[How Outpatient Psychotherapists Deal with Patients' Traumatic Experiences in Consideration of an Additional Qualification in Trauma Therapy]. / Umgang ambulanter Psychotherapeut*innen mit traumatischen Erfahrungen von Patient*innen unter Berücksichtigung einer traumatherapeutischen Zusatzqualifikation.

OBJECTIVE: Investigation of the differences in dealing with traumatic experiences of patients between psychotherapists with and without further training in trauma therapy or partial qualification. METHODS: Online survey of outpatient psychotherapists (N = 148) on possible obstacles in addressing traumatic experiences of patients and self-reported professional practice. RESULTS: Further training in trauma therapy is associated with a higher level of competence in professional practice and fewer obstacles in addressing traumatic experiences. CONCLUSION: A lower level of competence among psychotherapists without further training in trauma therapy speaks for the need for compulsory trainings. The expansion of low-threshold treatment offers for those affected by traumatic experiences and the dismantling of access barriers is urgently needed.

Therapeutic interventions in in-person and remote psychotherapy: Survey with psychotherapists and patients experiencing in-person and remote psychotherapy during COVID-19.

OBJECTIVE: First, to investigate how psychotherapists and patients experience the change from in-person to remote psychotherapy or vice versa during COVID-19 regarding the therapeutic interventions used. Second, to explore the influence of therapeutic orientations on therapeutic interventions in in-person versus remote psychotherapy. METHOD: Psychotherapists (N = 217) from Austria were recruited, who in turn recruited their patients (N = 133). The therapeutic orientation of the therapists was psychodynamic (22.6%), humanistic (46.1%), systemic (20.7%) or behavioural (10.6%). All the data were collected remotely via online surveys. Therapists and patients completed two versions of the 'Multitheoretical List of Therapeutic Interventions' (MULTI-30) (version 1: in-person; version 2: remote) to investigate differences between in-person and remote psychotherapy in the following therapeutic interventions: psychodynamic, common factors, person-centred, process-experiential, interpersonal, cognitive, behavioural and dialectical-behavioural. RESULTS: Therapists rated all examined therapeutic interventions as more typical for in-person than for remote psychotherapy. For patients, three therapeutic interventions (psychodynamic, process-experiential, cognitive interventions) were more typical for in-person than for remote psychotherapy after correcting for multiple testing. For two therapeutic interventions (behavioural, dialectical-behavioural), differences between the four therapeutic orientations were more consistent for in-person than for remote psychotherapy. CONCLUSIONS: Therapeutic interventions differed between in-person and remote psychotherapy and differences between therapeutic orientations in behavioural-oriented interventions become indistinct in remote psychotherapy.

Perspectives of Psychotherapists and Psychiatrists on Mental Health Care Integration Within Primary Care Via Video Consultations: Qualitative Preimplementation Study.

BACKGROUND: Many patients with mental disorders remain untreated. Video-based mental health care demonstrates comparable effectiveness to face-to-face treatments and is a promising mode for delivering specialized care within primary care. Nevertheless, professionals struggle with implementing video consultations in their daily practice. Specifically, little is known about mental health specialists' acceptance of mental health video consultations in routine practice. The PROVIDE (ImPROving cross-sectoral collaboration between primary and psychosocial care: An implementation study on VIDEo consultations) project aims to improve cross-sectoral collaboration between primary and psychosocial care through implementing video consultations in primary care. To increase the uptake of video consultations, it is crucial to account for necessary prerequisites and to tailor interventions to the needs of the target group prior to implementation. OBJECTIVE: The aim of this study was to explore the acceptance of video consultations embedded in primary care from the perspectives of mental health specialists in Germany. METHODS: We conducted a qualitative, exploratory, preimplementation study in urban and rural counties. We conducted three semistructured focus groups with 11 mental health specialists. We used qualitative content analysis combining an inductive-deductive approach, applying the Tailored Implementation in Chronic Diseases (TICD) framework to the text material, which comprises individual health professional factors; patient factors; professional interactions; incentives and resources; capacity for organizational change; social, political, and legal factors; and guideline factors. RESULTS: Against the background of long waiting times and a shortage of mental health specialists, especially in rural areas, participants valued video consultations as a potential means to improve access to mental health care. With respect to the TICD framework domains, the participants most often discussed individual health professional factors, followed by patient factors. All participants highlighted the importance of a trusting relationship between the patient and the therapist and doubted whether such a relationship could be established through video consultations (11/11, 100%). However, participants considered mental health specialist video consultations to be particularly suited for patients in rural areas, those with impaired mobility, and those who may otherwise remain untreated (6/11, 55%). Most participants expected video consultations to help the aforementioned patient groups avoid tedious searching for an available therapist and save on travel time and, therefore, improve access to specialized care for patients (7/11, 64%). Moreover, the participants expected video consultations to improve collaboration with the family physician (6/11, 55%). Finally, participants identified organizational aspects, such as reliable scheduling, the duration of the individual consultation (9/11, 82%), and reimbursement conditions (7/11, 67%), as key drivers for the acceptance and adoption of the model. CONCLUSIONS: While mental health specialists expect video consultations to improve access to specialized care for some patients, they consistently wonder whether such consultations can establish a trusting patient-therapist relationship. When implementing video consultations, these concerns should be addressed by training providers in managing technology-based treatment settings, with extra consideration for fostering the patients' and therapists' engagement. TRIAL REGISTRATION: German Clinical Trials Register DRKS00012487; https://tinyurl.com/uhg2one.

