"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.

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.

The association between quality of therapeutic alliance and treatment outcomes in teletherapy: A systematic review and meta-analysis.

OBJECTIVE: The strength of the therapeutic alliance is widely understood to impact treatment outcomes, however, the alliance-outcome relationship in teletherapy has remained relatively unexamined. The aim of this meta-analysis is to systematically summarize the relationship between therapeutic alliance and treatment outcomes in teletherapy with adult patients conducted via videoconferencing or telephone. METHODS: We conducted a systematic search of the databases PsycINFO, PsycARTICLES, ProQuest Dissertation Databases, EMBASE, The Cochrane Library, MEDLINE, Google Scholar, and PubMed for studies published before June 26, 2023. We identified 31 studies with 34 independent samples (4862 participants). RESULTS: The average weighted effect size was 0.15, p = .001, 95% CI [0.07, 0.24], k = 34. reflecting a small effect of therapeutic alliance on mental health outcomes. There was significant heterogeneity in the effect sizes, which was driven by between-study differences in the alliance-outcome correlation. The alliance-outcome effect was larger when the alliance was measured late in treatment and when the outcome was measured from the patient's perspective. CONCLUSION: Very few teletherapy treatment studies were identified that initially reported on alliance-outcome associations, underlining that this is an under-researched area. The association between alliance-teletherapy outcomes in this meta-analysis was small but significant, and somewhat weaker than the alliance-outcome associations reported for in-person treatments and other online interventions. This might indicate that there are other processes at play in teletherapy that explain variance of treatment outcomes, or that the therapist (and the relationship) has less influence on the treatment outcomes than in in-person therapy.

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.

Therapist-Reported Differences between Teletherapy via Phone and via Videoconferencing.

When therapists provide teletherapy they can choose between teletherapy via phone and teletherapy via videoconferencing, however, little is known about differences between using these two teletherapy formats. We aimed to compare therapists' attitudes, level of professional self-doubt, and experience of the therapeutic relationship in sessions conducted via phone versus via videoconferencing. We administered an online survey to 117 therapists who had experience with sessions both via phone and videoconferencing. The results suggested that therapists' attitudes and perceptions of the therapeutic relationship were similar. However, therapists' level of professional self-doubt was higher in sessions conducted via videoconferencing. Therapists with previous experience of conducting teletherapy via phone perceived phone sessions more positively. Thus, familiarity with videoconferencing technology might be more important in shaping therapists' attitudes and confidence than the type of technology per se. This highlights the importance of practicing with new technologies.

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.

Mastery of teletherapy is related to better therapeutic relationship and presence in teletherapy: the development of the teletherapy intervention scale.

Introduction: Providing teletherapy requires a unique therapeutic approach and mastery of the teletherapy context. We aimed to develop a self-report scale for therapeutic interventions pertinent to teletherapy, and to examine its relationship with teletherapy process variables, and therapists' attitudes towards teletherapy technology. Method: A total of 839 therapists participated in a survey study that included standardized measures of therapeutic process (real relationship, working alliance, therapeutic presence), attitudes towards and intention to use teletherapy in the future, and a list of 13 teletherapy intervention items that we hypothesized to be specific to the teletherapy format. Results: Twelve of the 13 teletherapy intervention items loaded on one factor, with good reliability. The 12-item Teletherapy Intervention Scale was positively related to working alliance, the real relationship, therapeutic presence in teletherapy sessions, as well as to positive attitudes towards teletherapy and intention to use teletherapy in the future. Discussion: Aspects specific to the practice of teletherapy may be successfully captured by a self-report scale, and adequately navigating the challenges and opportunities of teletherapy might enhance the therapeutic process. Further studies are needed to provide additional validation of the scale, and in how to best use this Teletherapy Intervention Scale in research and clinical training.

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.

Heterogeneity in trajectories of traumatic distress at the start of the COVID-19 pandemic.

OBJECTIVE: The COVID-19 outbreak has led to an increase in posttraumatic stress symptoms (PTSSs; Prout et al., 2020) for some individuals, whereas others appeared to be more resilient. It remains relatively unclear what characterizes these potentially different response trajectories ( Chen & Bonanno, 2020). This study sought to (a) assess individuals' PTSS levels at the start of the pandemic and at two subsequent timepoints 3 and 6 months later, (b) identify different trajectories of PTSSs over time, and (c) describe which individual characteristics influenced the likelihood of each of these different trajectories to occur. METHOD: A community sample (n = 317) responded to an online survey during the first weeks of the pandemic, 3 and 6 months later. RESULTS: Among those who reported acute levels of PTSSs, latent class growth analyses identified three different resilience trajectories-resilient (low baseline PTSSs and a slight decrease over time), chronic (severe PTSSs at baseline and no change over time), and recovered (severe PTSSs at baseline but a sharp improvement over time). Baseline childhood adversity, depression, anxiety, defensive functioning, and somatization predicted trajectories. Demographics (age, gender, preexisting chronic illness) and COVID-related factors (knowing someone diagnosed with or who died of COVID-19) were unrelated to trajectories. CONCLUSIONS: Results suggest that although high PTSS levels decreased over time on average, heterogenous change trajectories can be identified based on baseline psychological characteristics. This implies that mental health, including past and present experiences, as well as adaptational mechanisms may shape individuals' experiences with pandemic-related ongoing stress. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

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.

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.

The Relationship Between Patients' Personality Traits, the Alliance, and Change in Interpersonal Distress in Intensive Group Treatment for Personality Dysfunction.

This study examined patients' personality traits as operationalized by the five-factor model in relation to early alliance and reduction of interpersonal distress through an intensive group treatment program for personality dysfunction. A sample of 79 consecutively admitted psychiatric outpatients with personality dysfunction who attended an 18-week intensive group treatment program completed the NEO Five-Factor Inventory at pretreatment, the Inventory of Interpersonal Problems at pre- and posttreatment, and the Edmonton Therapeutic Alliance Scale, a measure of the therapeutic alliance with the program therapist, at Session 5. Results indicated that patients who were relatively extraverted tended to rate the alliance with their program therapist higher and subsequently reported more improvement of interpersonal distress. The presence of a personality disorder did not moderate this mediation. Patients' extraversion likely promotes a bonding with the therapist and facilitates the interpersonal group work necessary for improvement. Assessing patients' level of extraversion before starting intensive group treatment might indicate which intervention strategies could be useful with that patient within the program frame.

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.

Practicing Online During COVID-19: Psychodynamic and Psychoanalytic Therapists' Experiences.

During the Covid-19 pandemic, psychotherapists quickly transitioned to provide online therapy, while facing many challenges. This study aimed to explore psychodynamic and psychoanalytically oriented therapists' (N = 1450) experiences with online therapy during the first weeks of the pandemic and two months later. Results showed that therapists had little pre-pandemic experience with providing online therapy and even less training in it, and that younger therapists reported more challenges in the transition to online therapy. During the first weeks of the pandemic, most therapists thought that online therapy was less effective than in-person therapy, and they reported a wide range of relational and technical challenges, feeling more tired, less confident and competent, and less connected and authentic in online sessions, compared to previous in-person sessions. At follow-up, therapists viewed online therapy as more comparable to in-person therapy; the majority felt connected and authentic as they had during the initial weeks of the pandemic, or more so, but were still as tired as before. The most challenging aspect of online therapy was distraction in sessions, which increased over time. This study demonstrates the professional adaptability of therapists and highlights the need for more training and professional support for clinicians providing remote psychotherapy.

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.