Love yourself as a therapist, doubt yourself as an institution? Therapist and institution effects on outcome, treatment length, and dropout.

OBJECTIVE: Research suggests that some therapists achieve better outcomes than others. However, an overlooked area of study is how institution differences impact patient outcomes independent of therapist variance. This study aimed to examine the role of institution and therapist differences in adult outpatient psychotherapy. METHOD: The study included 1428 patients who were treated by 196 therapists at 10 clinics. Two- and three-level hierarchical linear regression models were employed to investigate the effects of therapists and institutions on three dependent patient variables: (1) symptom change, (2) treatment duration, and (3) dropout. Level three explanatory variables were tested. RESULTS: The results showed that therapist effects (TE) were significant for all three types of treatment outcome (7.8%-18.2%). When a third level (institution) was added to the model, the differences between therapists decreased, and significant institution effects (IE) were found: 6.3% for symptom change, 10.6% for treatment duration, and 6.5% for dropout. The exploratory analyses found no predictors able to explain the systematic variation at the institution level. DISCUSSION: TE on psychotherapy outcomes remain a relevant factor but may have been overestimated in previous studies due to not properly distinguishing them from differences at the institution level.

The Cooperative Revolution Reaches Clinical Psychology and Psychotherapy: An Example From Germany.

Background: Psychology is at the beginning of a cooperative revolution. Traditionally, psychological research has been conducted by individual labs, limiting its scope in clinical samples and promoting replication problems. Large-scale collaborations create new opportunities for highly powered studies in this resource-intensive research area. To present the current state of a Germany-wide platform for coordinating research across university outpatient clinics for psychotherapy. Method: Since 1999, over 50 such clinics were created in Germany. They represent a unique infrastructure for research, training, and clinical care. In 2013, a steering committee initiated a nationwide research platform for systematic coordination of research in these clinics (German abbreviation "KODAP"). Its main goal is to aggregate and analyze longitudinal treatment data - including patient, therapist, and treatment characteristics - across all participating clinics. Results: An initial survey (100% response rate) yielded recommendations for improved integration of data collection. Pilot data from 4,504 adult (16 clinics) and 568 child and adolescent patients (7 clinics) proved feasibility of data transfer and aggregation despite different data formats. Affective, neurotic, stress, and somatoform (adults) and anxiety and behavioral (children and adolescents) disorders were most frequent; comorbidity was high. Overcoming legal, methodological, and technical challenges, a common core assessment battery was developed, and data collection started in 2018. To date, 42 clinics have joined. Conclusions: KODAP shows that research collaboration across university outpatient clinics is feasible. Fulfilling the need for stronger cumulative and cooperative research in Clinical Psychology will contribute to better knowledge about mental health, a core challenge to modern societies.

Post-stroke depression and functional impairments - A 3-year prospective study.

BACKGROUND: Post-Stroke Depression (PSD) is a severe condition, affecting about 30% of stroke survivors within a five-year period after stroke. Post-stroke functional impairments (FI) and social support are associated with PSD. It is inconclusive, whether one of the factors, post-stroke FI and PSD, shows a stronger predictive value on the respective other over time. The aims of the present study were to 1) investigate the relationship between PSD, FI, and social support of stroke patients in a 3-year prospective design, and 2) address methodological shortcomings of previous studies. METHODS: We investigated 174 stroke survivors and assessed PSD with a structured clinical interview and a dimensional symptom rating scale. We conducted regression analyses and applied the approach of multiple imputations (MI) for missing data due to dropout during follow-up. RESULTS: PSD prevalence was 32.2% in the acute phase after stroke. Individuals with a PSD in this phase revealed a fivefold higher risk for PSD 3 years later. FI in the acute phase did not additionally contribute to the prediction of PSD at follow-up. Compared to individuals without PSD in the acute phase, individuals with PSD had an increased risk for FI at follow-up. Limitations regarding sample characteristics, design, and dropout are discussed. CONCLUSIONS: Results indicate that PSD rather than FI represents a crucial risk factor for negative long-term consequences regarding physical and psychological health after stroke. Post-stroke treatment might be optimized by a routine assessment of PSD and FI after stroke and considering the results for personalized treatment options.

The phase model of psychotherapy outcome: Domain-specific trajectories of change in outpatient treatment.

