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We face increasing demand for greater access to effective routine mental health services, including telehealth. However, treatment outcomes in routine clinical practice are only about half the size of those reported in controlled trials. Progress feedback, defined as the ongoing monitoring of patients' treatment response with standardized measures, is an evidence-based practice that continues to be under-utilized in routine care. The aim of the current review is to provide a summary of the current evidence base for the use of progress feedback, its mechanisms of action and considerations for successful implementation. We reviewed ten available meta-analyses, which report small to medium overall effect sizes. The results suggest that adding feedback to a wide range of psychological and psychiatric interventions (ranging from primary care to hospitalization and crisis care) tends to enhance the effectiveness of these interventions. The strongest evidence is for patients with common mental health problems compared to those with very severe disorders. Effect sizes for not-on-track cases, a subgroup of cases that are not progressing well, are found to be somewhat stronger, especially when clinical support tools are added to the feedback. Systematic reviews and recent studies suggest potential mechanisms of action for progress feedback include focusing the clinician's attention, altering clinician expectations, providing new information, and enhancing patient-centered communication. Promising approaches to strengthen progress feedback interventions include advanced systems with signaling technology, clinical problem-solving tools, and a broader spectrum of outcome and progress measures. An overview of methodological and implementation challenges is provided, as well as suggestions for addressing these issues in future studies. We conclude that while feedback has modest effects, it is a small and affordable intervention that can potentially improve outcomes in psychological interventions. Further research into mechanisms of action and effective implementation strategies is needed.
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BACKGROUND: While considerable progress has been made in exploring the psychological, the neural, and the neurochemical dimensions of OCD separately, their interplay is still an open question, especially their changes during psychotherapy. METHODS: Seventeen patients were assessed at these three levels by psychological questionnaires, fMRI, and venipuncture before and after inpatient psychotherapy. Seventeen controls were scanned at comparable time intervals. First, pre/post treatment changes were investigated for all three levels separately: symptom severity, whole-brain and regional activity, and the concentrations of cortisol, serotonin, dopamine, brain-derived neurotrophic factor (BDNF), and immunological parameters (IL-6, IL-10, TNFα). Second, stepwise linear modeling was used to find relations between the variables of the levels. RESULTS: The obsessive-compulsive, depressive, and overall symptom severity was significantly reduced after psychotherapy. At the neural level, the activity in the anterior cingulate cortex (ACC), in frontal regions, in the precuneus, and in the putamen had significantly decreased. No significant changes were found on the neurochemical level. When connecting the levels, a highly significant model was found that explains the decrease in neural activity of the putamen by increases of the concentrations of cortisol, IL-6, and dopamine. CONCLUSION: Multivariate approaches offer insight on the influences that the different levels of the psychiatric disorder OCD have on each other. More research and adapted models are needed.
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Transtorno Obsessivo-Compulsivo , Encéfalo/diagnóstico por imagem , Lobo Frontal , Giro do Cíngulo/diagnóstico por imagem , Humanos , Imageamento por Ressonância Magnética , Transtorno Obsessivo-Compulsivo/terapiaRESUMO
Objective: While destabilization periods characterized by high variability and turbulence in a patient's psychological state might seem obstructive for psychotherapy, a complex systems approach to psychopathology predicts that these periods are actually beneficial as they indicate possibilities for reorganization within the patient. The present study tested the hypothesis that destabilization is related to better treatment outcome.Method: 328 patients who received psychotherapy for mood disorders completed daily self-ratings about their psychotherapeutic process. A continuous measure of destabilization was defined as the relative strength of the highest peak in dynamic complexity, a measure for variability and turbulence, in the self-ratings of individual patients.Results: Destabilization was found to be related to better treatment outcome. When improvers and non-improvers were analyzed separately, destabilization was found to be related to better treatment outcome in improvers but not in non-improvers.Conclusions: Destabilization in daily self-ratings of the psychotherapeutic process is associated with better treatment outcome. The identification of destabilization periods in process-monitoring data is clinically relevant. During destabilization, patients are believed to be increasingly sensitive to the effects of therapy. Clinicians could tailor their interventions to these sensitive periods.