Therapist effects vary significantly across psychological treatment care sectors.

Psychological intervention outcomes depend in part on the therapist who provides the intervention (a therapist effect). However, recent reviews suggest that therapist effects may vary as a function of the context in which care is provided and therefore should not be generalized beyond that context. This study statistically analysed therapist effect differences between care sectors delivering psychological interventions. The sample comprised routine clinical data from 26,814 patients (69% female; mean age 38) and 466 therapists in five care sectors: primary care, secondary care, university, voluntary, and workplace. Therapist effects were analysed using multilevel models and Markov chain Monte Carlo credible intervals. The therapist effect was significantly larger in primary care (8.4%) than in any other sector (1.1%-2.3%) except secondary care (4.1%), after controlling for explanatory baseline and process variables as well as accounting for differences between clinics. There were no other significant differences detected between care sectors. These findings support the hypothesis that differences in effectiveness between therapists vary depending on the context in which psychological treatment is provided. Differences in relative therapist impact can vary by a factor of 4-8 across treatment sectors. This should be considered in the application of research evidence, treatment planning, and the design and delivery of psychological care provision.

Outcomes, skill acquisition, and the alliance: Similarities and differences between clinical trial and student therapists.

Considerable evidence from clinical trials supports the efficacy of cognitive therapy (CT) of depression. Less is known about outcomes when provided in other contexts, such as when provided by student therapists. We conducted a non-randomized comparison of student therapists vs. clinical trial therapists on change in depressive symptoms, dropout, change in CT skills, and therapeutic alliance among 100 clients with moderate to severe depression. Treatment manual and duration were the same. Clients treated by student therapists had largely comparable outcomes on depressive symptom change, therapeutic alliance, and CT skills. Results supported non-inferiority of student therapists on change in depressive symptoms, but non-inferiority was not supported when using an interviewer evaluated measure of depression. Evidence of non-inferiority was also obtained for client CT skills and therapeutic alliance. In fact, conventional superiority analyses indicated student therapists outperformed clinical trial therapists on alliance and CT skills. The rate of dropout among student therapists (30%) was numerically higher than among clinical trial therapists (17%) and our results did not support non-inferiority on dropout. CT provided by student therapists can achieve outcomes similar to those in a clinical trial, but more research about dropout is needed.

[The Frequency of Cases of Child Abuse - Results of a Survey of Brandenburg Child and Adolescent Psychotherapists]. / Die Häufigkeit von Fällen von Kindesmisshandlung ­ Ergebnisse einer Befragung von Brandenburger Kinder- und Jugendlichenpsychotherapeuten.

