Does technique matter? A multilevel meta-analysis on the association between psychotherapeutic techniques and outcome.

The extent to which psychotherapeutic techniques have an impact on outcome has been studied on a regular basis. To date, there are no meta-analytic attempts to clarify the association between techniques and outcome in multi-therapeutic approach measures. This study aims to conduct a meta-analysis of the described association. A three-level meta-analysis and moderator-analysis were used. The meta-analysis revealed 13 studies with a total of 177 effect sizes. There was a significant effect r=.193 (t[176]=4.77, p<.01) with higher use of psychotherapeutic techniques being associated with better outcome. Significant moderator was therapeutic approach-specific subscales. The mean effect of cognitive-behavioral techniques was r=.088 (t[147]=1.50, p=.14, d=0.18; s=11, k=79), and the mean effect of psychodynamic techniques was r=.286 (t[147]=5.06, p<.01, d=0.60; s=11, k=70). The measurements for psychotherapeutic technique (Comparative Psychotherapy Process Scale and Psychotherapy-Process Q-Sort) showed no significant difference related to the association between technique and outcome (F[1, 175]=0.38, p=.54). This meta-analysis showed a positive relation between psychotherapeutic techniques and outcome. This leads to the assumption that specific psychotherapeutic techniques have positive effects on post-treatment outcome.

[Learning Evidence-Based Practice - Multi-Perspective Competence Development using the Example of Generalised Anxiety Disorder]. / Evidenzbasierte Praxis lernen ­ Multiperspektivische Kompetenzentwicklung am Beispiel der generalisierten Angststörung.

Within the framework of the evidence-based practice model of the American Psychological Association (APA, 2006), psychotherapeutic core competences are mostly formulated transdiagnostically and transtheoretically, but do not exclude the systematic consideration of symptom-specific aspects. This article provides an exemplary case study of a person suffering from a generalized anxiety disorder to illustrate how evidence-based practice can be implemented. Multi-perspective competence development can be stimulated in training through the following therapeutic areas: (1) through broad assessment and psychodiagnostics, (2) through joint development of an individual explanatory model, (3) through inclusion of symptom-specific models, (4) through broad consideration of stringent interventions, (5) through application of various treatment modalities, (6) through patient-centred treatment implementation. The article concludes with a list of study examples of how psychotherapeutic competence development can be researched within the framework of the evidence-based practice model.

Is symptom outcome the whole story?-A multilevel meta-analysis of systemic therapy for adults including family system functioning.

OBJECTIVE: Systemic Therapy conceives mental health symptoms in the context of social systems. Previous meta-analyses on Systemic Therapy focused on symptoms. This meta-analysis aims to focus on family system functioning while including all types of outcomes. METHOD: We conducted a systematic literature research in multiple databases (PsycInfo, PubMed, Embase, Cochrane Central). We included RCT-studies on adults with psychiatric diagnoses, which compared Systemic Therapy with active psychosocial control. The literature research resulted in 171 coded effect sizes of 32 RCTs. We conducted a random-effects three-level meta-analysis. We categorized outcomes into symptoms of patients, family system functioning, further secondary outcomes of patients, and psychopathology of family members. RESULTS: The results show a small significant overall effect size of g = .30 (CI: .15-.45, p < .001, k = 171, s = 32) for all outcomes. Systemic Therapy revealed small effect sizes with regard to family system functioning (g = .34, z = 3.51, p = .0004, k = 26, s = 12), symptoms (g = .30, z = 3.74, p = .0002, k = 73, s = 29), and further secondary outcomes (g = .32, z = 3.83, p = .0001, k = 63, s = 19). The effect sizes for psychopathology of family system members were reported rarely (k = 9, s = 6). CONCLUSION: This meta-analysis shows the potential relevance of investigating family system functioning as a primary outcome for Systemic Therapy.

Psychotherapy Works - An Inclusive and Affirming View to a Modern Mental Health Treatment.

