Four Versions of Transtheoretical Stances, and the Bernese View.

A brief characterization of transtheoretical stances to which existing approaches can be allocated is followed by a description of the "Bernese view", that is, what Klaus Grawe and his colleagues, including the authors of this article have developed: the origins, a model of the multiple constraint satisfaction construction of therapist action, a discussion of psychotherapy integration, the crucial role of supervisors in an integrative multiple constraint satisfaction approach, and a discussion of when and how trainees should be introduced to a transtheoretical stance.

A longitudinal view of an approach to responsiveness: Principles followed and lessons learned.

AbstractResponsiveness is currently a hot topic in the psychotherapy literature with a large variation in what the term means to colleagues of various orientations. This adds to its popularity but limits the scope of whatever is written or said about responsiveness. The fact that the meaning of responsiveness has developed over time within the approaches adds also to the variation, while an understanding of development has the potential of deepening the understanding of each approach. As a fair description and comparison of even just the most important approaches is by far out of reach for a page-limited article, the development of one approach, which may be termed the "Bernese" approach is described here, along with lessons learnt and general comments. The approach includes Plan Analysis case formulations, the concept of complementary or Motive-Oriented Relationship, a description of a combined qualitative and quantitative assessment, and many methodological and conceptual considerations. Personal development is woven in. Overall, it seems fair to say that this approach, at its core developed long before responsiveness became popular, has turned out to still be useful, with a gain in depth as far as concepts and assessment are concerned.

Using case formulation for prediction of the therapeutic alliance in treatment for borderline personality disorder.

Case formulation is a central tool for psychotherapists, which helps them tailor psychotherapy to the individual patient, particularly for treatments for complex and multilayered clinical problems, such as personality disorders (Kramer, 2019). Case formulation methodologies are still underutilized in psychotherapy research in the prediction of therapy processes. The present study included N = 60 patients with borderline personality disorder undergoing a brief treatment using an individualized treatment component (n = 31), as compared with a standard brief treatment (n = 29; Kramer et al., 2014). For each patient (in both groups as post hoc analysis based on videos), we performed a Plan analysis case formulation (Caspar, 2019): the idiographic information from the formulation was translated into quantitative scores (on a Likert-type scale) assessing patient's interactional agreeableness (vs. antagonism; Zufferey et al., 2019). We modeled the session-by-session predictions of the progression of the therapeutic alliance-rated by the patient and the therapist-over the course of treatment, as a function of interactional agreeableness, the individualization of treatment, as well as their interaction with the session number. Patients with high levels of agreeableness have a significant increase in their alliance assessment over time. Treatment based on the case formulation predicted session-by-session increase of the therapeutic alliance as rated by the therapists. This study was the first to explore intra- and interindividual dynamics of the therapeutic alliance in relationship with idiographic information extracted from case formulations. The results may help understand relationship struggles at the beginning of therapy for complex clinical problems, such as borderline personality disorder. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The impact of integrating emotion focused components into psychological therapy: A randomized controlled trial.

OBJECTIVES: This paper presents a randomized controlled trial on assimilative integration, which is aimed at integrating elements from other orientations within one approach to enrich its conceptual and practical repertoire. Elements from Emotion-Focused Therapy (EFT) were integrated into a form of cognitive behavior therapy: Psychological Therapy (PT). In one treatment condition, EFT was added to PT (+EFT) with the intent to enhance therapists' working with emotions. In the other condition, concepts and interventions based on the socialpsychological self-regulation approach were added to PT (+SR). Our assumption was that the +EFT would lead to greater and deeper change, particularly in the follow-up assessments. METHOD: Patients (n = 104) with anxiety, depression, or adjustment disorders were randomized to the two conditions and treated by 38 therapists who self-selected between the conditions. Primary outcome was symptom severity at 12-month follow-up; secondary outcomes included several measures such as interpersonal problems and quality of life. Variables were assessed at baseline, after 8 and 16 sessions, at posttreatment, and at 6- and 12-month follow-up. RESULTS: Contrary to our hypothesis, no significant between-group effects were found. CONCLUSION: The findings first suggest the difficulty of topping an already very effective approach to psychotherapy. Alternative interpretations were that the EFT training, while corresponding to regular practice in AI, was not sufficient to make a difference in outcome, or that while profiting from the enhancement of abilities for working with emotions, this was outbalanced by negative effects of difficulties related to the implementation of the new elements.

Disaggregating between- and within-patient effects of ruptures and resolutions on the therapeutic alliance and symptom severity.

