Therapist verification of patient self-concepts as a responsive precondition for early alliance development and subsequent introject change.

OBJECTIVE: Social psychological research has indicated that people strive for self-consistent feedback and interactions, even if negative, to preserve the epistemic security of knowing themselves. Without such self-verification, any interpersonal exchange may become frustrated, anxiety-riddled, and at risk for deterioration. Thus, it may be important for therapists to meet patients' self-verification needs as a responsive precondition for early alliance establishment and development. We tested this hypothesis with patients receiving cognitive behavioral therapy for generalized anxiety disorder-a condition that may render one's self-verification needs especially strong. We also tested the hypothesis that better early alliance quality would relate to subsequent adaptive changes in and posttreatment level of patients' self-concepts. METHOD: Eighty-four patients rated their self-concepts at baseline and across treatment and follow-up, their postsession recollection of their therapist's interpersonal behavior toward them during session 2, and their experience of alliance quality rated after sessions 3-6. RESULTS: As predicted, the more therapists verified at session 2 a patient's baseline self-concepts (which trended toward disaffiliative and overcontrolling, on average), the more positively that patient perceived their next-session alliance. Moreover, better session 3 alliance related to more adaptive affiliative and autonomy-granting self-concepts at posttreatment. CONCLUSION: Results are discussed within a therapist responsiveness framework.

Indirect effect of patient outcome expectation on improvement through alliance quality: A meta-analysis.

Objective: A meta-analysis revealed a positive correlation between patients' optimistic baseline, or early treatment, outcome expectation (OE) and posttreatment improvement (Constantino, Vîsla, et al., [2018]. A meta-analysis of the association between patients' early treatment outcome expectation and their posttreatment outcomes. Psychotherapy, 55(4), 473-485. https://doi.org/10.1037/pst0000169). However, little is known about mechanisms through which OE operates. Increasingly, several individual studies have pointed to higher therapeutic alliance quality as a promising mediator (candidate mechanism) of the positive OE-improvement link. In this study, we conducted the first meta-analysis of this indirect effect, hypothesizing that alliance would partially mediate the OE-outcome link.Method: We included published articles involving a clinical sample; therapist-led treatment of at least 3 sessions; pre- or early treatment patient OE measures; during-treatment patient-rated alliance measures; posttreatment outcome measures; and statistical tests of mediation. This meta-analysis included 10 independent samples and over 1,000 patients.Results: As expected, better alliance quality partially mediated the association between more optimistic OE and improvement; that is, although both were significant, a multivariate analysis revealed that the direct effect was significantly lower than the total effect (standardized difference = -.12, p < .001, 95% CI [-.20, -.05]). Publication bias was low, as was heterogeneity except for the alliance-outcome path.Conclusions: Better alliance may be one process that helps transmit the therapeutic influence of early patient OE.

Childhood Trauma and Psychosis: An Updated Review.

There is growing evidence to support the link between childhood trauma and psychosis. Childhood trauma increases the risk for psychosis and affects severity and type of psychotic symptoms, and frequency of comorbid conditions, including depression and substance use. Childhood trauma is linked to more severe functional impairment in individuals with psychosis. There is evidence to support gender differences in the influence of childhood trauma on the course of psychotic illnesses, appearing to be more profound in girls and women. Other biological markers that may explain the link between childhood trauma and psychosis include brain-derived neurotrophic factor and other inflammatory markers.

Patient motivational language in the prediction of symptom change, clinically significant response, and time to response in psychotherapy for generalized anxiety disorder.