Psychotherapy is a highly collaborative and individualized mental health practice developed in (post-) modern societies. The mental health outcomes of psychotherapy cover a broad range of psychological factors including the reduction of suffering/symptoms as well as the promotion of well-being, personal values, and personal strengths. There is extensive meta-analytic evidence that legitimate psychotherapy works remarkably well and robustly for most common mental disorders. In addition, there is a large body of meta-analytic evidence supporting the potential relevance of transdiagnostic relationship principles and transtheoretical psychotherapy factors. Based on this ongoing empirical evidence, we propose four relevant implications for future training and practice in transdiagnostic psychotherapy: 1) the development of a transtheoretical legal framework for psychotherapeutic treatments, 2) the formulation of evidence-based transtheoretical interpersonal skills, 3) an orientation toward transtheoretical therapeutic factors, and 4) the exploration of comprehensive psychotherapy outcomes. We conclude with some more general guidance for future directions.

Understanding the patients' concept of the alliance-One step back to take two steps forward.

Current health care systems emphasize consensual collaboration between clinicians and patients to reduce symptoms and improve well-being (e.g., World Health Organization, 2023). The alliance is the internationally best-studied collaborative process characteristic in psychotherapy research. Recent empirical studies on the alliance have tripled in comparison to the entire 20th century. This increase in empirical data illustrates the cumulative outstanding scientific activities in this field (e.g., Wampold & Flückiger, 2023). The reasons for the international popularity of the pantheoretical alliance concept may lie in the practical experience of many practitioners that a balanced collaborative quality is a central ethical and conceptual premise for treatment progress (Horvath, 2018). The aim of a "Viewpoint" article is to provide thought-provoking notes on the current state of research, innovations, weaknesses in the field, and current debates. This article is limited to three aspects. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The Impact of Mental Imagery Instructions on Patients' and Therapists' Positive Affect and Strength-Based Behaviours Within Psychotherapy Sessions: A Randomized Controlled Process Study.

OBJECTIVE: Increased attention has recently been paid to the well-being and flourishing of patients in psychotherapy. This study investigated the occurrence of positive affect (PA) and strength-based behaviours within psychotherapy sessions contrasting positive versus neutral imagery instructions. METHODS: This is a secondary analysis of a randomized controlled trial. Seventy-eight sessions of cognitive behavioural therapy involving 26 patients (69.23% female; Mage = 40.31) treated by 13 therapists were selected. PA and strength-based behaviours of patients and therapists were coded on a minute-by-minute basis with the Resource-Oriented Microprocess Analysis. Each session started with a brief mental imagery instruction. Data were analysed using multilevel modelling. RESULTS: Mild levels of PA were very common, whereas stronger expressions were occasional, especially at the beginning and end of sessions. Strength-based behaviours were employed in one-fifth of the videos analysed. Therapists in the positive imagery instruction showed more strength-based behaviours in the beginning phase of sessions, p < 0.05. The two imagery instructions significantly differed in the session trajectories of PA, p < 0.05. A quadratic trend with higher initial values and a sharper decline in PA were found in the positive instruction, whereas the neutral instruction showed a flatter trend. CONCLUSION: Patients and therapists experience PA and discuss strengths in psychotherapy sessions despite patients' distress. The positive imagery instructions potentially induced a positive focus at baseline for therapists but had a negligible effect on the subsequent session progression. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03767101 (registered December 6, 2018).

The relationship between interpersonal problems and therapeutic alliance in psychotherapy: A three-level mixed-effects meta-analysis.

