Asylee perspectives on psychotherapies for posttraumatic stress.

Asylees (i.e., asylum seekers) have a higher prevalence of mental health concerns, particularly posttraumatic distress, than the general population due to both their exposure to traumatic experiences and prolonged uncertain status in a new country. Meta-analyses of randomized controlled trials with asylees have found that culturally adapted cognitive behavioral therapy (CA-CBT), eye movement desensitization and reprocessing (EMDR), and narrative exposure therapy (NET) are efficacious in treating trauma-related symptoms and posttraumatic stress disorder (PTSD); however, treatment utilization remains low. Thus, it is imperative to determine what PTSD interventions are effective, credible, and acceptable for asylees. We employed structured virtual interviews with 40 U.S. asylees from diverse countries living with one or more symptoms of PTSD. Participants were asked about treatment engagement, perceived barriers to treatment, goals for psychotherapy, and perceptions of the effectiveness and difficulty of engaging in CA-CBT, EMDR, NET, and (non-exposure-based) interpersonal therapy (IPT) for PTSD. Participants perceived IPT to be significantly less difficult than all exposure-based treatments, with medium effect sizes, ds = 0.55-0.71. A qualitative analysis of asylees' comments provided valuable insights into how they think about these treatments. Ways in which these results can be considered when informing recommendations for improving interventions for asylees are discussed.

Disordered eating- and exercise-related behaviors and cognitions during the first year college transition.

ObjectiveDuring the college transition, vulnerability to disordered eating and exercise behaviors and cognitions may increase. We studied how behaviors and cognitions change differentially over time, in the context of gender, athletic participation, and contingencies of self-worth. Participants: 229 diverse, first-year students at a competitive liberal arts college. Methods: Three-wave longitudinal study employing surveys before, during, and following the first semester, using linear mixed model analyses. Results: There were changes over time in one measure of disordered exercise-related cognitions and exercise frequency; disordered eating showed no significant changes over time. Athletic participation and basing a lower amount of self-worth on appearance were protective against subclinical disordered cognitions and behaviors; gender was not predictive. Conclusion: Health personnel should consider athletic participation and contingencies of self-worth when assessing students' risk for ED symptoms, in both genders. Early interventions may be useful, as changes were observed within the first three months of college.

Sustaining outcomes research in residential treatment: A 15-year study of the Gould Farm program.

We present findings from a study of outcomes of residential treatment for people who have mental illness, primarily schizophrenia-spectrum and bipolar disorders. The study assesses a range of individual variables before and after participation in the program, to examine clinical and personal recovery and facilitate program improvement. To our knowledge, it is the longest ongoing outcomes study (15+ years) of its kind. The program, Gould Farm, provides recovery-focused, milieu treatment on a 700-acre working farm. It integrates counseling and medication with a work program that provides opportunities for the development of daily living, social, and work skills as well as mental and physical health. Clients were interviewed in person at intake and at discharge. Also, since study year 10 when the follow-up arm began, former clients were interviewed at 6, 18, and 36 months postdischarge via phone. Interview protocols included standard measures of psychiatric symptoms and functioning, substance use, quality of life, and treatment satisfaction. Follow-up interview protocols also assessed individuals' living, working, family, and social situations as well as their satisfaction in these areas of recovery. Statistically significant improvements on all measures were found at discharge, and were not moderated by key demographic or clinical factors. Preliminary follow-up data showed maintenance of treatment gains, and high treatment satisfaction. We discuss clinical implications of the findings as well as limitations, directions for future research, and recommendations for sustaining outcomes research in organized care settings. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Perceived Marital Support and Incident Mental Illness: Evidence from the National Comorbidity Survey.

Social support in marriage may be associated with reduced risk for mental illness. Past studies are limited by short follow up and a focus on depression. A two-wave nationally representative survey in the United States (n = 2,503) is used to examine whether social support in marriage is associated with the onset of each of four clusters of disorders-internalizing, externalizing, phobic, and bipolar-10 years later. Results indicate that higher levels of perceived marital support were protective against internalizing, fear, and bipolar disorders, and against incident externalizing disorders for women. Protective effects of social support in marriage against mental illness are long-lasting, and sometimes differ by gender. Findings suggest the importance of mental health assessment in clinical practice.

