Treatment Effects of Introducing the Neurosequential Model of Therapeutics in a Norwegian Residential Treatment Facility for Children Aged 7-13.

This study investigates the impact of the Neurosequential Model of Therapeutics (NMT) in child and adolescent psychiatric care, addressing a gap in current clinical methodologies that tend to focus on single problems rather than the interconnected nature of many real-life mental health issues. The study was conducted in a residential setting over an extended period, including children aged 7-13, to observe the effects of implementing NMT. The children presented with complex symptoms and multiple diagnoses. The methods incorporated the NMT approach, emphasizing individualized treatment plans based on each child's unique brain development, and aimed at addressing multiple, interconnected problems simultaneously. Results from multilevel model analyses of behavioral difficulties, measured using the Child Behavior Checklist (CBCL), revealed substantial improvements in treatment effectiveness post-NMT implementation. Despite the limitations, such as a non-randomized participant selection and limited sample size, the findings strongly suggest that NMT enhances care effectiveness in real-world clinical settings, particularly for children with complex mental health issues. The study concludes that relationally oriented milieu therapy, and specifically the NMT approach, holds great promise for advancing pediatric psychiatric care, advocating for its broader application and further research to refine and substantiate its efficacy.

Medication-Free Treatment in Mental Health Care How Does It Differ from Traditional Treatment?

Background: Norwegian authorities have implemented treatment units devoted to medication-free mental health treatment nationwide to improve people's freedom of choice. This article examines how medication-free treatment differs from treatment as usual across central dimensions. Methods: The design was mixed methods including questionnaire data on patients from a medication-free unit and two comparison units (n 59 + 124), as well as interviews with patients (n 5) and staff (n 8) in the medication-free unit. Results: Medication-free treatment involved less reliance on medications and more extensive psychosocial treatment that involved a culture of openness, expression of feelings, and focus on individual responsibility and intensive work. The overall extent of patient influence for medication-free treatment compared with standard treatment was not substantially different to standard treatment but varied on different themes. Patients in medication-free treatment had greater freedom to reduce or not use medication. Medication-free treatment was experienced as more demanding. For patients, this could be connected to a stronger sense of purpose and was experienced as helpful but could also be experienced as a type of pressure and lack of understanding. Patients in medication-free treatment reported greater satisfaction with the treatment, which may be linked to a richer psychosocial treatment package that focuses on patient participation and freedom from pressure to use medication. Conclusion: The findings provide insights into how a medication-free treatment service might work and demonstrate its worth as a viable alternative for people who are not comfortable with the current medication focus of mental health care. Patients react differently to increased demands and clinicians should be reflexive of the dimensions of individualism-relationism in medication-free treatment services. This knowledge can be used to further develop and improve both medication-free treatment and standard treatment regarding shared decision-making. Trial Registration: This study was registered with ClinicalTrials.gov (Identifier NCT03499080) on 17 April 2018.

Psychometric properties of the affect integration inventory - short form in a sample of patients with personality disorder.

Introduction: Affect integration comprises the capacity to access and utilize the motivational and signal properties of affects. This capacity is essential for personal adjustment, mental health, and well-being. Affect integration is commonly operationalized through the Affect Integration Inventory. This study examines the psychometric properties of a short-form (AII-SF-42) of the instrument in a sample of patients with personality disorders (n = 87). Methods: Analyses of internal-consistency reliability, along with standardized mean differences-, and associations between short- and long-forms are reported. Internal structure was assessed by confirmatory factor analyses and external criterion validity was addressed by tests of associations between the AII-SF-42-scale scores and measures of alexithymia, symptom distress, interpersonal problems and level of personality dysfunction. Results: The study demonstrated satisfactory reliability and validity for scores derived from the AII-SF-42, including acceptable internal consistency and strong correspondence with long-form scores, a consistent factor structure organized according to discrete affects, and systematic patterns of convergent and discriminant associations with external measures. Conclusion: Taken together, the results of the study demonstrate that in clinical settings, including patients with personality disorders the AII-SF-42 is a valid and useful alternative to the full-length version of the instrument.

Self-compassion and fear of compassion in the treatment of chronic depression: Mechanisms of change?

