The Promise and Challenges of Practice-Oriented Research: A Commentary on the Special Issue.

At the centre of POR is the concept of collaboration between patients, therapists, agencies, and third-party payers. For this commentary, I review the articles of the special issue with attention to both the opportunities and challenges offered by practice-oriented research (POR). I also reviewed some previous research on practice-research networks and how that research might inform POR. The use of routine outcome monitoring (ROM), artificial intelligence (AI), and program evaluation (PE) models show promise for advancing POR. However, each comes with its challenges. The use of ROM to improve patient outcomes has research support. However, researchers have identified problems with implementing ROM because of low uptake by clinicians and because clinicians may see ROM as a potential intrusion. AI shows promise to improve patient outcomes by potentially providing therapists with immediate and nuanced data to inform interventions and interpersonal stances specific to each patient. However, the scaling up of AI runs the risk of dehumanizing psychological interventions. PE may provide a context for allowing therapists to engage in POR to address real-world processes and outcomes of mental health interventions. However, like ROM PE faces the challenge of trust among clinicians and patients who may be reluctant to participate. Despite these challenges, and because of efforts to nurture and maintain respectful collaborations, articles in this special issue highlight how POR can play a pivotal role in bridging the gap between theory and practice.

Group member attachment style interacts with actor and partner helping alliance to predict decreasing binge eating episodes.

OBJECTIVE: An individual's attachment style may impact how they interact with their therapy group. This study examined the moderating role of a group member's attachment on the dynamic relationships between that group member's (actor) and other group members' (partner) therapeutic alliances and symptom outcomes. Method: This is a secondary analysis of data from a trial testing the outcome of emotionally-focused group therapy for binge-eating disorder. The sample consisted of 2,360 sessions nested within 118 group members who attended a 20-session treatment. Patients recorded binge eating episodes (BEE), their body weight and an alliance measure session-by-session. RESULTS: Dynamic structural equation modelling showed decreases in BEE and weight over the therapy. When attachment style was not included in the model, higher-than-average partner's alliance scores in the previous session were related to decreases in BEE in the current session. Attachment style moderated these actor and partner effects. For patients with preoccupied attachments, higher-than-average actor alliance in the previous session was related to subsequent decreases in BEE. For patients with dismissing or disorganized attachments, higher partner alliance in the previous session was related to subsequent decreases in BEE. CONCLUSION: Group members' attachment characteristics can play a role in the development of alliance-outcome patterns in group therapy.

The efficacy of group psychotherapy for adults with perfectionism: A randomized controlled trial of dynamic-relational therapy versus psychodynamic supportive therapy.

OBJECTIVE: This randomized controlled trial investigated the efficacy of group dynamic-relational therapy (DRT) relative to group psychodynamic supportive therapy (PST) in treating perfectionism and improving psychological functioning. HYPOTHESIS: Psychodynamically informed therapies, particularly DRT, will be efficacious in treating perfectionism and functioning outcomes. METHOD: Based on a comprehensive conceptualization of perfectionism, 80 community-recruited, highly perfectionistic individuals were randomly allocated to 12 sessions of group DRT (n = 41; 5 groups) or group PST (n = 39; 5 groups). Patients completed measures of trait perfectionism, perfectionistic self-presentation, perfectionistic cognitions, symptom distress, life satisfaction, and work and social adjustment at pre-, mid-, and posttreatment and 6 months posttreatment. RESULTS: Multigroup latent growth curve modeling revealed significant (p < .05) decreases in all perfectionism components and improvements in all functioning outcomes from pretreatment to 6-month follow-up in both DRT and PST. Likewise, analyses revealed substantial reliable improvement across conditions for all perfectionism components. Last, moderate-to-large between-group differences favoring DRT over PST were found for self-oriented perfectionism, perfectionistic self-promotion, nondisplay of imperfection, nondisclosure of imperfection, and work and social adjustment. CONCLUSION: Findings provide evidence for the use of psychodynamic approaches in the treatment of perfectionism and support the relative efficacy of DRT for components of perfectionism. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Detecting defense mechanisms from Adult Attachment Interview (AAI) transcripts using machine learning.