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Transtornos do Humor , Processos Psicoterapêuticos , Humanos , Transtornos do Humor/terapia , Psicoterapia , Resultado do TratamentoRESUMO
Psychotherapy is a dynamic process produced by a complex system of interacting variables. Even though there are qualitative models of such systems the link between structure and function, between network and network dynamics is still missing. The aim of this study is to realize these links. The proposed model is composed of five state variables (P: problem severity, S: success and therapeutic progress, M: motivation to change, E: emotions, I: insight and new perspectives) interconnected by 16 functions. The shape of each function is modified by four parameters (a: capability to form a trustful working alliance, c: mentalization and emotion regulation, r: behavioral resources and skills, m: self-efficacy and reward expectation). Psychologically, the parameters play the role of competencies or traits, which translate into the concept of control parameters in synergetics. The qualitative model was transferred into five coupled, deterministic, nonlinear difference equations generating the dynamics of each variable as a function of other variables. The mathematical model is able to reproduce important features of psychotherapy processes. Examples of parameter-dependent bifurcation diagrams are given. Beyond the illustrated similarities between simulated and empirical dynamics, the model has to be further developed, systematically tested by simulated experiments, and compared to empirical data.
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Cognição , Emoções , Transtornos Mentais/terapia , Motivação , Processos Psicoterapêuticos , Psicoterapia , Simulação por Computador , Humanos , Modelos Teóricos , Dinâmica não Linear , Avaliação de Processos em Cuidados de Saúde , Índice de Gravidade de DoençaRESUMO
We studied the synchronization dynamics of a therapist and patient during a psychotherapy session. This investigation was developed in order to explore a new possible perspective and methodology for studying the expression of emotions. More specifically, literature concerning synchronization of in-session non-verbal variables emphasises its positive correlation with empathy and therapeutic outcomes. We compared the dynamics of galvanic skin response (GSR) and linguistic prosody, chosen as indicators of emotional expression in different domains. We studied their synchronization through complementary methodologies: Recurrence Quantification Analysis (RQA) and Principal Component Analysis (PCA), Markov Transition Matrix (MTM) and Cross-Recurrence Quantification Analysis (CRQA). We investigated the nonlinearity of GSR in terms of self-similarity and power-law, as emerged in autocorrelation functions and signal variations. We considered time-lagged correlations as a measure of dynamical systems' memory. This article concludes by highlighting the importance of a deeper study of all variables related to the psychotherapeutic process and their synchronization in order to extend our knowledge of general human dynamics.
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Terapia Cognitivo-Comportamental , Emoções/fisiologia , Resposta Galvânica da Pele/fisiologia , Relações Interpessoais , Comunicação não Verbal , Psicoterapia Breve , Comportamento Verbal/fisiologia , Adulto , Empatia/fisiologia , Feminino , Humanos , Masculino , Modelos Estatísticos , Dinâmica não Linear , Acústica da Fala , Estatística como AssuntoRESUMO
The COVID-19 pandemic has led to a global health crisis and a significant increase in psychological distress and psychopathological symptoms. We conducted a randomized controlled trial with two online interventions derived from positive psychology (PP) and acceptance and commitment therapy (ACT) in N = 138 "homestayers" during the first lock-down period in Germany. PP exercises had a positive impact on anxiety scores, which decreased significantly during the intervention, particularly in participants without access to a garden. Direct or indirect social contact, movement/exercise, and exposure to nature were the most frequently reported helpful coping strategies. We conclude that low-threshold online interventions with a focus on positive aspects of people's lives may be helpful to support mental health during pandemic crises. From a mental health perspective, the results also reinforce the approach of countries that allow their citizens to, for example, still go for walks during periods of contact restrictions, compared to full lock-down conditions.