OBJECTIVE: The Phase model of psychotherapy outcome assumes a log-linear trajectory of change and allows predictions about the three outcome domains of Well-being, Symptoms, and Interpersonal functioning. Although the model has been partly validated, little is known about the types of trajectories in the specific domains and about the transferability of the model to treatments of longer duration. This study tested whether the domain-specific change trajectories followed a log-linear curve as postulated by the Phase model. Furthermore, it was examined whether the speed of change differed between the domains. METHOD: Growth curves were modeled using hierarchical linear modeling on an outpatient sample (N = 351), with treatment duration averaging 52 sessions. RESULTS: A log-linear curve best explained the change trajectories of the domains Well-being and Symptoms as well as the Global score of psychopathology, whereas Interpersonal functioning tends to improve in a linear pattern. Estimated slopes were biggest for Well-being and smallest for Interpersonal functioning. CONCLUSIONS: In the present study, the predictions of the Phase model concerning multidimensional phases were validated. The finding that trajectories of change are not uniformly log-linear, but either log-linear or linear in a domain-specific manner, is partly inconsistent with the model. Clinical or methodological significance of this article: This article extends previous research in the field of psychotherapeutic change by providing results from the modeling of change trajectories in psychotherapeutic treatments with larger amounts of sessions (i.e., more than 20 sessions). Our findings of domain-specific different shapes (i.e., log-linear for Well-Being and Symptoms and linear for Interpersonal functioning) and speed (i.e., fastest for Well-Being and slowest for Interpersonal function) of trajectories of psychotherapeutic change may be clinically applied by means of guidelines for therapists to plan and adapt their treatments. In addition to content-related aspects of a continuous adjustment of treatment goals (e.g., merely symptom-oriented or focusing on interpersonal change) and interventions, this adaptive planning is also related to health care considerations (e.g., may justify longer treatments if therapy goals target several domains of change).

Predicting psychotherapy outcome based on therapist interpersonal skills: A five-year longitudinal study of a therapist assessment protocol.

OBJECTIVE: In the past decade, variation in outcomes between therapists (i.e., therapist effects) have become increasingly recognized as an important factor in psychotherapy. Less is known, however, about what accounts for differences between therapists. The present study investigates the possibility that therapists' basic therapy-related interpersonal skills may impact outcomes. METHOD: To examine this, psychotherapy postgraduate trainees completed both an observer- and an expert-rated behavioral assessment: the Therapy-Related Interpersonal Behaviors (TRIB). TRIB scores were used to predict trainees' outcomes over the course of the subsequent five years. RESULTS: Results indicate that trainees' with more positively rated interpersonal behaviors assessed in the observer-rated group format but not in a single expert-rated format showed superior outcomes over the five-year period. This effect remained controlling for therapist characteristics (therapist gender, theoretical orientation [cognitive behavioral or psychodynamic], amount of supervision, patient's order within therapist's caseload), and patient characteristics (patient age, gender, number of comorbid diagnoses, global severity, and personality disorder diagnosis). CONCLUSIONS: These findings underscore the importance of therapists' interpersonal skills as a predictor of outcome and source of therapist effects. The potential utility of assessing therapists' and therapists-in-training interpersonal skills are discussed.

[The Phase Model of Psychotherapeutic Outcome: Validation of the "Questionnaire for the Evaluation of Psychotherapeutic Change Processes" (FEP)]. / Das Phasenmodell therapeutischer Veränderung: Validierung des Fragebogens zur Evaluation von Psychotherapieverläufen (FEP).

Sufficiently theoretically founded and validated measures in German language to assess psychotherapeutic change are rare. The German Questionnaire for the Evaluation of Psychotherapeutic Change Processes (FEP) was designed on the basis of the Phase model of psychotherapeutic outcome. In the present study, the psychometric properties of the FEP and especially its factorial structure are validated. Psychometric values were calculated and confirmatory factor analyses were performed (outpatient sample, N=427). Itemindices, reliability - with exception of retest-reliability - and validity reached overall good to very good values. The best model-fit indices were obtained for the 3-factor-structure corresponding to the FEP-subscales Well-being, Symptoms and Interpersonal relations which represent the dimensions postulated by the Phase model. The FEP proved to be a psychometrically well-founded transdiagnostic measure of outcome and change which represents multidimensional phases of change. Its application in outcome monitoring is recommended.