OBJECTIVE: Defensive functioning (i.e., unconscious process used to manage real or perceived threats) may play a role in the development of various psychopathologies. It is typically assessed via observer rating measures, however, human coding of defensive functioning is resource-intensive and time-consuming. The purpose of this study was to develop a machine learning approach to automate coding of defense mechanisms from interview transcripts. METHOD: Participants included a clinical sample of women with binge-eating disorder (n = 92) and a community sample without binge-eating disorder (n = 66). We trained and evaluated five RoBERTa-based models to detect the presence of defenses in 16,785 interviewer-participant talk-turn pairs nested within 192 interviews. A model detected the presence of any defense, while four additional models detected the most common defenses in this sample (repression, intellectualization, reaction formation, undoing). RESULTS: The models were capable of distinguishing defenses (ROC-AUC .82-.90) but were not proficient enough to warrant replacing human coders (PR-AUC .28-.60). Follow-up analysis was performed to assess other practical uses of these models. DISCUSSION: Our machine learning models could be used to assist coders. Future research should conduct a deployment study to determine if human coding of defense mechanisms can be expedited using machine learning models.

Training community-based psychotherapists to maintain a therapeutic alliance: A psychotherapy practice research network study.

The goal of this study was to test the efficacy of training community-based psychotherapists who were part of a practice research network to be more attuned to their patients' experiences of the therapeutic relationship. We were particularly interested in the effect of therapist training on the congruence of alliance ratings with their patients. Forty psychotherapists who treated 117 patients were randomly assigned to receive either no training or training, whose learning objectives were to help therapists to develop and maintain a therapeutic alliance. The training included workshops and ongoing consultations to help the clinician to strengthen the therapeutic relationship with the use of mentalizing, attachment theory, countertransference management, and metacommunication. Therapeutic alliance and well-being outcomes were measured at each of six consecutive early psychotherapy sessions. We used the truth and bias model and response surface analysis within a multilevel modeling context to test hypotheses. There was a significantly faster rate of alliance growth in the training versus the no training condition when the alliance was rated by therapists, but not when rated by patients. Trained therapists experienced greater temporal congruence in alliance ratings with their patients compared to untrained therapists. Patient well-being outcomes improved in a session when trained therapists and their patients agreed in their positive alliance ratings in a previous session. This association not significant among untrained therapists. Training therapists in key interpersonally focused skills may lead them to be better attuned to their patients' experiences of the therapeutic relationship. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Attachment insecurity predicts outcomes in an ACT-CBT group therapy for adults in a physical rehabilitation centre.

Adapting to chronic illness or disability is accompanied by acute and ongoing illness stressors. Psychological factors such as emotional distress and low self-efficacy are common experiences in chronic illness and disability and interfere with adaptation and psychosocial outcomes such as health-related quality of life. Transdiagnostic group psychotherapy may provide a parsimonious approach to psychological treatment in rehabilitation care by targeting shared illness stressors across mixed chronic illnesses and disabilities, and shared processes that maintain psychological symptoms. Attachment theory may explain individual differences in outcomes and help identify individuals at risk of poor health-related quality of life trajectories. Adults (N=109) participated in an 8-week process-based ACT-CBT psychotherapy group at a tertiary care physical rehabilitation centre between 2016 and 2020. Participants completed measures of emotional distress, self-efficacy, health-related quality of life, and attachment at pre- and post-treatment. Multilevel analyses indicated that patients improved on most outcomes at post-treatment. Attachment anxiety at pre-treatment was associated with more positive outcomes. Reliable change indices suggest clinically meaningful change for the majority of participants, but most were not recovered. Results provide proof-of-concept for the transdiagnostic group intervention and suggest that a longer course of treatment may be clinically indicated. Results warrant replication with larger and more diverse samples, and more robust designs.

The role of sense of coherence in reducing anxiety and depressive symptoms among patients at the first acute coronary event: A three-year longitudinal study.