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BACKGROUND: Based on evidence that mental health is more than an absence of mental disorders, there have been calls to find ways to promote flourishing at a population level, especially in young people, which requires effective and scalable interventions. Despite their potential for scalability, few mental wellbeing apps have been rigorously tested in high-powered trials, derived from models of healthy emotional functioning, or tailored to individual profiles. We aimed to test a personalised emotional competence self-help app versus a cognitive behavioural therapy (CBT) self-help app versus a self-monitoring app to promote mental wellbeing in healthy young people. METHODS: This international, multicentre, parallel, open-label, randomised controlled trial within a cohort multiple randomised trial (including a parallel trial of depression prevention) was done at four university trial sites in four countries (the UK, Germany, Spain, and Belgium). Participants were recruited from schools and universities and via social media from the four respective countries. Eligible participants were aged 16-22 years with well adjusted emotional competence profiles and no current or past diagnosis of major depression. Participants were randomised (1:1:1) to usual practice plus either the emotional competence app, the CBT app or the self-monitoring app, by an independent computerised system, minimised by country, age, and self-reported gender, and followed up for 12 months post-randomisation. The primary outcome was mental wellbeing (indexed by the Warwick-Edinburgh Mental Well Being Scale [WEMWBS]) at 3-month follow-up, analysed in participants who completed the 3-month follow-up assessment. Outcome assessors were masked to group allocation. The study is registered with ClinicalTrials.gov, NCT04148508, and is closed. FINDINGS: Between Oct 15, 2020, and Aug 3, 2021, 2532 participants were enrolled, and 847 were randomly assigned to the emotional competence app, 841 to the CBT app, and 844 to the self-monitoring app. Mean age was 19·2 years (SD 1·8). Of 2532 participants self-reporting gender, 1896 (74·9%) were female, 613 (24·2%) were male, 16 (0·6%) were neither, and seven (0·3%) were both. 425 participants in the emotional competence app group, 443 in the CT app group, and 447 in the self-monitoring app group completed the follow-up assessment at 3 months. There was no difference in mental wellbeing between the groups at 3 months (global p=0·47). The emotional competence app did not differ from the CBT app (mean difference in WEMWBS -0·21 [95% CI -1·08 to 0·66]) or the self-monitoring app (0·32 [-0·54 to 1·19]) and the CBT app did not differ from the self-monitoring app (0·53 [-0·33 to 1·39]). 14 of 1315 participants were admitted to or treated in hospital (or both) for mental health-related reasons, which were considered unrelated to the interventions (five participants in the emotional competence app group, eight in the CBT app group, and one in the self-monitoring app group). No deaths occurred. INTERPRETATION: The emotional competence app and the CBT app provided limited benefit in promoting mental wellbeing in healthy young people. This finding might reflect the low intensity of these interventions and the difficulty improving mental wellbeing via universal digital interventions implemented in low-risk populations. FUNDING: European Commission.
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BACKGROUND: Effective, scalable interventions are needed to prevent poor mental health in young people. Although mental health apps can provide scalable prevention, few have been rigorously tested in high-powered trials built on models of healthy emotional functioning or tailored to individual profiles. We aimed to test a personalised emotional competence app versus a cognitive behavioural therapy (CBT) self-help app versus a self-monitoring app to prevent an increase in depression symptoms in young people. METHODS: This multicentre, parallel, open-label, randomised controlled trial, within a cohort multiple randomised trial (including a parallel trial of wellbeing promotion) was done at four university trial sites in the UK, Germany, Spain, and Belgium. Participants were recruited from schools, universities, and social media from the four respective countries. Eligible participants were aged 16-22 years with increased vulnerability indexed by baseline emotional competence profile, without current or past diagnosis of major depression. Participants were randomly assigned (1:1:1) to usual practice plus either the personalised emotional competence self-help app, the generic CBT self-help app, or the self-monitoring app by an independent computerised system, minimised by country, age, and self-reported gender, and followed up for 12 months post-randomisation. Outcome assessors were masked to group allocation. The primary outcome was depression symptoms (according to Patient Health Questionnaire-9 [PHQ-9]) at 3-month follow-up, analysed in participants who completed the 3-month follow-up assessment. The study is registered with ClinicalTrials.gov, NCT04148508, and is closed. FINDINGS: Between Oct 15, 2020, and Aug 3, 2021, 1262 participants were enrolled, including 417 to the emotional competence app, 423 to the CBT app, and 422 to the self-monitoring app. Mean age was 18·8 years (SD 2·0). Of 1262 participants self-reporting gender, 984 (78·0%) were female, 253 (20·0%) were male, 15 (1·2%) were neither, and ten (0·8%) were both. 178 participants in the emotional competence app group, 191 in the CBT app group, and 199 in the self-monitoring app group completed the follow-up assessment at 3 months. At 3 months, depression symptoms were lower with the CBT app than the self-monitoring app (mean difference in PHQ-9 -1·18 [95% CI -2·01 to -0·34]; p=0·006), but depression symptoms did not differ between the emotional competence app and the CBT app (0·63 [-0·22 to 1·49]; p=0·15) or the self-monitoring app and emotional competence app (-0·54 [-1·39 to 0·31]; p=0·21). 