Meta-analysis of the alliance-outcome relation in couple and family therapy.

This article reviews meta-analytic evidence for the alliance-outcome relation in couple and family therapy (CFT), with implications for clinical practice. We begin by describing the unique features of CFT alliances and their measurement, followed by two case descriptions. We explain that due to the systemic context of CFT, each patient's personal alliance with the therapist affects and is affected by other family members' levels of collaboration. Because family members often seek help when they are in conflict with one another, "split" alliances are common, as are problematic within-system alliances, defined as the degree to which family members agree on the nature of their problems and value participating in therapy together to achieve shared goals. In our meta-analysis of 48 studies with 40 independent samples, we used a three-level random effects model (Ns = 2,568 families, 1,545 couples, and 491 effect sizes) and found r = .297. In another analysis with seven independent samples and 31 effect sizes, the split alliance-outcome association was also significant, r = .316, indicating that the more split or unbalanced the alliance, the poorer the outcome. Moderator analyses showed that alliance-outcome associations did not differ for couple versus family therapy, but correlations were significantly stronger in samples with younger problem children, older adults, proportionally more male youth and adults, and when the families voluntarily sought help (as compared with involuntary or mandated families). The article concludes with research-informed strategies for building and sustaining strong systemic alliances in CFT. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Local terms and understandings of mental health problems in Burundi.

A pilot study and two intensive studies were conducted to document the local vocabularies used by Burundians to describe mental health problems and their understandings about the causes. The pilot study-in which 14 different large groups of community members awaiting appointments at a village health clinic were engaged in open-ended discussions of the local terminology and causal beliefs about mental health problems-suggested three key syndromes: akabonge (a set of depression-like symptoms), guhahamuka (a set of trauma-related symptoms), and ibisigo (a set of psychosis-like symptoms). In Study 1 ( N = 542), individual interviews or surveys presented participants with the names of these syndromes and asked what they considered to be the symptoms and causes of them. Study 2 ( N = 143) cross-validated these terms with a different sample (also in individual interviews/surveys), by presenting the symptom clusters and asking what each would be called and about their causes. Findings of both studies validated this set of terms and yielded a rich body of data about causal beliefs. The influence of education level and gender on familiarity with these terms was also assessed. Implications for the development of mental health services and directions for future research are discussed.

Mental health treatment outcome expectancies in Burundi.

Best practices in global mental health stress the importance of understanding local values and beliefs. Research demonstrates that expectancies about the effectiveness of a given treatment significantly predicts outcome, beyond the treatment effect itself. To help inform the development of mental health interventions in Burundi, we studied expectancies about the effectiveness of four treatments: spiritual healing, traditional healing, medication, and selected evidence-based psychosocial treatments widely used in the US. Treatment expectancies were assessed for each of three key syndromes identified by previous research: akabonge (a set of depression-like symptoms), guhahamuka (a set of trauma-related symptoms), and ibisigo (a set of psychosis-like symptoms) . In individual interviews or written surveys in French or Kirundi with patients ( N = 198) awaiting treatment at the clinic, we described each disorder and the treatments in everyday language, asking standard efficacy expectations questions about each ("Would it work?" "Why or why not?"). Findings indicated uniformly high expectancies about the efficacy of spiritual treatment, relatively high expectancies for western evidence-based treatments (especially cognitive behavior therapy [CBT] for depression-like symptoms), lower expectancies for medicine, and especially low expectancies for traditional healing (except for traditional healing for psychosis-like symptoms). There were significant effects of gender but not of education level. Qualitative analyses of explanations provide insight into the basis of people's beliefs, their explanations about why a given treatment would or would not work varied by type of disorder, and reflected beliefs about underlying causes. Implications for program development and future research are discussed.

25 years of systemic therapies research: progress and promise.