OBJECTIVE: Although several studies suggest an association between psychological distress and increased morbidity and mortality in various cardiac populations, little is known about positive psychological resources, like Sense of Coherence (SOC), that may reduce distress. This longitudinal observational study aimed to test the hypothesis that a strong SOC predicted a longitudinal decrease in anxiety and depression in a sample of patients after their first acute coronary event. METHODS: A sample of 275 patients completed the Hospital Anxiety Depression Scale (HADS) and the SOC Scale at five time-points (at the baseline and after 6, 12, 24, and 36 months). Longitudinal trajectories of anxiety, depression, and SOC were examined through hierarchical (generalized) linear models, controlling for sociodemographic and clinical indicators. RESULTS: 38.6% of patients experienced clinically relevant anxiety symptoms soon after the cardiovascular event, whereas only 20.8% experienced clinically relevant depressive symptoms. Anxiety symptoms decreased over time, plateaued, and then slightly increased, whereas depressive symptoms tended to be stable; these variables were positively associated during all time points. The SOC did not change over time; a strong SOC at baseline predicted decreased anxiety and depression. CONCLUSION: Findings showed a strong relationship between SOC and symptoms of anxiety and depression, and they suggested the importance of a salutogenic approach in clinical practice and the relevance of interventions aimed at increasing resilience resources like the SOC in patients with cardiovascular diseases.

The alliance-outcome association in group interventions: A multilevel meta-analysis.

OBJECTIVE: The therapeutic alliance has been studied in group interventions, but its relationship to patient outcome is still controversial. This study systematically reviewed the association of both the member-leader and member-group alliance with patient outcomes, and assessed the effects of several theoretically informed moderators. METHOD: A three-level meta-analysis was conducted on 57 studies to disentangle within- and between-study variability in the alliance-outcome association. RESULTS: The overall effect size of the unconditional model was r = -.259 (95% CI: -.302, -.214; p < .001), whereas the correlation between alliance and outcome based on the three-level meta-analytic model was r = -.215 (95% CI: -.252, -.178; p < .001) indicating a medium effect. Meta-regressions of moderators showed that the alliance-outcome correlation was higher when patients reported on their alliance with the group/other members compared with when they rated the alliance with the leader. Outcome type, rating perspective, theoretical orientation, treatment length, and year of publication were significant moderators of the relationship between alliance and outcome. CONCLUSIONS: The current meta-analysis highlighted that the therapeutic alliance, especially with other group members, is a significant predictor of outcomes in group therapies even after controlling for several moderators and adopting more conservative statistical modeling. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The Effects of Attachment, Temperament, and Self-Esteem on Technology Addiction: A Mediation Model Among Young Adults.

Excessive use of technology has become a worldwide problem due to its high prevalence, fast growth rate, and undesirable consequences. However, little is known about underlying psychological mechanisms that maintain excessive use of technology. We investigated the mediating role of self-esteem, novelty seeking, and persistence on the relationship between attachment dimensions and technology addiction among young adults. Data were collected from 727 young adults (females, N = 478; 66.3 percent), aged 23.44 ± 3.02 years. Participants completed self-report measures of secure and insecure attachment dimensions, personality, and temperament characteristics (i.e., self-esteem, novelty seeking, and persistence), technology addiction and frequency of technology use (i.e., own technology use, perceived use by peers and parents). The mediation model was tested through a path analysis. The effects of attachment insecurity on technology addiction were partially mediated by the levels of persistence and self-esteem, whereas the effects of attachment security on technology addiction were fully mediated. The effects remained robust even after controlling for the frequency of technology use. The model was gender and age invariant, suggesting that the mediation worked in a similar way for both men and women and across ages. Findings suggest that attachment dimensions exert not only a direct but also an indirect effect on technology addiction through self-esteem and persistence. Such findings may help to develop psychosocial interventions that are sensitive to young adults' attachment, personality, and temperament characteristics.

A group's level of defensive functioning affects individual outcomes in group psychodynamic-interpersonal psychotherapy.