31 of the 541 participants who completed any of the follow-up assessments received treatment in hospital or were admitted to hospital for mental health-related reasons considered unrelated to interventions (eight in the emotional competence app group, 15 in the CBT app group, and eight in the self-monitoring app group). No deaths occurred. INTERPRETATION: The CBT app delayed increases in depression symptoms in at-risk young people relative to the self-monitoring app, although this benefit faded by 12 months. Against hypotheses, the emotional competence app was not more effective at reducing depression symptoms than the self-monitoring app. CBT self-help apps might be valuable public mental health interventions for young people given their scalability, non-consumable nature, and affordability. FUNDING: European Commission.
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A complex systems approach to psychopathology proposes that general principles lie in the dynamic patterns of psychopathology, which are not restricted to specific psychological processes like symptoms or affect. Hence, it must be possible to find general change profiles in time series data of fully personalized questionnaires. In the current study, we examined general change profiles in personalized self-ratings and related these to four measures of treatment outcome (International Symptom Rating, 21-item Depression Anxiety and Stress Scale, daily symptom severity, and self-reflective capacity). We analyzed data of 404 patients with mood and/or anxiety disorders who completed daily self-ratings on personalized questionnaires during psychotherapy. For each patient, a principal component analysis was applied to the multivariate time series in order to retrieve an univariate person-specific time series. Then, using classification and regression methods, we examined these time series for the presence of general change profiles. The change profile classification yielded the following distribution of patients: no-shift (n = 55; 14%), gradual-change (n = 52; 13%), one-shift (n = 233; 58%), reversed-shift (n = 39; 10%) and multiple-shifts (n = 25; 6%). The multiple-shift group had better treatment outcome than the no-shift group on all outcome measures. The one-shift and gradual-change groups had better treatment outcome than the no-shift group on two and three outcome measures, respectively. Overall, this study illustrates that person-specific (idiographic) and general (nomothetic) aspects of psychopathology can be integrated in a complex systems approach to psychopathology, which may combine "the best of both worlds." (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Transtornos de Ansiedade , Psicopatologia , Humanos , Transtornos de Ansiedade/diagnóstico , Transtornos de Ansiedade/terapia , Afeto , Psicoterapia , Avaliação de Resultados em Cuidados de SaúdeRESUMO
Flexibility is a key feature of psychological health, allowing the individual to dynamically adapt to changing environmental demands, which is impaired in many psychiatric disorders like obsessive-compulsive disorder (OCD). Adequately responding to varying demands requires the brain to switch between different patterns of neural activity, which are represented by different brain network configurations (functional connectivity patterns). Here, we operationalize neural flexibility as the dissimilarity between consecutive connectivity matrices of brain regions (jump length). In total, 132 fMRI scans were obtained from 17 patients that were scanned four to five times during inpatient psychotherapy, and from 17 controls that were scanned at comparable time intervals. Significant negative correlations were found between the jump lengths and the symptom severity scores of OCD, depression, anxiety, and stress, suggesting that high symptom severity corresponds to inflexible brain functioning. Further analyses revealed that impaired reconfiguration (pattern stability) of the brain seems to be more related to general psychiatric impairment rather than to specific symptoms, e.g., of OCD or depression. Importantly, the group × time interaction of a repeated measures ANOVA was significant, as well as the post-hoc paired t-tests of the patients (first vs. last scan). The results suggest that psychotherapy is able to significantly increase the neural flexibility of patients. We conclude that psychiatric symptoms like anxiety, stress, depression, and OCD are associated with an impaired adaptivity of the brain. In general, our results add to the growing evidence that dynamic functional connectivity captures meaningful properties of brain functioning.