Psychotherapy is an interpersonal process of collaboration toward specified treatment goals. The therapeutic alliance is well established as an important factor of psychotherapeutic change. However, the experience of distress in social interactions, commonly referred to as interpersonal problems, might be interfering with the collaborative process during psychotherapy. This study systematically reviews the literature and obtains an estimate of the relationship between pretreatment interpersonal problems and the quality of the therapeutic alliance. Overall, 27 studies with 48 correlation coefficients were included in the final analysis. Due to the nested structure of the data, a three-level meta-analytic approach with a restricted maximum likelihood estimator was applied. Alliance assessment phase, alliance rater, alliance measure instrument, and treatment type were tested as potential moderators. Heterogeneity and publication bias test were performed. The meta-analysis showed a small, but significant negative relationship between interpersonal problems at the beginning of psychotherapy and subsequent therapeutic alliance (r = -.12, SE = .02, 95% CI [-.16, -.08], p < .001, d = -.27). Only alliance assessment phase accounted for significant variability. There were no indications for a substantial publication bias. Interpersonal problems of patients before psychotherapy are a robust predictor for lower therapeutic alliance quality, albeit a small effect size. Consequently, patients who experience interpersonal problems may face greater challenges in developing a strong alliance with their therapists, especially in early stages of the treatment. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

A systematic review and meta-analysis of transdiagnostic cognitive behavioural therapies for emotional disorders.

Transdiagnostic cognitive behavioural psychotherapy (TD-CBT) may facilitate the treatment of emotional disorders. Here we investigate short- and long-term efficacy of TD-CBT for emotional disorders in individual, group and internet-based settings in randomized controlled trials (PROSPERO CRD42019141512). Two independent reviewers screened results from PubMed, MEDLINE, PsycINFO, Google Scholar, medRxiv and OSF Preprints published between January 2000 and June 2023, selected studies for inclusion, extracted data and evaluated risk of bias (Cochrane risk-of-bias tool 2.0). Absolute efficacy from pre- to posttreatment and relative efficacy between TD-CBT and control treatments were investigated with random-effects models. Of 56 identified studies, 53 (6,705 participants) were included in the meta-analysis. TD-CBT had larger effects on depression (g = 0.74, 95% CI = 0.57-0.92, P < 0.001) and anxiety (g = 0.77, 95% CI = 0.56-0.97, P < 0.001) than did controls. Across treatment formats, TD-CBT was superior to waitlist and treatment-as-usual. TD-CBT showed comparable effects to disorder-specific CBT and was superior to other active treatments for depression but not for anxiety. Different treatment formats showed comparable effects. TD-CBT was superior to controls at 3, 6 and 12 months but not at 24 months follow-up. Studies were heterogeneous in design and methodological quality. This review and meta-analysis strengthens the evidence for TD-CBT as an efficacious treatment for emotional disorders in different settings.

Adverse events in psychotherapy randomized controlled trials: A systematic review.

Objective: Although evidence for benefits of psychotherapy is substantial, less is known about potential harm. Therefore, we systematically summarized randomized controlled trials (RCTs) to compile evidence-based data on the frequency and characteristics of adverse events (AEs) of psychotherapy. Method: This systematic review of result publications is based on a review of harm consideration in psychotherapy study protocols. Results: On the basis of 115 study protocols, 85 RCTs with 126 psychotherapy and 61 control conditions were eligible for inclusion. The sample consisted of 14,420 participants with the most common mental disorders. Harmful events, e.g., AEs, number of individuals with symptom deterioration, were explicitly reported in 60% of the studies. Conceptualization, recording, and reporting of AEs were heterogeneous. For most reported AEs, the association to study treatment remained unclear. Conclusions: Because the AE recording approaches of the individual studies differed substantially, results could only be compared to a limited extent. Consistent with other findings, this review demonstrates that AEs can be expected to affect more than one in ten participants. Serious AEs occurred more than in one in 21 participants in psychotherapy RCTs. To allow a balanced risk/benefit evaluation of psychotherapy, systematic harm monitoring and reporting should become standard in psychotherapy RCTs.

One year later: Longer-term maintenance effects of a digital intervention to change personality traits.