OBJECTIVE: The aim of this naturalistic process study was to investigate the relationship between self-compassion, fear of compassion from others, and depressive symptoms over the course of psychotherapy in patients with chronic depression. METHOD: A sample of 226 patients with chronic depression who received inpatient short-term psychodynamic psychotherapy (STPP) provided weekly self-report measures of self-compassion, fear of compassion, and depressive symptoms (Patient Health Questionnaire-9). Trivariate latent curve modeling with structured residuals was applied to investigate the between- and within-patient relationships among the variables. RESULTS: At the between-patient level, a significant positive correlation was found between slope of depression and the slope of fear of compassion. At the within-patient level, a lower than expected level of fear of compassion predicted a subsequent lower than expected level of depression (mean weekly effect size = 0.12), with a smaller reciprocal relationship (mean weekly effect size = 0.08). There was no significant within-patient effect of self-compassion predicting subsequent depression, but a significant effect of a lower than expected level of depression predicting a subsequent higher than expected level of self-compassion (mean weekly effect size = -0.13). No within-patient effect between self-compassion and fear of compassion was found. CONCLUSIONS: In the context of this study, it appears that fear of compassion may be a putative mechanism of change involved in alleviating depressive symptoms in patients with chronic depression treated with STPP. On the other hand, self-compassion appears to be an outcome of psychotherapy. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Driven or lacking access: Integration types as a subdimension of the affect consciousness construct.

Introduction: This article examines integration types as a sub-dimension of the affect consciousness construct to account for individual differences in how problems with the experience and expression of affects manifest. The two integration types driven and lack of access describe prototypical ways of experiencing and expressing affect, differentiating between problems characterized by too much or too little affective mobilization. Methods: Archival data from a non-clinical sample (n = 157) was used to examine the validity and reliability of integration type scales from the Affect Integration Inventory (AII 2.0). Internal structure was assessed through confirmatory factor analyses (CFAs) by structural equation modelling. Nomological validity was examined through tests of patterns of hypothesized associations between integration types across various affects and specific types of interpersonal problems (as measured by the Inventory of Interpersonal Problems; IIP-64). Results: CFAs indicated acceptable fit for the different integration type scales and overall construct structure. Distinct sinusoidal patterns of correlations between integration types and interpersonal problems were found for the various affects examined. All correlation patterns had good fit (GoF ≥ 0.87), with significant differences in magnitude between peak and low point correlations. Discussion: We conclude that differences in prototypical ways of experiencing and expressing affects can be assessed easily, quickly, and reliably, have theoretically consistent intra-domain relationships and valid structural psychometric properties, are robustly related to interpersonal functioning in general, and are systematically and differentially related to specific and theoretically hypothesized interpersonal problem types.

Direction of dependence analysis for pre-post assessments using non-Gaussian methods: a tutorial.

OBJECTIVE: We introduced methods for solving causal direction of dependence between variables observed in pre- and post-psychotherapy assessments, showing how to apply them and investigate their properties via simulations. In addition, we investigated whether changes in depressive symptoms drive changes in social and occupational functioning as suggested by the phase model of psychotherapy or vice versa, or neither. METHOD: As a Gaussian (normal-distribution) model is unidentifiable here, we used an identifiable linear non-Gaussian structural vector autoregression model, conceptualizing instantaneous effects as during-psychotherapy causation and lagged effects as pre-treatment predictors of change. We tested six alternative estimators in six simulation settings that captured different real-world scenarios, and used real psychotherapy data from 1428 adult patients (Finnish Psychotherapy Quality Registry; assessments on Patient Health Questionnaire-9 and Social and Occupational Functioning Assessment Schedule). RESULTS: The methodology was successful in identifying causal directions in simulated data. The real-data results provided no evidence for single direction of dependence, suggesting shared or reciprocal causation. CONCLUSIONS: A powerful new tool was presented to investigate the process of psychotherapy using observational data. Application to patient data suggested that depression symptoms and functioning may reciprocate or reflect third variables instead of one predominantly driving the other during psychotherapy.

Referral assessment and patient waiting time decisions in specialized mental healthcare: an exploratory study of early routine collection of PROM (LOVePROM).