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Transtorno Obsessivo-Compulsivo , Encéfalo/diagnóstico por imagem , Mapeamento Encefálico , Humanos , Imageamento por Ressonância Magnética , Vias Neurais , Transtorno Obsessivo-Compulsivo/diagnóstico por imagem , Transtorno Obsessivo-Compulsivo/terapia , PsicoterapiaRESUMO
OBJECTIVE: Home-based treatment of families with low socio-economic status and multiple psychosocial problems (multi-problem families, MPFs) is gaining importance in clinical social epidemiology and health services research. The sustainability of the treatment is of special importance in order to breach transgenerational effects. METHODS: We examined outcome, effect size, and clinical significance of home-based treatment for 84 multi-problem families in a naturalistic setting. 48 of the families were available for a follow-up after 3 years. The baseline characteristics of these family systems included low collaboration, an increased family adversity index, minors with high rates of child psychiatric disorders, a high prevalence of comorbidity, low relational family functioning, and adolescents who refused any form of treatment or had unilaterally terminated different forms of treatment before. The home-based family therapy consisted of one or two face-to-face counseling sessions per week over an average of 28.8 months (SD = 19.2). The symptoms and competence of the adolescents, the caregivers, and the family structure were assessed with 13 variables. RESULTS: All variables showed significant improvement rates (pre- vs. post- treatment) with medium to high effect sizes (mean of Cohen's d = 1.04, range = 0.34 - 2.18). All variables showed a sustained or even further improvement at follow-up. CONCLUSION: This study provides evidence of statistically (p), practically (d), and clinically (RCI) significant changes in symptom and competence-related variables among adolescents and caregivers in MPFs with sustainable long-term effects in the 3-year follow-up period.
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OBJECTIVE: We examined individual overall trajectories of change and the occurrence of sudden gains in daily self-rated problem severity and the relation of these patterns to treatment response. METHOD: Mood disorder patients (N = 329, mean age = 44, 55% women) completed daily self-ratings about the severity of their complaints as a standard part of treatment, using the Therapy Process Questionnaire (TPQ). Per individual, the best-fitting defined (linear, log-linear, 1-step) trajectory was tested for significance: for change over time, and for specificity of the best-fitting trajectory. Two-hundred and three cases had ICD-10 Symptom Rating (ISR) depression scores posttreatment: a score ≤1 identified 114 treatment responders. Relation to response was examined for sudden gains and type of change trajectory. RESULTS: 138 cases (42%) had a significant decrease in problem severity, of which 54 cases (16%) had a defined trajectory: 50 cases with one-step improvement, and 4 with a linear improvement in daily problem severity. Sudden gains occurred in 28% of the total sample, and within 58% of improvement patterns. Specifically, sudden gains occurred in 68% of significant 1-step trajectories and 25% of the linear cases. Sudden gains and nonspecific change trajectories were significantly more frequent for treatment responders. CONCLUSIONS: At the day-level, patterns of improvement are nonlinear for most patients. Sudden gains occur within various forms of overall change and are associated with treatment response. Clinically relevant improvements in depression occur both gradually and abruptly, and this finding allows for the possibility that the remission process functions according to dynamical systems principles. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
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Afeto , Transtorno Depressivo/terapia , Adulto , Transtorno Depressivo/diagnóstico , Transtorno Depressivo/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Inquéritos e Questionários , Resultado do TratamentoRESUMO
For patients with Obsessive-Compulsive Disorder (OCD), whose triggers are highly idiosyncratic, individual stimulus material has been used in several fMRI studies. This study aims at comparing individual to standardized picture sets and at investigating a possible overlap of the former with the self-referential neuronal network. During fMRI-scanning, 17 inpatients with OCD and 17 healthy controls were exposed to pictures of their personal triggers, photographed in their domestic environments, to standardized pictures designed to provoke OCD symptoms, and to neutral pictures. Whole-brain analyses were calculated and the pictures were rated by both patients and controls with respect to valence, arousal, and coping. Patients rated the individualized stimuli lower in valence and coping and higher in arousal compared to controls, and also compared to standardized OCD- and neutral stimuli. The individual stimuli elicited neuronal activity in the cingulate cortex, hippocampus, insula, middle frontal/precentral gyrus, superior/inferior parietal lobe, and precuneus, while no group difference was detected by the standardized OCD-stimuli. In conclusion, individual picture sets facilitate the detection of neuronal activity, but the results might be confounded due to the overlap with the network of self-referential processing and memory retrieval. The use of individual symptom-provoking and individual neutral stimuli would therefore be optimal.