We used an actor-partner interdependence model (APIM) to study the association between the individual group member and other group therapy members' defensive functioning on an individual group member's treatment outcome. We hypothesized that (a) more adaptive individual defensive functioning at pretreatment will be significantly related to better treatment outcomes (i.e., lower binge-eating and interpersonal distress) at 6 months post-treatment; and (b) more adaptive other group members' defensive functioning at pretreatment will be significantly related to better treatment outcomes at 6 months post-treatment. Participants (N = 136) were individuals with BED enrolled in group psychodynamic-interpersonal psychotherapy (GPIP). Participants completed attachment interviews and were assessed on interpersonal distress and days binged at pretreatment and 6 months post-treatment. The interview audio recordings were transcribed and used to code defensive functioning. We found that individual overall defensive functioning (ODF) scores at pretreatment were not significantly associated with binge-eating frequency or interpersonal distress at 6 months post-treatment. Other group members' mean ODF scores at pretreatment were significantly associated with individual interpersonal distress at 6 months post-treatment. However, the other group members' mean ODF scores were not significantly associated with individual binge-eating outcomes at 6 months post-treatment. Defensive functioning of other members of a therapy group may be particularly important for improving interpersonal functioning in individuals with BED. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Impact of repeating somatic cues on the depth of experiencing for withdrawers and pursuers in emotionally focused couple therapy.

Emotionally Focused Couple Therapy, an experiential modality, views emotion central to therapeutic change. In this exploratory study, we examined therapists' repetition of somatically focused interventions (therapist verbalizing somatic cues, such as facial expressions) and their impact on clients' emotional experiencing in-session. We also assessed difference for withdrawing versus pursuing partners. The sample included 13 EFT therapists who worked with one couple each for a single session. From transcripts we coded therapists' repetition of somatically focused interventions and clients' depth of experiencing pre-and post-intervention. Multilevel modeling demonstrated that a higher number of repetitions of somatically focused interventions predicted greater increase in depth of experiencing, unlike length of time spent repeating interventions. Somatically focused interventions resulted in greater increase in depth of experiencing for withdrawing as compared to pursuing partners. The results of this exploratory study suggest that such interventions may be a specific technique of EFT therapists that enhances emotional experiencing especially among withdrawing partners.

Somatic experience of emotion in emotionally focused couple therapy: Experienced trainer therapists' views and experiences.

In general, arousal of emotions is often felt and expressed as a somatic experience in the body. In Emotionally Focused Couple Therapy (EFT), the deepening of emotional experiencing enables therapeutic change. This research explores the experiences of eight experienced EFT trainer therapists regarding their somatic experiences in their work with couples. Using interpretative phenomenological analysis of transcribed in-depth interviews, this research data yielded three core themes that captured therapists' experiences of using their own and couples' somatic experiences in therapy: (1) the importance and relevance of somatic experiences, (2) therapists' use of their own somatic experiences, and (3) working with clients' somatic experiences. The findings suggest that therapists do focus on their own and couples' somatic experiences in their work with couples, and that EFT therapists could benefit from a map to guide therapists how to focus on felt, somatic experiences as a way of maintaining an emphasis on emotional experience.

Psychological changes in successful completers of an HIV-tailored smoking cessation program: mood, attachment and self-efficacy.

High rates of cigarette smoking is the leading contributor to the increasing risk of cardiovascular disease (CVD) among people living with HIV (PLH). Relapse rates among PLH who quit smoking are high among those receiving standard care, which may be due to several unique social and psychological challenges PLH face when they attempt to quit smoking. The purpose of the current study was to examine change in relevant psychological factors in a subgroup of participants (n = 14) who remained smoke-free at 6-months follow-up in an HIV-tailored smoking cessation counselling program (N = 50). We examined self-reported depressive symptoms, attachment style and self-efficacy across 5 time points (baseline, quite date, 4, 12 and 24 weeks). At study baseline, mean depression scores fell above the clinical cut off of 16 (M = 16.31; SD = 13.53) on the Centre for Epidemiological Studies - Depression (CES-D) scale and fell below the clinical cut off at 24 weeks post quit date (M = 13.36; SD = 10.62). Results of multi-level modeling indicated a significant linear reduction in depressive symptoms and a significant linear improvement in self-efficacy to refrain from smoking across study visits. These results suggest that positive change in mood and self-efficacy may be helpful for PLH who remain smoke-free during a quit attempt.