BACKGROUND: Norway has prioritized health services according to the principle of "severity of conditions", where waiting time reflects patients' medical urgency. We aim to investigate if the "severity-of-condition" principle performs well in the priority setting of waiting time, between and within groups of patients using community mental health services. We also aim to investigate the association between patients' diagnoses and symptom severity at the start of treatment and the corresponding waiting time. METHODS: The study analyzed routine data from Lovisenberg electronic Patient-Reported Outcome Measurement (LOVePROM) at Lovisenberg Diaconal Hospital in Norway. We estimated patient-reported severity by using Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM), together with patients' diagnoses to identify patients' needs in general. To assess the performance of current prioritization, we compared waiting times for patients with major depressive disorder and their maximum recommended waiting time. Multivariate regression models were used to assess the association between patient-reported severity, their diagnosis, and waiting times. RESULTS: Of the 6108 mental health disorder patients, patients with moderate to severe conditions waited seven weeks, while patients with mild conditions or below clinical cutoff waited 8 weeks. Included in the sample, 1583 were diagnosed with depression. Results indicated that patients with moderate and severe depression had a slightly shorter wait-time than patients with mild depression. However, 32.4% patients with moderate depression and 83.3% patients with severe depression, waited longer than their maximum recommended waiting time. CORE-OM identified depressive patients with risk-to-self harm, who had a 0.84 weeks shorter wait-time. These results were also applied to patients with other common mental health disorders. CONCLUSION: Overall, patients waited in accordance with the "severity of condition" principle, but the trend was not strong. Therefore, we advocate that there is substantial room for quality improvements in priority setting on waiting time. We suggest further research should investigate if routine collection of PROM and assessment of referral letters, can better inform specialists when deciding on waiting time.

Text Topics and Treatment Response in Internet-Delivered Cognitive Behavioral Therapy for Generalized Anxiety Disorder: Text Mining Study.

BACKGROUND: Text mining methods such as topic modeling can offer valuable information on how and to whom internet-delivered cognitive behavioral therapies (iCBT) work. Although iCBT treatments provide convenient data for topic modeling, it has rarely been used in this context. OBJECTIVE: Our aims were to apply topic modeling to written assignment texts from iCBT for generalized anxiety disorder and explore the resulting topics' associations with treatment response. As predetermining the number of topics presents a considerable challenge in topic modeling, we also aimed to explore a novel method for topic number selection. METHODS: We defined 2 latent Dirichlet allocation (LDA) topic models using a novel data-driven and a more commonly used interpretability-based topic number selection approaches. We used multilevel models to associate the topics with continuous-valued treatment response, defined as the rate of per-session change in GAD-7 sum scores throughout the treatment. RESULTS: Our analyses included 1686 patients. We observed 2 topics that were associated with better than average treatment response: "well-being of family, pets, and loved ones" from the data-driven LDA model (B=-0.10 SD/session/∆topic; 95% CI -016 to -0.03) and "children, family issues" from the interpretability-based model (B=-0.18 SD/session/∆topic; 95% CI -0.31 to -0.05). Two topics were associated with worse treatment response: "monitoring of thoughts and worries" from the data-driven model (B=0.06 SD/session/∆topic; 95% CI 0.01 to 0.11) and "internet therapy" from the interpretability-based model (B=0.27 SD/session/∆topic; 95% CI 0.07 to 0.46). CONCLUSIONS: The 2 LDA models were different in terms of their interpretability and broadness of topics but both contained topics that were associated with treatment response in an interpretable manner. Our work demonstrates that topic modeling is well suited for iCBT research and has potential to expose clinically relevant information in vast text data.

Treated together-changed together: The application of dyadic analyses to understand the reciprocal nature of alliances and couple satisfaction over time.

In a Norwegian study of 73 couples attending a residential couple therapy program lasting between 6 and 12 weeks, weekly self-report data on therapy alliance and couple satisfaction were collected using routine outcome monitoring (ROM). The aim was to show how dyadic analyses could be applied to examine the predictive association between alliances and couple satisfaction. Results showed that improved alliance between dyad members and their couple therapist predicted their spouses' couple satisfaction. Furthermore, improved couple satisfaction predicted improvement in spouse's alliance. The clinical implication of these findings should heighten awareness to the importance of establishing and maintaining the alliance of male partners in couple therapy, something that predicts their spouses' couple satisfaction. These findings help nuance the already existing literature on the working alliance. Furthermore, we propose that dyadic analyses should be widely used in any psychotherapeutic research that aims to understand the reciprocal effects of dyads.