OBJECTIVE: Recent research suggests that personality traits can be changed by psychological interventions. However, it is unclear whether these intended personality changes can be maintained or merely reflect ephemeral shifts. METHOD: The present study reports 1-year follow-up effects of a 3-month digital intervention for personality trait change. Personality traits were measured before the intervention (pretest: N = 1523), directly after the intervention (posttest: n = 554), and 3 months (follow-up 1: n = 437) and 1 year (follow-up 2: n = 157) after the end of the intervention. RESULTS: Attrition analyses suggest that participants who completed the 1-year follow-up were significantly more open to experience (d = 0.19), less neurotic (d = 0.20), more agreeable (d = 0.35) and more conscientious (d = 0.27) than participants who did not complete the 1-year follow-up. Also, until the 1-year follow-up, personality trait changes achieved remained stable (for those who wanted to increase in extraversion and conscientiousness) or even changed further in the desired direction (for those who wanted to decrease in neuroticism). CONCLUSION: These results suggest that changes in personality traits due to a targeted intervention are not just ephemeral shifts and can even continue.

Using machine learning algorithms to predict the effects of change processes in psychotherapy: Toward process-level treatment personalization.

This study aimed to develop and test algorithms to determine the individual relevance of two psychotherapeutic change processes (i.e., mastery and clarification) for outcome prediction. We measured process and outcome variables in a naturalistic outpatient sample treated with an integrative treatment for a variety of diagnoses (n = 608) during the first 10 sessions. We estimated individual within-patient effects of each therapist-evaluated process of change on patient-evaluated subsequent outcomes on a session-by-session basis. Using patients' baseline characteristics, we trained machine learning algorithms on a randomly selected subsample (n = 407) to predict the effects of patients' process variables on outcome. We subsequently tested the predictive capacity of the best algorithm for each process on a holdout subsample (n = 201). We found significant within-patient effects of therapist perceived mastery and clarification on subsequent outcome. In the holdout subsample, the best-performing algorithms resulted in significant but small-to-medium correlations between the predicted and observed relevance of therapist perceived mastery (r = .18) and clarification (r = .16). Using the algorithms to create criteria for individual recommendations, in the holdout sample, we identified patients for whom mastery (14%) or clarification (18%) were indicated. In the mastery-indicated group, a greater focus on mastery was moderately associated with better outcome (r = .33, d = .70), while in the clarification-indicated group, the focus was not related to outcome (r = -.05, d = .10). Results support the feasibility of performing individual predictions regarding mastery process relevance that can be useful for therapist feedback and treatment recommendations. However, results will need to be replicated with prospective experimental designs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Mental health of help-seeking outpatients pre and post COVID-19: A real-world data, multicentre study.

OBJECTIVE: A great deal of research addresses the mental health implications of the COVID-19 pandemic for the general population. Little is known about the implications for mental health of help-seeking outpatients and for the effectiveness of mental health services. The present study investigated the mental health and treatment response of help-seeking outpatients before and during the COVID-19 pandemic. METHOD: Routine outcome monitoring data from 3706 clients in the United States and Northern Europe was analysed using multilevel modelling with global subjective well-being as the dependent variable. RESULTS: As opposed to before the pandemic, during the pandemic, well-being scores were significantly higher at intake and improvement throughout treatment was significantly smaller in the US sample, while both were comparable in the EU sample. CONCLUSION: Although there is also evidence of less effective treatments since the pandemic, no conclusive picture emerges that portrays the impact of the pandemic on mental health as uniform. More research is needed to elucidate the impact of the pandemic on the help-seeking population.

Social reward processing in depressed and healthy individuals across the lifespan: A systematic review and a preliminary coordinate-based meta-analysis of fMRI studies.