OBJECTIVE: In this article we describe and assess the state of the science on systemic psychotherapies. In the quarter century since the first issue of Psychotherapy Research was published, considerable progress has been made. There is an increasingly solid evidence base for systemic treatments, which includes a wide range of approaches to working conjointly with couples and families. Moreover, there are exciting new developments that hold promise for explicating the dynamic processes of therapeutic change in couple and family systems. METHOD: We begin by explaining how we view "systemic therapies" as different from individual approaches and then summarize what we have learned in the past 25 years about this set of treatments, how we have learned it, and what we have yet to learn. RESULTS AND CONCLUSIONS: We consider current trends in research on outcomes and change process mechanisms, and end with speculations about what lies ahead in the interrelated domains of systemic research and practice.

Relationship satisfaction of HIV-positive Ugandan individuals with HIV-negative partners.

Challenges of relational coping are well documented in the literature on couples and chronic illnesses, but there is significantly less research on the psychological aspects of couple relationships and HIV, particularly in international contexts. Coping with the uncertainty of illness progression, family planning, disclosure to friends and family, social isolation and stigma, fear of transmission, sexual intimacy, changes to social and physical functioning, and receiving and providing care pose special challenges for couples with discordant HIV statuses. This study examined the correlates of relationship satisfaction in Ugandan HIV-positive individuals seeking treatment at a community clinic. Relationship satisfaction of HIV-positive individuals was uniquely predicted by their couple identity and depression, underscoring the importance of mental and relational health in HIV/AIDS.

Lessons offered, lessons learned: reflections on how doing family therapy can affect therapists.

Only in working conjointly with couples and families do therapists literally witness clients struggling to improve their most intimate relationships. In writing this article, we realized that, in true systemic fashion, not only have many of our clients benefited from working with us, but also we have learned some invaluable lessons from them. Indeed, practicing couple and family therapy gives therapists many opportunities to learn about themselves, especially when it is done thoughtfully. In this article, we reflect on myriad ways in which couples and family therapy has affected each of us personally-as individuals, as partners, as parents, as adult children in our families of origin, and as educators.

Applying Group Cognitive Behavioral Therapy for Anxiety Disorders in Community Settings: Retention, Outcome, and Clinical Considerations.

The efficacy, and to a lesser extent, effectiveness, of individual cognitive behavioral therapy (CBT) for anxiety disorders has been demonstrated, but whether manualized treatments work in a group format in community settings is less established. We investigated the predictors of retention and outcome in 26 groups (11 Generalized Anxiety Disorder, 11 Panic, 4 Social Phobia groups), conducted for more than 10 years in a semirural community mental health center by 19 therapists. Members of the Anxiety Disorders Treatment Team delivered manualized group CBT treatments. Analysis of standard symptom measures at pre- and posttreatment and archival data revealed significant pre-post decreases in anxiety, retention rates comparable to past findings on group retention, and several significant predictors of retention and outcome. Manualized group CBT for anxiety appears to be a viable treatment in community settings. Limitations of the study as well as related practice-research implications of the findings are discussed.

How do therapists ally with adolescents in family therapy? An examination of relational control communication in early sessions.

Sequential analyses examined associations between the working alliance and therapist-adolescent communication patterns in 10 Spanish cases of brief conjoint family therapy. Early sessions with strong versus problematic alliances, rated by observers, were selected for coding of relational control communication patterns. No differences were found in the frequency of exchanges, but competitive responding by the therapists (reflecting an interpersonal struggle for control) was significantly more likely in problematic alliance sessions than in strong alliance sessions. Cases in which the adolescent's alliance with the therapist remained positive from Session 1 as compared with Session 3 showed a decrease in the likelihood of competitive symmetry. Notably, when the quality of the alliance deteriorated over time, the therapists were increasingly more likely to respond to the adolescents' domineering messages in a competitive manner. Results underscore the need to avoid competitive responding in order to ally with adolescents in conjoint family treatment.

Using the e-SOFTA for video training and research on alliance-related behavior.