Emotional clarity and tolerance of emotional distress as mechanisms of change in short-term psychodynamic psychotherapy for chronic depression.

OBJECTIVE: The aim of this naturalistic process study was to investigate the relationship between emotional clarity and tolerance of emotional distress and depressive symptoms over the course of short-term psychodynamic psychotherapy for chronically depressed patients. METHOD: Weekly self-reports of emotional clarity, tolerance of emotional distress, and depressive symptoms (PHQ-9) were provided by 252 patients with chronic depression who were admitted to a 13-week inpatient treatment program. Latent curve modeling with structured residuals (LCM-SR) was applied to investigate the between- and within-person effects of week-to-week change in emotional clarity and tolerance of emotional distress as predictors of subsequent depression. The relationship between emotional clarity and tolerance of emotional distress was also investigated. RESULTS: At the within-person level, higher level of emotional clarity and tolerance of emotional distress predicted subsequent lower level of depression. A reciprocal relationship was found for tolerance of emotional distress (lower level of depression predicted subsequent level of tolerance emotional distress) but not for emotional clarity. No within-person effect between emotional clarity and tolerance of emotional distress was found. DISCUSSION: The results indicate that emotional clarity and tolerance of emotional distress may be mechanisms of change in short-term psychodynamic psychotherapy for chronic depression. The results are consistent with previous findings of the importance of emotional clarity and tolerance of emotional distress in psychotherapy. This study demonstrated the utility of LCM-SR as a method to identity mechanisms of change in psychotherapy. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Validation of the Affect Integration Inventory in a sample of patients with personality disorders: A cross-sectional study.

Affect integration is defined as the capacity to comprehend emotional experiences as meaningful and to convert this knowledge into well-adjusted motivation, communication and behavior. Thus, affect integration is considered essential for personal adjustment and well-being, and it has been operationalized through the Affect Integration Inventory. However, the validity of this questionnaire has been examined only in non-clinical respondents. Therefore, the purpose of this study was to investigate the psychometric properties of the questionnaire in a sample of patients with personality disorders (n = 87). The internal structure and consistency were addressed using Cronbach's alpha and confirmatory factor analysis. To determine aspects of convergent and discriminant validity, the correlations between the scores on the questionnaire and the scores on content-related questionnaires and scales were examined. Finally, scores from the clinical respondents and existing data from a previously collected non-clinical sample (n = 157) were compared to evaluate the external validity. The overall results demonstrated satisfactory internal consistency, a consistent factor structure, and systematic patterns of convergent and discriminant validity. Additionally, the findings indicated that the instrument clearly differentiated the clinical sample from the non-clinical sample.

Clinical Hypnosis in Medical Care: A Mixed-Method Feasibility Study.

BACKGROUND: Preoperative hypnosis has shown promising effects in controlling side effects from breast cancer surgery, but the feasibility and effects are largely unknown outside the US. METHODS: A mixed-methods approach was applied involving a large-scale population survey and a small-scale pilot study. The survey assessed attitudes toward hypnosis in a representative sample from the general population (n = 1049), while the pilot study involved interviews with 5 women who received hypnosis prior to mastectomy/lumpectomy. RESULTS: In the survey, 8% reported to have previous experience with hypnosis, and 67% reported willingness to accept hypnosis in a medical setting. Increasing age was associated with more skepticism, while previous experience was associated with less skepticism. In the pilot study, 4 themes were identified: (1) caretaking, (2) experiences related to hypnosis, (3) thoughts and feelings related to diagnosis, and (4) surgery. All participants reported positive experiences related to hypnosis, and none described unpleasant side effects or postoperative pain (pain intensity > 3) after surgery. CONCLUSIONS: The results indicate that the general public is positive toward clinical hypnosis as a supplement to medical treatment and that preoperative hypnosis is feasible in Norwegian breast cancer patients. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04300283.

Emotional dysfunction in avoidant personality disorder and borderline personality disorder: A cross-sectional comparative study.