Change in Defensive Functioning Following Group Psychodynamic-Interpersonal Psychotherapy in Women With Binge-Eating Disorder.

We examined change in defensive functioning following group psychodynamic-interpersonal psychotherapy (GPIP) for binge-eating disorder (BED) compared to a waitlist control. We hypothesized that defensive functioning will improve to a greater extent at posttreatment for those in GPIP compared with those in a waitlist control condition. Participants were women with BED assigned to GPIP (n = 131) or a waitlist control (n = 44) condition in a quasi-experimental design. Those who received GPIP had significantly greater improvements in defensive functioning from pretreatment to six months posttreatment compared to the control group. GPIP may be effective for improving defensive functioning in individuals with BED. A randomized controlled trial is needed to confirm that GPIP is efficacious for addressing defensive functioning among women with BED.

Attachment avoidance and health-related quality of life: Mediating effects of avoidant coping and health self-efficacy in a rehabilitation sample.

PURPOSE/OBJECTIVE: The onset of chronic illness or disability (CID) can be conceptualized as a threat that activates the attachment system. Moreover, the waxing-and-waning nature of CID-related symptoms and management of acute and chronic illness stressors means that the attachment system may be repeatedly activated. Contending with repeated threats to health (i.e., security) can complicate psychosocial adjustment to CID and can negatively impact health-related quality of life (HRQoL). Adjustment to CID requires intrapersonal resources, such as adaptive coping and self-efficacy. In spite of attachment theory's relevance to conceptualizing adaptation to CID, no models of psychosocial adaptation to CID account for individual differences in coping behaviors and health self-efficacy through an attachment lens. This limits future theory-driven research. Thus, the present study proposes and tests an integrated model of psychosocial adaptation to CID using an attachment framework. Research Method/Design: Participants in this study included adults referred for psychological services at a tertiary care physical rehabilitation center between 2016 and 2020. Ninety adults completed measures of attachment anxiety and attachment avoidance, coping, health self-efficacy, and HRQoL at one time point. RESULTS: Path analysis indicated that the proposed model fits the data well. Higher attachment avoidance was significantly related to lower HRQoL, as mediated by higher avoidant coping and lower health self-efficacy. CONCLUSIONS/IMPLICATIONS: Results suggest that individuals high on attachment avoidance may require additional support to move toward psychosocial adaptation. Further research examining the role of attachment insecurity dimensions in adaptation to CID is warranted and should include longitudinal designs to replicate these findings. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

No association between dopaminergic polymorphisms and response to treatment of binge-eating disorder.

BACKGROUND: The genetics of binge-eating disorder (BED) is an emerging topic, with dopaminergic genes being implicated in its etiology due to the role that dopamine (DA) plays in food reward sensitivity and self-regulation of eating behavior. However, no study to date has examined if DA genes influence response to behavioral treatment of BED. OBJECTIVE: The primary objective of this study was to examine the ability of DA-associated polymorphisms to predict BED treatment response measured using binge frequency over 12 months. As secondary objectives, this study examined cross-sectional relationships between these polymorphisms and anthropometrics in women living with and without BED and obesity. METHODS: Women aged 18-64 years old were genotyped for the DA-related SNPs DRD2/ANKK1 Taq1A (rs1800497) and COMT (rs4680), as well as the DA-related uVNTRs DAT-1 (SLC6A3) and MAO-A. A multi-locus DA composite score was formed from these 4 polymorphisms using genotypes known to have a functional impact resulting in modified DA signaling. Binge frequency (Eating Disorder Examination - Interview) and body composition (Tanita BC-418) were assessed in a pre-post analysis to examine genetic predictors of treatment response in women living with obesity and BED. Secondary data analysis was conducted on a cross-sectional comparison of three groups of women enrolled in trial group treatment for BED: women living with obesity and BED (n = 72), obesity without BED (n = 27), and normal-weight without BED (n = 45). RESULTS: There were no significant genotype × time interactions related to anthropometrics or binge frequency for any individual DA genotypes, or to the composite score reflecting DA availability. At baseline, there were no significant between-group differences in frequencies of DA-related alleles, nor were there associations between genotypes and anthropometrics. CONCLUSIONS: Our study found no evidence to suggest that the DRD2/ANKK1 Taq1A, COMT, MAO-A, or DAT-1 polymorphisms are associated with response to behavioral intervention for BED as measured by changes in binge frequency. Future studies should examine a greater variety of dopaminergic polymorphisms, other candidate genes that target other neurotransmitter systems, as well as examine their impact on both behavioral and pharmacological-based treatment for BED.