Post-stroke depression and post-stroke anxiety: prevalence and predictors.

BACKGROUND: Epidemiological research on post-stroke affective disorders has been mainly focusing on post-stroke depression (PSD). In contrast, research on post-stroke anxiety (PSA) is in its early stages. The present study proposes a broad picture on post-stroke affective disorders, including PSD and PSA in German stroke in-patients during rehabilitation. In addition, we investigated whether lifetime affective disorders predict the emergence of PSD and PSA. METHODS: 289 stroke patients were assessed in the early weeks following stroke for a range of mood and anxiety disorders by means of the Structured Clinical Interview relying on the Diagnostic and Statistical Manual of Mental Disorders IV. This assessment was conducted for two periods: for post-stroke and retroactively for the period preceding stroke (lifetime). The covariation between PSD and PSA was investigated using Spearman-ρ correlation. Predictors of PSD and PSA prevalence based on the respective lifetime prevalence were investigated using logistic regression analyses. RESULTS: PSD prevalence was 31.1%, PSA prevalence was 20.4%. We also found significant correlations between depression and anxiety at post-stroke and for the lifetime period. Interestingly, lifetime depression could not predict the emergence of PSD. In contrast, lifetime anxiety was a good predictor of PSA. CONCLUSIONS: We were able to highlight the complexity of post-stroke affective disorders by strengthening the comorbidity of depression and anxiety. In addition, we contrasted the predictability of PSA based on its lifetime history compared to PSD which was not predictable based on lifetime depression.

Relevance of therapy goals in outpatient cognitive-behavioral and psychodynamic psychotherapy.

OBJECTIVE: Against a background of sparse research and contradictory findings, the present study investigates determinants of psychotherapy goals and predictive value for therapy success in outpatient psychotherapy. METHOD: The sample consisted of 473 patients from a university-based polyclinic and their corresponding 103 therapists. Goals were coded with the Bern Inventory of Treatment Goals (BIT-T). RESULTS: The results show that goal congruence between therapists and patients is relatively small. Theoretical orientation had a significant influence on the complexity of goal structure and goal preferences. With regard to the prognostic validity, only patients' problem- and symptom-focused goals enabled the prediction of treatment success independent of basic therapeutic variables. CONCLUSIONS: These findings underline the importance of consideration of patients' individual treatment goals in clinical practice and underpin the relevance of therapy goals for future psychotherapy research.

[Latent classes of personality disorders: group comparisons and course of psychotherapy]. / Latente Klassen von Persönlichkeitsstörungen: Gruppenvergleiche und Psychotherapieverläufe.

Using latent class analysis the Personality Disorder Screening (PDS) classifies patients into 4 groups: personality disordered (PD) patients (PDS+), healthy patients (PDS -) and 2 hybrid classes with exaggerated personality styles (histrionic/dependent and avoidant/obsessive-compulsive). The present study investigated if the PDS groups differ concerning sociodemographic and clinical variables, psychological distress and treatment outcome. We analyzed the PDS response patterns of 555 outpatients. PDS+ group membership is associated with typical PD characteristics, chronic depression and a high level of general psychological distress. Patients of both hybrid classes are found to show average psychological distress. The treatment was effective for all patients. Membership in the histrionic/dependent hybrid class is associated with early drop out from outpatient therapy.

Dynamic testing in schizophrenia: does training change the construct validity of a test?

Dynamic testing typically involves specific interventions for a test to assess the extent to which test performance can be modified, beyond level of baseline (static) performance. This study used a dynamic version of the Wisconsin Card Sorting Test (WCST) that is based on cognitive remediation techniques within a test-training-test procedure. From results of previous studies with schizophrenia patients, we concluded that the dynamic and static versions of the WCST should have different construct validity. This hypothesis was tested by examining the patterns of correlations with measures of executive functioning, secondary verbal memory, and verbal intelligence. Results demonstrated a specific construct validity of WCST dynamic (i.e., posttest) scores as an index of problem solving (Tower of Hanoi) and secondary verbal memory and learning (Auditory Verbal Learning Test), whereas the impact of general verbal capacity and selective attention (Verbal IQ, Stroop Test) was reduced. It is concluded that the construct validity of the test changes with dynamic administration and that this difference helps to explain why the dynamic version of the WCST predicts functional outcome better than the static version.