According to the literature, avoidant personality disorder (APD) is often overlooked in research on personality disorders. In the present study, patients with APD were compared to patients with borderline personality disorder (BPD) with respect to emotional dysfunction. Emotional dysfunction was operationalized through the Affect Integration Inventory. Sixty-one patients receiving treatment at specialized outpatient hospital facilities for either BPD (n = 25) or APD (n = 36) (Diagnostic and Statistical Manual of Mental Disorders, fifth edition) were included in a cross-sectional study. Supporting our expectations of no difference in the global capacity for affect integration between groups, the estimated difference was 0.00 (95% confidence interval [CI] [-0.53, 0.53]). On the other hand, the expected increased dysfunction in APD regarding Expression could not be confirmed. Furthermore, problems with specific affects distinguished the groups; integration of Interest was worse in APD (p = 0.01), whereas integration of Jealousy was worse in BPD (p = 0.04). In terms of prototypical modes of experiencing affects, APD was characterized by decreased access to the motivational properties of Interest (p < 0.01), while BPD was more driven by Interest (p < 0.01), Anger (p < 0.01), and Jealousy (p = 0.01). In conclusion, even though the two disorders are characterized by similar overall levels of emotional dysfunction, they differ systematically and predictably regarding specific affects and modes of experiencing. These findings carry implications for the understanding of emotional dysfunction in APD and BPD, suggesting specific areas of emotional dysfunction that could be targeted in tailored psychotherapeutic interventions.

Why Service Users Choose Medication-Free Psychiatric Treatment: A Mixed-Method Study of User Accounts.

PURPOSE: Medication has been a central part of treatment for severe mental disorders in Western medicine since the 1950s. In 2015, Norwegian Health Authorities decided that Norwegian health regions must have treatment units devoted to medication-free mental health treatment to enhance service users' freedom of choice. The need for these units has been controversial. The aim of this study was to examine why service users choose medication-free services. This article examines what purpose these units serve in terms of the users' reasons for choosing this service, what is important for them to receive during the treatment, and what factors lay behind their concerns in terms of medication-related views and experiences. METHODS: Questionnaires were answered by 46 participants and 5 participants were interviewed in a mixed-method design integrated with a concurrent triangulation strategy applying thematic analysis and descriptive statistics. RESULTS: Negative effects of medications and unavailable alternatives to medication in ordinary health care were important reasons for wanting medication-free treatment. Medication use may conflict with personal values, attitudes, and beliefs. CONCLUSION: This study broadens the understanding of why the demand for separate medication-free units has arisen. The findings may contribute to making medication-free treatment an option in mental health care in general. To this end, clinicians are advised to communicate all treatment alternatives to service users and to be mindful of the effect of power imbalances in their interactions with them.

The Relationship between Affect Integration and Psychopathology in Patients with Personality Disorder: A Cross-Sectional Study.

Background and Objectives: Emotional dysfunction is considered a key component in personality disorders; however, only few studies have examined the relationship between the two. In this study, emotional dysfunction was operationalized through the Affect Integration Inventory, and the aim was to examine the relationships between the level of affect integration and the levels of symptom distress, interpersonal problems, and personality functioning in patients diagnosed with personality disorder according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition. Materials and Methods: Within a hospital-based psychiatric outpatient setting, 87 patients with personality disorder referred for treatment were identified for assessment with the Affect Integration Inventory and other measures (e.g., the Symptom Checklist-90, Revised, the Inventory of Interpersonal Problems 64 circumplex version, and the Severity Indices of Personality Problems). Results: The analyses revealed that problems with affect integration were strongly and statistically significantly correlated with high levels of symptom distress, interpersonal problems, and maladaptive personality functioning. Additionally, low scores on the Affect Integration Inventory regarding discrete affects were associated with distinct and differentiated patterns of interpersonal problems. Conclusion: Taken together, emotional dysfunction, as measured by the Affect Integration Inventory, appeared to be a central component of the pathological self-organization associated with personality disorder. These findings have several implications for the understanding and psychotherapeutic treatment of personality pathology. Furthermore, they highlight the importance of considering the integration of discrete affects and their specific contributions in the conceptualization and treatment of emotional dysfunction in patients with personality disorders.

