Pretreatment insight as a predictor of alliance strengthening in supportive vs. supportive-expressive treatment.

OBJECTIVE: The available literature points to the potential therapeutic benefits of alliance strengthening during treatment. Both supportive and expressive techniques have been suggested to be associated with strengthening of the alliance. The present study investigates whether patients may show different effects of supportive vs. expressive techniques in improving alliance as a function of their pretreatment insight levels. METHOD: Fifty-five patients were randomly assigned to either supportive treatment (ST) or supportive-expressive treatment (SET), as part of a larger randomized controlled trial. Clinical interviews were administered at pretreatment to evaluate the patients' level of insight. The working alliance was measured after each of the 16 sessions. A multilevel model, including a 3-way interaction of pretreatment insight by treatment condition (ST vs. SET) by time, was used to predict alliance strengthening. RESULTS: The findings suggest that, for individuals receiving ST, those with higher levels of insight show greater alliance strengthening. For individuals receiving SET, those with lower levels of insight show greater alliance strengthening. CONCLUSION: The current study suggests that one size may not fit all and, whereas some individuals may benefit more from ST to achieve alliance strengthening, others may benefit more from SET.

The development of a comprehensive coding system for evaluating insight based on a clinical interview: The SUIP-I coding system.

Gaining insight is considered a cornerstone of psychodynamic psychotherapy. Existing tools used to measure insight mainly include patients' self-report questionnaires and external coding of therapy sessions. To expand on the available tools, the present study developed a comprehensive coding system for the Self-Understanding of Interpersonal Patterns Scales-Interview (SUIP-I; Gibbons & Crits-Christoph, 2017). A total of 55 patients enrolled in a randomized controlled trial received psychodynamic psychotherapy for depression and were interviewed using the SUIP-I at baseline. A comprehensive coding system was developed for rating the interviews, based on a Likert scale for each of the six levels of insight. The content validity, psychometric properties, and the reliability and validity of the coding system were examined. The new SUIP-I coding system demonstrated interrater reliability in the "excellent" range, ICC (1, 1) = .91-.97, for all the six levels, and adequate internal consistency (Cronbach's α = .81). Support for convergent validity was gained, as manifested in a significant positive association of the SUIP-I with alliance expectation and affiliation, and a significant negative association with avoidance attachment. Support for discriminant validity was also gained, as manifested in a weak, nonsignificant association between the SUIP-I and self-esteem. The proposed comprehensive coding system shows good initial reliability and validity. Research is needed to further establish the psychometric properties of the new SUIP-I coding system. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Insight as a dual-perspective construct: Convergence between patients' and professional evaluators' perspective on baseline level of insight and on changes in insight.

Insight gained by patients during treatment has been theorized to be a central mechanism of change in psychotherapy, but empirical studies examining the association between patients' insight and psychopathological symptoms have produced mixed results. The present study addresses these inconsistencies by investigating convergence between the perspectives of patient and professional evaluator on insight and disentangling two potentially distinct components of insight: pretreatment individual differences and changes in insight during treatment. A sample of 393 patients receiving psychodynamic psychotherapy completed pre- and posttreatment measures on symptoms and insight. Professional evaluators evaluated patients' insight based on clinical interviews pre- and posttreatment. Polynomial regression and response surface analyses were used to examine congruence. The results indicate that when there was agreement between the patient and the evaluator on insight, both baseline level of insight and the changes in insight during treatment were found to be related to symptomatic change, although showing different patterns of association. Lower baseline levels of insight were significantly associated with greater symptomatic improvement than were higher levels of insight. At the same time, greater increase in insight during treatment was moderately significantly associated with greater reduction in symptoms, as long as the changes in insight were not minimal. The findings underscore the importance of assessing the congruence between patients' and professional observers' perspectives on patient insight and the potentially distinct roles of between-patients baseline differences and within-patient changes in insight during treatment. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Are there any robust predictors of "sudden gainers," and how is sustained improvement in treatment outcome achieved following a gain?

OBJECTIVE: It has been widely demonstrated that the process of change many patients undergo in therapy is not linear. Some patients benefit greatly from large sudden improvements, commonly referred to as "sudden gains." It is less clear whether certain baseline characteristics make patients more prone to displaying sudden gains, as well as what mechanisms are responsible for the lasting effects of sudden gains. METHOD: In a sample of 547 patients receiving treatment in an outpatient mental health clinic, a machine learning approach was used to search for potential predictors of sudden gains. A within-patient mediation model was used to investigate whether alliance serves as a mechanism underlying the sustained effect of sudden gains. RESULTS: Twelve percent of patients showed sudden gains. Consistent with previous studies, no robust predictors of sudden gains were found, even when using an approach capable of evaluating the contributions of multiple predictors and their interactions. A significant within-patient mediation model was found, according to which sudden gains predict subsequent strengthening in alliance, which in turn predict subsequent improvement in life satisfaction and psychological dysfunction. These findings support the proposed theoretical framework whereby alliance is an important ingredient of an upward spiral that may results in sustained sudden gains. CONCLUSIONS: The findings provide first evidence of the presence of an ingredient responsible for the sustained effect of sudden gains, using a within-patient mediation model. The findings support the important role alliance may play in the consolidation and subsequent expansion of the effect of sudden gains. (PsycINFO Database Record (c) 2019 APA, all rights reserved).