients with somatic symptom disorder: applying the URICA-S scale.

BACKGROUND: Therapeutic intervention programs for somatic symptom disorder (SSD) show only small-to-moderate effect sizes. These effects are partly explained by the motivational problems of SSD patients. Hence, fostering treatment motivation could increase treatment success. One central aspect in SSD patients might be damage to motivation because of symptomatic relapses. Consequently, the aim of the present study was to investigate associations between motivational relapse struggle and therapeutic outcome in SSD patients. METHODS: We assessed 84 inpatients diagnosed with SSD in the early, middle and late stages of their inpatient treatment. The maintenance subscale of the University of Rhode Island Change Assessment-Short (URICA-S) was applied as a measure to assess motivational relapse struggle. Additionally, patients completed measures of treatment outcome that focus on clinical symptoms, stress levels and interpersonal functioning. RESULTS: The results from multiple regression analyses indicate that higher URICA-S maintenance scores assessed in early stages of inpatient treatment were related to more negative treatment outcomes in SSD patients. CONCLUSIONS: SSD patients with ambivalent treatment motivation may fail in their struggle against relapse over the course of therapy. The URICA-S maintenance score assessed at therapy admission facilitated early identification of SSD patients who are at greater risk of relapse. Future studies should incorporate randomized controlled trials to investigate whether this subgroup could benefit from motivational interventions that address relapse.

The therapeutic alliance in different mental disorders: A comparison of patients with depression, somatoform, and eating disorders.

OBJECTIVE: The therapeutic alliance is intensively investigated in psychotherapy research. However, there is scarce research on the role of the specific diagnosis of the patient in the formation of the therapeutic alliance. Hence, the aim of this study was to address this research gap by comparing the alliance in different mental disorders. DESIGN: Our sample comprised 348 patients (mean age = 40 years; 68% female; 133 patients with depression, 122 patients with somatoform disorders, and 93 patients with eating disorders). METHODS: Patients completed the Working Alliance Inventory and measures of therapeutic outcome in early, middle, and late stages of inpatient psychotherapy. We applied multivariate multilevel models to address the nested data structure. RESULTS: All three disorder groups experienced positive alliances that increased across the course of therapy and showed similar alliance-outcome relations that were of comparable strengths as in current meta-analyses. However, we found perspective incongruence of alliance ratings from patient and therapist in the three disorder groups. CONCLUSIONS: Our results generally indicate that the working alliance is of importance irrespective of the specific mental disorder. Perspective incongruence feedback of working alliance experiences could help to strengthen coordination between patient and therapist and thereby improve the therapeutic process. Further implications of these findings are discussed. PRACTITIONER POINTS: We found no differences in the strengths of alliance ratings and alliance-outcome associations in depressive, somatoform, and eating disorder patients. This indicates that the working alliance is of general clinical importance irrespective of the disorder group and should be a central target in all therapies. We found perspective incongruence in alliance ratings between patient and therapist in all three disorder groups. Perspective incongruence feedback of working alliance experiences could help to strengthen coordination between patient and therapist and thereby improve the therapeutic process.

A meta-analysis of the relation between therapeutic alliance and treatment outcome in eating disorders.

The therapeutic alliance has demonstrated an association with favorable psychotherapeutic outcomes in the treatment of eating disorders (EDs). However, questions remain about the inter-relationships between early alliance, early symptom improvement, and treatment outcome. We conducted a meta-analysis on the relations among these constructs, and possible moderators of these relations, in psychosocial treatments for EDs. Twenty studies met inclusion criteria and supplied sufficient supplementary data. Results revealed small-to-moderate effect sizes, ßs = 0.13 to 0.22 (p < .05), indicating that early symptom improvement was related to subsequent alliance quality and that alliance ratings also were related to subsequent symptom reduction. The relationship between early alliance and treatment outcome was partially accounted for by early symptom improvement. With regard to moderators, early alliance showed weaker associations with outcome in therapies with a strong behavioral component relative to nonbehavioral therapies. However, alliance showed stronger relations to outcome for younger (vs. older) patients, over and above the variance shared with early symptom improvement. In sum, early symptom reduction enhances therapeutic alliance and treatment outcome in EDs, but early alliance may require specific attention for younger patients and for those receiving nonbehaviorally oriented treatments.

Development and psychometric validation of the 'Parent Perspective University of Rhode Island Change Assessment-Short' (PURICA-S) Questionnaire for the application in parents of children with overweight and obesity.

INTRODUCTION: High prevalence rates of childhood obesity urgently call for improved effectiveness of intervention programmes for affected children and their families. One promising attempt can be seen in tailoring interventions according to the motivational stages of parents as 'agents of change' for their children. Evidence from other behavioural contexts (eg, addiction) clearly shows the superiority of motivational-stage dependent tailored (behavioural) interventions. For the time-efficient assessment of motivational stages of change, this study aims to develop and psychometrically validate a 'Parent Perspective Version' of the existing University of Rhode Island Change Assessment-Short, an instrument assessing the motivational stages based on the theoretical fundamentals of the Transtheoretical Model of Psychotherapy. METHODS AND ANALYSIS: In a multistep Delphi procedure, involving experts from the study context, the original items of the University of Rhode Island Change Assessment-Short Questionnaire will be transformed from the 'self-perspective' ('I am having a problem') to the parent perspective ('my child is having a problem'). Following item adaptation, the new version of the questionnaire will be psychometrically validated in a cohort of N=300 parents with overweight or obese children. Parents will be recruited within a multicentre and multisite approach involving private paediatric practices, specialised outpatient clinics as well as inpatient and rehabilitation sites. Analyses will include confirmatory factor analyses, internal consistencies (reliability) as well as convergent and criterion validity. Convergent validity will be analysed using subscales of the HAKEMP-90 Questionnaire, an instrument which has been shown to differentiate between 'state' and 'action' orientation of individuals. ETHICS AND DISSEMINATION: This study has been granted ethics committee approval by the University of Tuebingen (number 644/2014BO2). The results of this study will be released to the participating study centres and will be submitted to peer-reviewed journals and presented at international conferences. TRIAL REGISTRATION NUMBER: VfD_PURICA-S_15_003607.