BACKGROUND: Social rewards (e.g., social feedback, praise, and social interactions) are fundamental to social learning and relationships across the life span. Exposure to social rewards is linked to activation in key brain regions, that are impaired in major depression. This is the first summary of neuroimaging literature on social reward processing in depressed and healthy individuals. METHOD: We screened 409 studies and identified 25 investigating task-based fMRI activation during exposure to social stimuli in depressed and healthy populations across the lifespan. We conducted a systematic review followed by an Activation Likelihood Estimation (ALE) analysis of three main contrasts: a) positive social feedback vs. neutral stimuli; b) negative social feedback vs. neutral stimuli; c) positive vs. negative social feedback. We also compared activation patterns in depressed versus healthy controls. RESULTS: Systematic review revealed that social rewards elicit increased activation in subcortical reward regions (NAcc, amygdala, ventral striatum, thalamus) in healthy and depressed individuals; and decreased activation in prefrontal reward regions (medial prefrontal cortex, orbitofrontal cortex) among depressed persons. Our meta-analysis showed, in both depressed and healthy individuals, increased cluster activation of the putamen and caudate in response to negative social stimuli vs. positive stimuli. We also found increased cluster activation in the inferior frontal gyrus (IFG) and the medial frontal gyrus (MFG) in healthy controls vs. depressed individuals, in response to negative social stimuli. CONCLUSIONS: Processing of social stimuli elicits activation of key brain regions involved in affective and social information processing. Interventions for depression can increase social reward responsivity to improve outcomes.

The effects of a personality intervention on satisfaction in 10 domains of life: Evidence for increases and correlated change with personality traits.

The desire to change one's personality traits has been shown to be stronger if people are dissatisfied with associated aspects of their life. While evidence for the effects of interventions on personality trait change is increasing, it is unclear whether these lead to subsequent improvements in the satisfaction with various domains of life. In this study, we examined the effects of a 3-month digital-coaching personality change intervention study on 10 domains of satisfaction. We focused on the three largest intervention groups of the study (N = 418), which included participants who wanted to increase their Emotional Stability, Conscientiousness, or Extraversion. Bivariate latent change score models were used to examine correlated change between the targeted personality traits and satisfaction domains. We found that global life satisfaction and satisfaction with oneself as a person increased in all three intervention groups. In addition, increases in specific satisfaction domains were reported for the Conscientiousness (e.g., work/school, health, friendships) and Emotional Stability (e.g., family, sexual relationships, emotions) group. Increases were stable up to the 3-month follow-up. In contrast, the waitlist control group did not report any changes in global or domain-specific life satisfaction. Changes in the satisfaction domains were positively correlated with self-reported personality trait change to a similar degree as the cross-sectional associations, but not to observer-reported personality trait change. The personality intervention thus seemed to have a positive effect on satisfaction with various domains of life, which was associated with the degree of self-reported personality trait change. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Evaluation of a male-specific psychotherapeutic program for major depressive disorder compared to cognitive behavioral therapy and waitlist: study protocol for a six-arm randomized clinical superiority trial examining depressed eugonadal and hypogonadal men receiving testosterone.

Background: Treatment of major depressive disorder (MDD) in men is complicated by the endorsement of traditional masculinity ideologies (TMI) often leading to reluctance toward psychotherapy, therapy interfering processes, or premature termination. In addition, it has been shown that men with MDD have a significantly increased risk of being hypogonadal (e.g., total testosterone levels <12.1 nmoL/L). Therefore, it is recommended to examine depressed men with regard to their testosterone status and if hypogonadism is present to combine psychotherapy with testosterone treatment (TT). Aim: This project aims to evaluate a male-specific psychotherapeutic program (MSPP) for MDD in depressed eugonadal and hypogonadal men receiving testosterone in comparison to a standard cognitive behavioral therapy (CBT) for MDD and a Waitlist. Methods: The study presents a 2×3 factorial study design. In total, 144 men aged between 25 and 50 will be stratified by testosterone status (eugonadal/hypogonadal) and then randomized into one of the three conditions (MSPP, CBT, or Waitlist). Additionally, a healthy control group of 100 men will be recruited, which will undergo only baseline assessments. Both standardized psychotherapy programs will encompass 18 sessions delivered in a weekly manner. Aligned with the TT-related medical visits of the 72 hypogonadal men, all participants will be followed up with clinical assessments and bio sampling at weeks 0, 6, 15, 24, and 36. Expected results: Compared to Waitlist control groups, treatment groups are expected to be more effective and efficacious (depression score reduction of ≥50%) at week 24 and at the follow-up at week 36. The MSPP is expected to show higher effectiveness and efficacy for depressive symptoms and higher acceptability (lower dropout rate) as compared to CBT. Discussion: This study represents the first attempt to test a male-specific psychotherapy for MDD in a single-setting compared to standard CBT and a Waitlist control condition using randomized clinical trial methodology. In addition, the potential positive adjunct effect of psychotherapy to TT in reducing depressive burden and improving quality of life in hypogonadal depressed men represents a neglected research area and might introduce new hypogonadism screening procedures in depressed men and combined treatment approaches for depressed men suffering from hypogonadism. Limitations are the rigorous inclusion and exclusion criteria, which limit the generalizability of the study results to first episode treatment naïve depressed men. Clinical Trial Registration: ClinicalTrials.gov, identifier NCT05435222.