The therapeutic alliance is considered a robust predictor of psychotherapy outcome. Ruptures and resolutions in the alliance have been the focus of recent alliance literature. Most previous studies investigated their between-patient effects. We used hierarchical linear models to disaggregate the between- and within-patient effects of ruptures on the alliance from patient- and therapist perspective and symptom severity. Further, the moderating effects of rupture resolutions were analyzed. The sample consisted of 56 patients diagnosed with depressive or anxiety disorders who received 25 ± 3 sessions of integrative cognitive behavioral therapy in the outpatient setting. The observer-rated rupture resolution rating system was applied to all 1st, 8th, 16th and 24th therapy sessions. The alliance quality and symptom severity were assessed using self-report questionnaires after these four sessions. Results showed that a higher intensity of ruptures across treatment was associated with lower alliance ratings from both patient- and therapist perspectives during treatment. After sessions with more intense confrontation ruptures, both reported a weaker alliance. Rupture resolutions significantly moderated the withdrawal rupture effect on the alliance. The results provide meaningful practical implications for therapist feedback and training. They further underline the importance of using appropriate statistical analyses to the data structure and nature of psychotherapy to better understand the role of the alliance, rupture, and repair during therapy. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

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

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

A longitudinal analysis of reflective functioning and its association with psychotherapy outcome in patients with depressive and anxiety disorders.

The ability to mentalize has been discussed as potential change mechanism in psychotherapy. Reflective functioning (RF) offers an empirical framework for the assessment of mentalization in therapy sessions. In the present study, we assessed RF longitudinally and examined its association with symptomatic distress, symptom severity of depression and anxiety, and interpersonal problems over the course of treatment. Thirty-seven patients diagnosed with depression or anxiety disorders received 25 ± 3 sessions of integrative cognitive-behavioral therapy (CBT) in an outpatient setting. The observer-rated in-session Reflective Functioning Scale (RFS) was applied to transcripts of therapy Sessions 1, 8, 16, and 24. The effects of RF were investigated both within and between patients using hierarchical linear modeling. RF significantly increased over the course of treatment, and this improvement in RF was significantly associated with depressive symptoms. This means that after a session where patients positively deviated from their own average RF during treatment, they reported lower depression severity. In post hoc analyses, we found a significant interaction effect of the within- and between-patient RF effects on interpersonal problems. Patients with overall higher levels of RF and with positive deviations from their own average RF over the course of treatment tended to have less interpersonal problems during psychotherapy. The present study contributes to the preliminary evidence that changes in RF may serve as a common factor in psychotherapy in contrast to being a specific factor in psychodynamic therapies. More longitudinal studies are necessary to gain a better understanding of RF as a change mechanism in psychotherapy. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Psychotherapeutic case formulation: Plan analysis for narcissistic personality disorder.

BACKGROUND: One of the relevant case formulation methods for personality difficulties is plan analysis. The present study aimed at delivering a prototypical plan analysis for clients presenting with a diagnosis of narcissistic personality disorder (NPD). The sample consisted of 14 participants diagnosed with an NPD. Based on audio clinical material, we developed 14 individual plan analyses that we then merged into a single prototypical plan analysis. For explorative purposes, we ran an ordinary least squares regression model to predict the narcissistic symptoms severity (NAR) measured on a scale of 1-7 of the 14 clients by the presence (respectively absence) of certain plans in their individual plan analysis. The synthesis revealed that clients with pathological narcissism share common basic motives. Results of the regression model reveal that the presence of the plan 'be strong' reduces the NAR scale by 1.52 points (p = 0.011). DISCUSSION: In the treatment of psychological disorders, precise case formulations allow therapists for making clinically appropriate decision, personalizing the intervention and gaining insight into the client's subjective experience. In the prototypical plan structure we developed for NPD, clients strive to strengthen their self-esteem and avoid loss of control, criticism and confrontation as well as to get support, understanding and solidarity. When beginning psychotherapy with a client presenting with NPD, the therapist can use these plans as valuable information to help writing tailored, and therefore more efficient, case formulations for their patients presenting with an NPD.

Disentangling within- and between-patient effects of defensive functioning on psychotherapy outcome using mixed models.