BACKGROUND: Within the field of (medical) child protection, child and adolescent psychotherapists are an important occupational group. However, that fact has mostly been overlooked in scientific discourse. The objectives of this study were to determine the prevalence and the approach to dealing with cases of (suspected) child abuse in psychotherapeutic practice. METHODS: All KJP who are admitted in the federal state of Brandenburg were asked to answer a questionnaire about the frequency of child abuse, divided by form of abuse and age. Furthermore, the number of reports to an authority/ agency, reasons for not reporting a (potential) case as well as necessary prerequisites for reliable recognition, evaluation and initiation of medico-legal, medical and psychotherapeutic interventions were recorded. RESULTS: In 2016, 74.4% and in 2017, 87% of child and adolescent psychotherapists registered at least one case of (suspected) child abuse. For both years, emotional negligence and emotional abuse were the most common types of abuse. The age group 6-13 was most affected by child abuse. In 2016, 34.4% and in 2017, 35% of child and adolescent psychotherapists who saw at least one case of (suspected) child abuse reported those to an agency. The most common reason (47.6%) for not reporting cases of (suspected) child abuse was the child's wish to not share any content discussed in therapy. 83.7% stated that clear criteria to reliably diagnose emotional negligence and emotional abuse are missing. Continuing education on medical/ psychotherapeutic and medico-legal aspects (53.3%), better cooperation between involved professions (43.4%) and inclusion of the overall topic in psychotherapist training and education (26.7%) were mentioned as the most important requirements for effective child protection. CONCLUSIONS: Cases of (suspected) child abuse are highly relevant in ambulant psychotherapeutic practice. Due to their close relationship with the patient, child and adolescent psychotherapists can identify emotional negligence and emotional abuse especially well. Their contribution to the care of children affected by abuse requires continuing education offers specific to their profession, the development of clear measures regarding the cooperation with Child Protective Services (county-level) as well as binding definitions and criteria for the different types of abuse.

A relational perspective on the association between working alliance and treatment outcome.

Objective: Evidence is inconclusive on whether variability in alliance ratings within or between therapists is a better predictor of treatment outcome. The objective of the present study was to explore between and within patient and therapist variability in alliance ratings, reciprocity among them, and their significance for treatment outcome. Method: A large primary care psychotherapy sample was used. Patient and therapist ratings of the working alliance at session three and patient ratings of psychological distress pre-post were used for analyses. A one-with-many analytical design was used in order to address problems associated with nonindependence. Results: Within-therapist variation in alliance ratings accounted for larger shares of the total variance than between-therapist variation in both therapist and patient ratings. Associations between averaged patient and therapist ratings of the alliance for the individual therapists and their average treatment outcome were weak but the associations between specific alliance ratings and treatment outcome within therapies were strong. Conclusions: The results indicated a substantial dyadic reciprocity in alliance ratings. Within-therapist variation in alliance was a better predictor of treatment outcome than between-therapist variation in alliance ratings.

Instrumental variable analyses for causal inference: Application to multilevel analyses of the alliance-outcome relation.

Objective: To introduce readers to instrumental variable analyses for causal inferences using as an example a test of the hypothesis that the quality of the therapeutic alliance has a causal role in relation to the outcome of psychotherapy. Method: We used data from a recent non-inferiority trial of cognitive and dynamic therapies for major depressive disorder in a community mental health setting. The data (N = 161) were analyzed using standard approaches as well as a multilevel 2-stage instrumental variables approach that allows for causal interpretations by removing the influence of unmeasured confounds. Results: Instrumental variables were created at the patient and therapist level using baseline patient and therapist variables. These baseline variables predicted the alliance but were otherwise unrelated to treatment outcome other than through their effects on the alliance. Standard multilevel mixed effects analyses revealed statistically significant associations of the alliance with outcome at the therapist level of analysis. The therapist level effect remained statistically significant when using the instrumental variables approach. Conclusion: Our results support the hypothesis that, at least at the therapist level, the alliance plays a causal role in producing better outcomes. Instrumental variable analyses can be a useful tool to supplement standard analyses.

Therapist effects on early change in psychotherapy in a naturalistic setting.

Objective: Client trajectories of change in psychotherapy differ. Early change is a trajectory that has been shown to be associated with better outcomes over time. Little is known about the mechanisms of this type of change, however. The current study examined the therapist effect in early change, and explored differences between therapists in the likelihood that early change would occur and how early in a course of therapy the change would occur.Methods: Using 20 years of archival data from a university counseling center, we identified 16,825 clients who had been seen by 273 therapists. We examined therapist differences using chi-square analyses, multilevel logistic regression, and survival analyses.Results: We found significant variance between therapists in both their likelihood to predict early change, and how early that change was predicted to occur. Therapist effects, however, accounted for a small portion of the overall variance; despite this small effect, differences between the best performing therapists and the worst performing therapists were substantial.Conclusions: Therapists were differentially effective in helping clients achieve early change. Future research examining mechanisms associated with these effects will be important in informing psychotherapy process and therapist training.