Existing research demonstrates that patient change-talk (CT), or self-arguments for change, associates variably with favorable outcomes, whereas counter change-talk (CCT), or self-arguments against change, associates consistently with poorer outcomes. However, most studies on change language have focused on posttreatment versus more proximal outcomes. Addressing this gap, we examined Session 1 CT and CCT as predictors of during-treatment worry change, likelihood of clinically significant response during treatment, and time to response across cognitive-behavioral therapy (CBT; n = 43) and CBT integrated with motivational interviewing (MI; n = 42) for generalized anxiety disorder. We also explored whether treatment moderated these associations. Multilevel modeling revealed that, across both treatments, more CT associated with lower midtreatment worry level (p = .04), whereas more CCT associated with lower worry level (p = .048) and a slower rate of worry reduction at midtreatment (p = .04). Treatment moderated only the associations between CT and both midtreatment worry level (p = .03) and rate of change (p = .03). CBT patients with higher versus lower CT had lower worry and a faster rate of worry reduction; in MI-CBT, CT was unrelated to these outcomes. Survival analyses revealed that, across both treatments, more CT associated with a greater likelihood of response (p = .004) and approached a faster time to response (p = .05), and more CCT associated with a lower likelihood of response (p = .001) and approached a slower time to response (p = .06). Motivational language predicts proximal outcomes and may be useful in treatment selection. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Extending the context-responsive psychotherapy integration framework to cultural processes in psychotherapy.

Psychotherapist competence in attending to cultural processes has long been considered an ingredient of successful treatment. Although some research findings support a positive association between clinician multicultural competence (MCC) and client improvement, others suggest that MCC may not be a skill that therapists uniformly acquire and then stably maintain. Rather, MCC is likely more fluid and contextualized, potentially rendering within-therapist variability across their patients and within-dyad variability across different moments in a given case. With such variability in perceptions and actual behavioral manifestations of therapist MCC, it may be important for clinicians to heed contextual markers that call for flexibility and evidence-informed responsivity. To this end, we extend Constantino, Boswell, Bernecker, and Castonguay's (2013) context-responsive psychotherapy integration framework, a pantheoretical, if-then approach to responding to common clinical process markers with modular, evidence-based therapeutic strategies. Specifically, we present a therapy case supporting that clients' social and cultural identities can serve as both specific-client contexts in themselves and unique factors that may influence other important therapeutic contexts (e.g., lowered client outcome expectation and alliance ruptures, client change ambivalence/resistance to treatment) that require context-relevant therapist responsivity. With this case, we provide examples both of successful responsivity and missed opportunities. (PsycINFO Database Record

Using interpersonal process recall to compare patients' accounts of resistance in two psychotherapies for generalized anxiety disorder.

In a trial examining whether cognitive-behavioral therapy (CBT) could be improved by integrating motivational interviewing (MI) to target resistance, MI-CBT outperformed CBT over 12-month follow-up (Westra, Constantino, & Antony, 2016). Given that effectively addressing resistance is both a theoretically and an empirically supported mechanism of MI's additive effect, we explored qualitatively patients' experience of resistance, possibly as a function of treatment. For 5 patients from each treatment who exhibited early in-session change ambivalence, and thus were at risk for later resistance, we conducted interpersonal process recall interviews after a session. Transcripts were analyzed with grounded theory and consensual qualitative research. A salient contrast in patient narratives was a sense of compliance engendered in standard CBT versus connection in MI-CBT. Yet both narratives supported the superordinate category of resistance as an interpersonal process triggered by patient perceptions of therapist beliefs and behaviors. Findings contribute to the conceptualization of resistance from patients' first-hand accounts.

Patients' Perceptions of Corrective Experiences in Naturalistically Delivered Psychotherapy.

Corrective experiences (CEs), which suggest transformative experience(s) for the psychotherapy patient, have a rich theoretical history; yet there is little empirical information on patients' own perceptions of what gets "corrected" from therapy, and what is "corrective" (i.e., the mechanisms driving the CE). To address this gap, we investigated 14 patients' posttreatment accounts of both CE elements in the context of naturalistically delivered individual psychotherapy, using a consensual qualitative research methodology. Extending prior research focused on patients' accounts of CEs while still engaged in treatment (Heatherington et al., 2012), the present results revealed that patients retrospectively identified an array of categories that were deemed corrected, such as positive changes in cognitions, interpersonal problems, self-concepts, symptoms, and behaviors. Patients also identified CEs that may have led to those shifts/transformations, including their therapist's actions (especially giving feedback), their own agentic actions (especially engaging in the therapeutic process), and the patient-therapist collaborative and engaged relationship. Clinical practice implications are discussed.