Problem mastery and motivational clarification as mechanisms of change in cognitive-behavioral therapy for depression: Secondary analysis of a randomized controlled trial.

OBJECTIVE: In process-outcome research, there is a growing body of literature investigating the therapeutic mechanisms underlying the promotion of positive change. This study investigated the between- and within-patient effects of problem mastery and motivational clarification on outcome in patients receiving two variations of cognitive therapies for depression. METHODS: This study drew on data of a randomized controlled trial conducted at an outpatient clinic and included 140 patients randomly assigned to 22 sessions of either cognitive-behavioral therapy or exposure-based cognitive therapy. To address the nested structure of the data and analyze mechanism effects, we used multilevel dynamic structural equations models. RESULTS: We found significant within-patient effects of both problem mastery and motivational clarification on subsequent outcome. CONCLUSION: The results suggest that changes in problem mastery and motivational clarification precede symptom improvement during cognitive therapy for depressed patients and thus there may be benefit in fostering these putative mechanisms during psychotherapy.

Interpersonal problems as a predictor of outcome in psychotherapy for depressive and anxiety disorders: A multilevel meta-analysis.

OBJECTIVE: Although interpersonal problems are assumed to play an important role in the treatment of depression and anxiety, meta-analytic attempts to explore the association between interpersonal problems and outcome in psychotherapy for these patients are missing. This study aims to conduct a systematic review and meta-analytic synthesis of the association between patients' baseline interpersonal problems and outcome in psychotherapy for depressive and anxiety disorders. METHOD: We conducted a three-level meta-analysis (i.e., disaggregating sampling variance, within-study variance, and between-study variance) of the interpersonal problems-outcome prediction (IPOP; as measured by the total distress factor of Inventory of Interpersonal Problems). RESULTS: We found 40 effect sizes (ESs) nested within 21 primary studies. The three-level model showed a significant aggregated effect size of IPOP, r = -.13, SE = 0.02, 95% CI [-.18, -.09]; t(39) = -5.71, p < .001; d = -0.27, with greater interpersonal distress being associated with worse psychotherapy outcome. Results showed significant heterogeneity across effect sizes with considerable variability across studies (I² = .39) and to a lower extent across reported outcomes (I² = .19). Graphical measures did not show evidence of a substantial publication bias. CONCLUSIONS: This meta-analysis showed that baseline overall interpersonal problems are a small but robust negative predictor of psychotherapy outcome. Therapists might benefit from exploring patients' interpersonal problems at the beginning of therapy to enhance their prognostic inferences. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Symptom severity in daily life, early response and posttreatment changes in anxiety and depressive symptoms in generalized anxiety disorder.