In this article, we describe a specific technology for training/supervision and research on the working alliance in either individual or couple/family therapy. The technology is based on the System for Observing Family Therapy Alliances (SOFTA; Friedlander, Escudero, & Heatherington, 2006), which contains four conceptual dimensions (Engagement in the Therapeutic Process, Emotional Connection with the Therapist, Safety within the Therapeutic System, and Shared Sense of Purpose within the Family), observational rating tools (SOFTA-o), and self-report measures (SOFTA-s) shown to be important indicators of therapeutic progress. The technology, e-SOFTA, is a computer program (available for PC downloading free of charge) that can be used to rate client(s) and therapist on the specific SOFTA-o behaviors that contribute to or detract from a strong working alliance in each dimension. In addition to providing time-stamped frequencies of alliance-related behaviors, e-SOFTA allows users to link the observed behaviors to qualitative comments and to compare one person's rating of a session to that of another person. Suggestions are provided for using e-SOFTA in research, in didactic training, and in supervision, including a specific training module for introducing graduate students to the working alliance and assessing their observational and executive skills.

Alliance in couple and family therapy.

Couple and family therapy (CFT) is challenging because multiple interacting working alliances develop simultaneously and are heavily influenced by preexisting family dynamics. An original meta-analysis of 24 published CFT alliance-retention/outcome studies (k = 17 family and 7 couple studies; N = 1,416 clients) showed a weighted aggregate r = .26, z = 8.13 (p < .005); 95% CI = .33, .20. This small-to-medium effect size is almost identical to that reported for individual adult psychotherapy (Horvath, Del Re, Flückiger, & Symonds, this issue, pp. 9-16). Analysis of the 17 family studies (n = 1,081 clients) showed a similar average weighted effect size (r = .24; z = 6.55, p < .005; 95% CI = .30, .16), whereas the analysis of the 7 couple therapy studies (n = 335 clients) indicated r = .37; z = 6.16, p < .005; 95% CI = .48, .25. Tests of the null hypothesis of homogeneity suggested unexplained variability in the alliance-outcome association in both treatment formats. In this article we also summarize the most widely used alliance measures used in CFT research, provide an extended clinical example, and describe patient contributions to the developing alliance. Although few moderator or mediator studies have been conducted, the literature points to three important alliance-related phenomena in CFT: the frequency of "split" or "unbalanced" alliances, the importance of ensuring safety, and the need to foster a strong within-family sense of purpose about the purpose, goals, and value of conjoint treatment. We conclude with a series of therapeutic practices predicated on the research evidence.

Coming to terms with coming out: review and recommendations for family systems-focused research.

For lesbian, gay, and bisexual (LGB) adolescents and young adults, coming out to family members, especially parents, is a major psychological decision and hurdle due to both perceived fears and actual negative consequences. But beyond the literature on factors associated with the decision to come out and parents' initial reactions to the disclosure, empirical studies of what unfolds afterward, and how the family adjusts to the LGB adolescent's identity over time, are sparse and scattered. This article reviews and integrates findings from studies of the individual-, dyadic-, and family-level variables associated with positive outcomes, focusing particularly on relationship variables. Methodological concerns within this body of research are discussed, and research recommendations are offered. A preliminary working model of how families successfully come to terms with coming out is proposed to guide future research that will advance theory and clinical work with LGB youth and their families.

Now why'd he do that? The nature and correlates of mothers' attributions about negative teen behavior.

This study examined the attributions that mothers make about their teens' negative behaviors and whether these attributions are related to their own attributional styles, as well as the relationship between mothers' attributions and parent-teen relationship conflict. Globality of mothers' attributions was particularly important: Globality of attributions about events in their own lives was correlated with globality of attributions about teens' behavior, and globality of mothers' attributions about teen behavior was correlated with conflict. The nature of the negative behavior (whether it directly involved the parent or did not) made a difference in predictable ways. The results highlight the ways in which a full understanding of the role of attributions in parent-teen relationships calls for more complex conceptualization of traditional attribution dimensions, notably, the internal-external dimension.

Change process research in couple and family therapy: methodological challenges and opportunities.

In our field, the study of therapeutic change processes lags behind the study of treatment efficacy. Nonetheless, in the past 10 years major strides have been made in delineating change process mechanisms in couple and family therapy. To focus the efforts of future change process researchers, the authors discuss 5 critical needs: (a) more well-articulated, midrange theory about systemic change processes; (b) more attention to client change processes; (c) more attention to covert intrapersonal processes (emotion, cognition, and clients' experience of the alliance); (d) better articulation of strategies for analyzing data from multiple participants; and (e) more focus on the degree to which various change processes work similarly (or not) for diverse couples and families.