Abstract There is a great need to identify predictors of treatment response, and the analysis of defense mechanisms is a promising approach. Defensive functioning may influence psychotherapy outcome in two ways: First, when it is generally higher or lower for some patients relative to others and second, as it shifts in individual patients over time. The present study examined both within- and between patient effects of defenses using hierarchical linear modeling. Forty-seven patients diagnosed with depression, anxiety, or adjustment disorders received 25 ± 3 sessions of integrative cognitive-behavioral therapy in a university outpatient clinic. The Defense Mechanism Rating Scale (DMRS) was used to assess defenses in the 1st, 8th, 16th, and 24th session and relate them to symptom severity of depression and anxiety. A higher number of adaptive defense mechanisms was associated with less severe depressive symptoms during treatment while a higher number of immature defenses was related to more severe depressive and anxiety symptoms. An increase in adaptive and a decrease in immature defenses over the course of treatment predicted symptom reduction of depression whereas a decrease in neurotic and immature defenses was associated with reductions in anxiety symptoms. Our results empirically support defensive functioning as a mechanism of change in psychotherapy.

Using the Personalized Advantage Index for individual treatment allocation to cognitive behavioral therapy (CBT) or a CBT with integrated exposure and emotion-focused elements (CBT-EE).

Even though different psychotherapeutic interventions for depression have shown to be effective, patients suffering from depression vary substantially in their treatment response. The goal of this study was to answer the following research questions: (1) What are the most important predictors determining optimal treatment allocation to cognitive behavioral therapy (CBT) or CBT with integrated exposure and emotion-focused elements (CBT-EE)?, and (2) Would model-determined treatment allocation using this predictive information result in better treatment outcomes? Bayesian Model Averaging (BMA) was applied to the data of a randomized controlled trial comparing the efficacy of CBT and CBT-EE in depressive outpatients. Predictions were made for every patient for both treatment conditions and an optimal versus a suboptimal treatment was identified in each case. An index comparing the two estimates, the Personalized Advantage Index (PAI), was calculated. Different predictors were found for both conditions. A PAI of 1.35 BDI-II points for the two conditions was found and 46% of the sample was predicted to have a clinically meaningful advantage in one of the therapies. Although the utility of the PAI approach must be further confirmed in prospective research, the present study study promotes the identification of specific interventions favorable for specific patients.

Social interaction patterns, therapist responsiveness, and outcome in treatments for borderline personality disorder.

OBJECTIVES: Inflexible social interaction patterns are defining features of borderline personality disorder (BPD). Specific beliefs about the self and others may be activated across interaction situations, often leading to instable relationships. It may be pivotal to address these difficulties in early treatment phases, through appropriate therapist responsiveness, which means an adaptation of therapist's activity to their client's behaviours using emerging information in the process (Stiles, 2009, Clinical Psychology: Science and Practice, 16, 86). DESIGN: In this process-outcome study, responsiveness is operationalized by the motive-oriented therapeutic relationship (Caspar, 2007, Handbook of psychotherapeutic case formulations, 2nd ed., 251-289, Guilford), based on the Plan analysis case formulation. The present study assesses the interplay between social interaction problems and therapist responsiveness, explaining symptoms at discharge and the therapeutic alliance. METHOD: In total, N = 50 clients with BPD entered the study, and standard and responsive treatments were compared. Social interaction patterns were assessed by the newly developed Borderline Interaction Patterns Scale (BIPS), applied to recorded material of three sessions per therapy. Outcome was measured by general symptoms (OQ-45), borderline symptoms (BSL-23), interpersonal problems (IIP), and the therapeutic alliance (WAI). RESULTS: Results suggest that in standard treatment, social interaction patterns are neither related to outcome nor the therapeutic alliance. In responsive treatment, more activation of social interaction patterns predicted better outcome on IIP and lower therapist ratings of the alliance. CONCLUSIONS: The conclusions seem promising for specific effectiveness of responsive treatments in particular in the interpersonal problem area of BPD. Identifying social interaction patterns early in treatment may be a crucial pathway to change for BPD. PRACTITIONER POINTS: Responsive therapy activating social interaction patterns may be crucial for better outcome. Future research should focus on mechanisms of change in early treatment phases for BPD. New scale for assessing social interaction patterns specific to borderline personality disorder.

Comparison and change of defense mechanisms over the course of psychotherapy in patients with depression or anxiety disorder: Evidence from a randomized controlled trial.