BACKGROUND: Meta-analytic research shows early response to psychotherapy to predict depression and anxiety outcomes posttreatment. However, little is known about which variables explain differences in early response. Moreover, for patients with generalized anxiety disorder (GAD), there is limited research on whether early response predicts longer-term changes in symptoms. In this study, we used anxiety and controllability beliefs assessed in daily life at intake to predict early response to treatment (until session 5), and we further examined if early response predicts longer-term changes in symptoms (until posttreatment, when adjusting for intake symptom severity) in patients with GAD. METHODS: Forty-nine individuals with GAD reported their anxiety and controllability beliefs using event-based (participant-initiated) ecological momentary assessment (EMA) for 7 days at intake. Symptoms were measured at pretreatment, session 5, session 10, and posttreatment. RESULTS: Results show anxiety levels reported during EMA to be associated with a higher reduction in both anxiety and depressive symptoms early in treatment. Moreover, higher controllability beliefs during EMA were associated with less early response. When predicting change in symptoms until posttreatment, results showed an early change to significantly predict change in symptoms until posttreatment. CONCLUSIONS: Given that we found early response to psychotherapy in patients with GAD to be a prognostic factor for long-term response, it is recommended to monitor response early in treatment and pay special attention to those patients showing less early response.

Strength-based methods - a narrative review and comparative multilevel meta-analysis of positive interventions in clinical settings.

OBJECTIVE: In psychotherapy, strength-based methods (SBM) represent efforts to build on patients' strengths while addressing the deficits and challenges that led them to come to therapy. SBM are incorporated to some extent in all major psychotherapy approaches, but data on their unique contribution to psychotherapy efficacy is scarce. METHODS: First, we conducted a systematic review and narrative synthesis of eight process-outcome psychotherapy studies that investigated in-session SBM and their relation to immediate outcomes. Second, we conducted a systematic review and multilevel comparative meta-analysis contrasting strength-based bona fide psychotherapy vs. other bona fide psychotherapy at post-treatment (57 effect sizes nested in 9 trials). RESULTS: Despite their methodological variability, the pattern of results in the process-outcome studies was generally positive, such that SBM were linked with more favorable immediate, session-level patient outcomes. The comparative meta-analysis found an overall weighted average effect size of g = 0.17 (95% CIs [0.03, 0.31], p < .01) indicating a small but significant effect in favor of strength-based bona fide psychotherapies. There was non-significant heterogeneity among the effect sizes (Q(56) = 69.1, p = .11; I2 = 19%, CI [16%, 22%]). CONCLUSION: Our findings suggest that SBMs may not be a trivial by-product of treatment progress and may provide a unique contribution to psychotherapy outcomes. Thus, we recommend integration of SBM to clinical training and practice across treatment models.

The alliance in mental health care: conceptualization, evidence and clinical applications.

The concept of alliance reflects the collaborative relationship between a clinician and a patient, defined as consisting of three elements: a) the agreement on the goals of treatment; b) the agreement on a task or series of tasks; c) the development of a bond. Although much of the theory and research on the alliance comes from the domain of psychotherapy, the concept is applicable to any practice involving a person seeking help and a socially sanctioned healer. An extensive research evidence suggests that the alliance (typically measured at the third or fourth session) is a robust predictor of the outcomes of various forms of psychotherapy, even when prior symptom improvement and other factors are considered. Both the clinician and the patient bring to the therapy situation different capacities to form an alliance. Factors concerning the patient include, among others, the diagnosis, attachment history and style, motivation, and needs for affiliation. However, the benefits of the alliance have been found to be mostly due to the therapist's contribution, in particular his/her facilitative interpersonal skills, including verbal fluency, communication of hope and positive expectations, persuasiveness, emotional expression; warmth, acceptance and understanding; empathy, and alliance rupture-repair responsiveness. Placebo studies have allowed to experimentally manipulate aspects of the relationship between a therapist and a patient in non-psychotherapy contexts. In these settings, two components of the relationship have emerged: an emotional one (involving being cared for and understood by the clinician) and a cognitive one (including the belief in the competence of the therapist to select and administer an effective treatment). Here we propose a model that describes three pathways through which the alliance creates benefits, named CARE (caring, attentive, real and empathic), EXPECTANCY, and SPECIFIC. Although research and clinical attention have mostly focused on the alliance between a clinician and a patient in face-to-face interactions, there is preliminary evidence concerning the alliance between patients and other clinic staff, systems of care, or the program in Internet-mediated services. These new research areas clearly require further development.