Self-esteem and binge eating: Do patients with binge eating disorder endorse more negatively worded items of the Rosenberg Self-Esteem Scale?

OBJECTIVE: Self-esteem is a core aspect of eating disorder symptomatology. This study aims to examine whether method effects associated with negatively worded items of the Rosenberg Self-Esteem Scale (RSES) may interact the negative self-evaluations experienced by patients with obesity and binge eating disorder (BED). We also examined whether negatively worded items were associated with psychological distress and eating symptoms. METHOD: Five hundred thirty three female outpatients (mean age: 42.59) with BED (n = 160) or obesity without BED (n = 373) completed the RSES and measures of interpersonal problems, psychological distress, and eating symptoms. RESULTS: Patients with BED responded more strongly to the negatively worded items of the RSES than those with obesity. The RSES negatively worded item factor was negatively associated with higher interpersonal problems, psychological distress, and binge eating. CONCLUSIONS: Patients with BED may be more responsive to negatively phrased items on the RSES consistent with their negative self-evaluations and self-perceptions.

Self-reported reflective functioning mediates the association between attachment insecurity and well-being among psychotherapists.

Objective: Subjective well-being is a crucial variable for mental health practitioners. This study examines the influence of therapists' attachment dimensions and self-reported reflective functioning on their perceived well-being. Further, it examines if reflective functioning mediates the association between attachment insecurity and well-being. Method: A total of 416 experienced psychotherapists were enrolled in this cross-sectional study, and completed self-report measures of attachment insecurity, reflective functioning, and well-being. We tested the hypothesized mediation model with path analysis that examined indirect effects. Results: Both attachment anxiety and avoidance dimensions had a significant negative association with perceived well-being with small to medium effects. "Certainty" in reflective functioning had a small positive effect on therapist well-being. Reflective functioning mediated the association between insecure attachment dimensions and well-being, suggesting that therapist's lower ability to mentalize may partially account for the effects of higher attachment insecurity on lower well-being. Conclusion: The well-being of psychotherapists with greater insecure attachment may deserve special attention, and therapists' mentalizing capacities may be targeted by researchers and trainers as a core ability to be cultivated in order to preserve therapists' professional and personal resources.

The reciprocal relationship between alliance and early treatment symptoms: A two-stage individual participant data meta-analysis.

OBJECTIVE: Even though the early alliance has been shown to robustly predict posttreatment outcomes, the question whether alliance leads to symptom reduction or symptom reduction leads to a better alliance remains unresolved. To better understand the relation between alliance and symptoms early in therapy, we meta-analyzed the lagged session-by-session within-patient effects of alliance and symptoms from Sessions 1 to 7. METHOD: We applied a 2-stage individual participant data meta-analytic approach. Based on the data sets of 17 primary studies from 9 countries that comprised 5,350 participants, we first calculated standardized session-by-session within-patient coefficients. Second, we meta-analyzed these coefficients by using random-effects models to calculate omnibus effects across the studies. RESULTS: In line with previous meta-analyses, we found that early alliance predicted posttreatment outcome. We identified significant reciprocal within-patient effects between alliance and symptoms within the first 7 sessions. Cross-level interactions indicated that higher alliances and lower symptoms positively impacted the relation between alliance and symptoms in the subsequent session. CONCLUSION: The findings provide empirical evidence that in the early phase of therapy, symptoms and alliance were reciprocally related to one other, often resulting in a positive upward spiral of higher alliance/lower symptoms that predicted higher alliances/lower symptoms in the subsequent sessions. Two-stage individual participant data meta-analyses have the potential to move the field forward by generating and interlinking well-replicable process-based knowledge. (PsycInfo Database Record (c) 2020 APA, all rights reserved).