BACKGROUND: Defense mechanisms play an important role in the development and maintenance of both health and psychopathology. Research is still in the early stages of investigating the specific relationships among diagnostic groups and defense mechanisms along with their response to different treatment types. METHODS: For the present study a total of 47 outpatients diagnosed with depression or anxiety disorders were randomized to receive 25±3 sessions of cognitive-behavioral therapy with integrated elements of either emotion-focused therapy (CBT + EFT) or treatment components based on self-regulation theory (CBT + SR). An observer-rated method, the Defense Mechanism Rating Scale (DMRS) was used to code transcripts of the 1st, 8th, 16th and 24th session to assess change in defensive functioning. RESULTS: Over the course of therapy, overall defensive functioning (ODF) as well as adaptive defenses increased significantly, whereas maladaptive and neurotic defenses did not change. At the beginning of treatment, the proportion of adaptive defenses and ODF was significantly higher in patients diagnosed with anxiety disorders than in patients with depressive disorders. However, depressed patients exhibited greater improvement in their defensive functioning over the course of therapy. CONCLUSIONS: Results support the view of defense mechanisms as a useful transdiagnostic and transtheoretical concept and supports the notion that change of defense mechanisms may be a relevant mechanism of change in psychotherapy.

Investigating the impact of early alliance on predicting subjective change at posttreatment: An evidence-based souvenir of overlooked clinical perspectives.

[Correction Notice: An Erratum for this article was reported in Vol 66(5) of Journal of Counseling Psychology (see record 2019-58882-002). In the article, a portion, +γ40ERit, was omitted in the Model 3 formula. The corrected formula is presented in the erratum. All versions of this article have been corrected.] Despite meta-analytic evidence showing that alliance is associated with posttreatment outcomes, several open questions still remain regarding this relation. First, we investigate whether (or not) the progressive aggregation of early alliance assessments increases the alliance-outcome relation across 2 distress and 4 subjective change measures. Second, we investigate whether the alliance-outcome relations using subjective change measures are independent from intake distress and early response. Third, we explore whether the progressive aggregation of the alliance on outcomes becomes particularly apparent between or within therapists again investigating these six outcome measures. Data were drawn from N = 430 patients treated by N = 151 therapists. Patient ratings of early alliance were assessed after Session 1 to 6. For outcome, 2 commonly used distress measures at intake and at posttreatment and 4 measures of retrospectively evaluated subjective change at posttreatment are integrated into a series of multilevel models. The proportion of variance in outcome predicted by alliance scores varied considerably depending on the number of alliance assessments which were aggregated, as well as on the type of outcome assessment (distress vs. subjective change measures) explaining up to 15% of outcome variance. Improvements in the strength of prediction with aggregated alliance assessments were most pronounced for subjective change measures for between-therapist components of the alliance. Examining associations with subjective change measures provides an additional, patient-centered perspective of the relation between early alliance and treatment outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The Role of Interactional Agreeableness in Responsive Treatments for Patients With Borderline Personality Disorder.

It has been shown that agreeableness of patients with borderline personality disorder (BPD) had an impact on therapy process and outcome (Hirsh, Quilty, Bagby, & McMain, 2012). The goal of our study was to test whether agreeableness affects the therapeutic alliance and outcome assessed after brief treatment for BPD, and whether this link is moderated by therapist responsiveness. We compared two types of interventions (N = 60) in 10-session treatments (Kramer et al., 2014): a general psychiatric management (GPM)-based treatment and the same treatment supplemented with motive-oriented therapeutic relationship (MOTR), based on plan analysis case conceptualizations (PA; Caspar, 1995), as operationalization of therapist responsiveness. The results showed that there was a significant link between agreeableness and outcome for the GPM, but not for the MOTR. No links between agreeableness and the therapeutic alliance were found in both conditions. MOTR enables suppression of the influences of the patient's initial characteristics on the therapeutic results.

Impact of confrontations by therapists on impairment and utilization of the therapeutic alliance.

OBJECTIVE: Striking the balance between creating challenge through confrontation (drawing attention to discrepancies) to encourage change and offering support through the therapeutic relationship to ensure safety for patients represents a central issue for psychotherapists. The aim of the present study was to assess immediate effects of confrontations by therapists on the therapeutic alliance. METHOD: We rated video recordings of 77 therapies to measure incidences of alliance ruptures/resolution attempts as well as confrontations by therapists. Change in the therapeutic alliance and therapy outcome were measured through questionnaires filled out by patients. RESULTS: Confrontations were significantly associated with ruptures/resolution attempts on the micro level. Changes in the therapeutic alliance moderated the association between confrontations and alliance ruptures on the macro level: The bigger the fraction of a session containing confrontations, the larger the fraction containing ruptures, given a prior positive change in the therapeutic alliance. Therapists' use of confrontation during a resolution attempt was associated with significantly better therapy outcomes than no use of confrontation during or no resolution attempt. CONCLUSIONS: Confrontations by therapists may temporarily impair the therapeutic alliance, but might also lead to better therapy outcomes when used to make an alliance rupture explicit as part of a resolution attempt. Clinical or methodological significance: This study provides quantitative explorations of therapists' fears and hopes regarding the use of confrontations (defined as focus on a discrepancy by the therapist). Results point to associations between confrontations and alliance ruptures, especially in the context of a secure alliance. Furthermore, resolution attempts might profit from initial confrontations regarding the relevant alliance rupture.