Comparing the magnitude of improvement for patients with and without personality disorders in open-ended psychotherapy.

There is limited evidence that patients with a personality disorder (PD) have poorer psychotherapy outcomes compared to those without, but the majority of these studies are from short-term and symptom-focused interventions. In contrast, the present study provided open-ended psychotherapy to a sample of patients (N = 370), half of which had a PD a pretreatment. The results revealed that patients with PD demonstrated equal symptomatic improvement and greater interpersonal improvement than patients without PD. Similarly, observer-rated diagnostic changes were equivalent across the two groups. The PD group needed significantly higher therapy doses to reach this level of change. Both groups demonstrated enduring improvements when assessed at a 2.5-year follow-up. However, patients with a PD at pretreatment were more likely to relapse and regain their Axis I clinical disorder during follow-up. The degree of personality pathology was positively related to magnitude of change. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Investigating the dose-response effect in open-ended psychotherapy.

Findings from previous psychotherapy research suggest that the majority of improvement takes place in the initial phase of treatment with the relative effectiveness dropping at a negatively accelerating rate. However, the evidence for this pattern of change comes from investigations of short-term treatments and it is unclear whether this also holds for more flexible and long-term psychotherapy. We provided open-ended treatments under routine-care conditions for a representative sample of 362 patients, including a large proportion characterized by severe psychopathology. Patients attended 52 sessions on average (SD = 59, range = 1-364, Mdn = 36). Our results indicated that the degree of improvement was linearly associated with time spent in psychotherapy and contingent upon the severity of psychological problems at intake. The least severely afflicted received the shortest treatments, experienced the most rapid change but demonstrated smaller overall magnitudes of improvement. More severely suffering patients received longer treatments, had slower rates of change but in general received greater overall benefits. We argue that previous suggestions of psychotherapy dosage have been less appropriate for patients suffering from moderate to severe psychopathology.

Does it make a difference to be more "on the same page"? Investigating the role of alliance convergence for outcomes in two different samples.

Objective: To better understand the complexity of dyadic processes, such as the mechanisms of the working alliance, researchers recommend taking advantage of innovations in data analytic procedures when studying the interactions between therapists and patients that are associated with favorable therapeutic outcomes. Inspired by a recent line of alliance research using dyadic multilevel modeling, the present study investigated the hypothesis that convergence in the patient-therapist working alliance (i.e., increased similarity in ratings of the alliance across treatment) would be associated with better outcomes. Method: Data were retrieved from two samples: 1. A randomized controlled trial for treatment resistant depression (N = 96 dyads), and 2. An archival dataset of naturalistic psychotherapies from public health care (N = 139 dyads). Multilevel growth curve analysis was employed to investigate the degree of change in session-to-session agreement of global WAI ratings between therapists and patients (i.e., alliance convergence) as a predictor of symptom reduction in the BDI-II and the SCL-90R. Results: Contrary to our expectations, alliance convergence did not predict outcome in either sample, but was negatively associated with symptom severity in Study 2. Implications for understanding the complexity of dyadic processes and alliance work in psychotherapy are discussed.

Effectiveness of Open-Ended Psychotherapy Under Clinically Representative Conditions.

OBJECTIVE: This study investigates the effectiveness of open-ended psychotherapy in a large, naturalistic, and diverse patient cohort using rigorous and multifaceted assessments. METHOD: Patients (N = 370) in open-ended psychotherapy completed an extensive set of self-report measures and diagnostic interviews, including long-term follow-up in order to assess stability of outcomes. About half of the patients qualified for a personality disorder at the onset of treatment. Treatments were open-ended, and on average therapists provided substantially larger treatment doses than common in the literature. RESULTS: A substantial majority recovered from their respective Axis I (58%) and/or Axis II (55%) disorders during treatment. Patients also experienced large positive changes in self-report measures of overall psychiatric symptoms and moderate positive changes in self-reported interpersonal problems, while very few (< 3%) demonstrated negative development. The patients maintained their diagnostic and self-assessed changes at a two-and-a-half-year follow-up. In contrast, self-reported occupational functioning showed minimal improvement throughout the treatment and follow-up phase. CONCLUSION: A naturalistic patient cohort undergoing open-ended psychotherapy demonstrates substantial and stable improvements.