Alleviation of Psychological Distress and the Improvement of Quality of Life in Patients With Amyotrophic Lateral Sclerosis: Adaptation of a Short-Term Psychotherapeutic Intervention.

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease that is inevitably fatal. To be diagnosed with a terminal illness such as ALS deeply affects one's personal existence and goes along with significant changes regarding the physical, emotional, and social domains of the patients' life. ALS patients have to face a rapidly debilitating physical decline which restrains mobility and impairs all activities of daily living. This progressive loss of autonomy may lead to a sense of hopelessness and loss of quality of life, which in turn may even result in thoughts about physician-assisted suicide. Here, we would like to propose a psychotherapeutic manualized, individual, semi-structured intervention to relieve distress and promote psychological well-being in ALS patients. This short-term intervention was originally developed for advanced cancer patients. "Managing Cancer and Living Meaningfully (CALM)" focuses on the four dimensions: (i) symptom management and communication with healthcare providers, (ii) changes in self and relations with close others, (iii) spirituality, sense of meaning and purpose and (iv) thinking of the future, hope, and mortality. We suggest to supplement the concept by two additional dimensions which take into account specific issues of ALS patients: (v) communication skills, and (vi) emotional expression and control. This therapeutic concept named "ManagIng Burden in ALS and Living Meaningfully (mi-BALM)" may be a further treatment option to help improving quality of life of ALS patients.

Studying Effects and Process in Psychotherapy for Personality Disorders.

This presentation gives an overview of the methods used for research on the process and outcome of psychotherapy. Possibilities as well as difficulties will be discussed, such as the conflict between internal and external validity and standardized versus individualized procedures as some of the issues deserving particular attention for research on psychotherapy for personality disorder patients. It is argued that good psychotherapy research is also good psychotherapy research for personality disorders, with heterogeneity, ego-syntony, and ambivalent motivation needing special attention. Adaptations of and alternatives for randomized clinical trials will be discussed.

Change in Biased Thinking in a Treatment Based on the Motive-Oriented Therapeutic Relationship for Borderline Personality Disorder.

Biased thinking is a common feature of patients presenting with borderline personality disorder (BPD). For the treatment of BPD, it was shown that the individualizing of the treatment, by using the motive-oriented therapeutic relationship (MOTR), had a beneficial short-term effect on process and outcome. So far, it remains unclear what the role of early change in biased thinking is in these treatments. The present study aims to assess whether there is a link between the MOTR, change in biased thinking, and outcome. The sample (N = 60) is based on a randomized controlled trial with two conditions: (a) 30 patients in a 10-session version of psychiatric management, and (b) 30 patients in a 10-session version of psychiatric management augmented with the MOTR. For each patient, three sessions (intake, middle, late) were selected, transcribed, and rated using the Cognitive Errors Rating Scale (CERS). An overall decrease of negative cognitive errors during 10 sessions of treatment was observed, independently of the treatment condition. No specific effect related to change in biased thinking may be attributed to the individualizing of the treatment. These results are discussed with regard to mechanisms of change in treatments for BPD, in particular with regard to the central role that biased thinking, as well as the MOTR, might play early in treatment.

Deficits in general emotion regulation skills-Evidence of a transdiagnostic factor.

OBJECTIVE: Deficits in emotion regulation (ER) skills are discussed as a transdiagnostic factor contributing to the development and maintenance of various mental disorders. However, systematic comparisons of a broad range of ER skills across diagnostic groups that are based on comparable definitions and measures of ER are still rare. METHOD: Therefore, we conducted two studies assessing a broad range of ER skills with the Emotion Regulation Skills Questionnaire in individuals meeting criteria for mental disorders (N1  = 1448; N2  = 137) and in a general population sample (N = 214). RESULTS: Consistent across the two studies, participants in the clinical samples reported lower general and lower specific ER skills than participants in the general population sample. Also consistent across the two studies, diagnostic subgroups of the clinical samples differed significantly with regard to general and specific ER skills. CONCLUSION: The studies provide evidence that deficits in ER are associated with various forms of psychopathology. However, mental disorders seem to differ with regard to how strongly they are linked to ER skills.