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Encéfalo/diagnóstico por imagem , Imageamento por Ressonância Magnética/métodos , Rede Nervosa/diagnóstico por imagem , Transtorno Obsessivo-Compulsivo/diagnóstico por imagem , Transtorno Obsessivo-Compulsivo/psicologia , Estimulação Luminosa/métodos , Adulto , Nível de Alerta/fisiologia , Encéfalo/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Rede Nervosa/fisiopatologia , Transtorno Obsessivo-Compulsivo/fisiopatologiaRESUMO
Objective: fMRI scans of patients with obsessive-compulsive disorder (OCD) consistently show a hyperactivity of the insular cortex, a region responsible for disgust-processing, when confronted with symptom-triggering stimuli. This asks for an investigation of the role of disgust and the insula in OCD patients. Methods: Seventeen inpatients with OCD and 17 healthy controls (HC) underwent fMRI scanning. Whole-brain contrasts were calculated for "Disgust vs. Neutral" for both groups, plus an analysis of variance (ANOVA) to assess the interaction between group and condition. Additionally, the emotional dimensions of valence and arousal, along with the ability to cope, were assessed by picture ratings. Results: The picture ratings confirmed the patients' heightened sensitivity to disgust with higher values for arousal and inability to cope, but not for valence. fMRI scans revealed no hyperactivity of the insula in patients compared to controls for the condition "Disgust vs. Neutral," indicating no basic hypersensitivity to disgusting stimuli. Increased activity in the precuneus in controls for this condition might correspond to the downregulation of arousal. Conclusions: The absent differences in neural activity of the insula in patients compared to controls for the disgust-condition, but heightened activity for symptom-provoking conditions, suggests that the illness is due to an erroneous recruitment of the insula cortex for OCD-stimuli. The finding is interpreted within the framework of the neural reuse hypothesis.
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Context: Families with high rates of childhood adversities (CAs) (multi problem families, MPF) have an increasing importance in public health-policy. Objective: The present study addresses the relationship between risk- and protective factors and the severity and treatment-outcome of mental disorders. Setting: Family-therapeutic home-based treatment for MPF. We examined a clinical sample (N = 1031) of children between the age of 4 to 17, and a non-clinical sample of 148 children. We hypothesized that of all children of the clinical group have a predominance of risk factors and a higher number of psychopathological symptoms. Furthermore, we hypothesized that children with a predominance of protective factors benefit stronger from psychotherapy. Main Results: In the clinical sample, most children met the criteria of a psychopathological diagnosis (95.7%, as compared to 21.6% in the non-clinical sample) and showed significant higher rates of CAs and significant less protective factors as compared to the non-clinical sample. The clinical group showed a significant reduction of psychopathological symptoms and benefited equally well from treatment. The number of risk factors was a significant predictor for a child from the non-clinical sample to meet the criteria of a psychopathological diagnosis, while the number of protective factors significantly predicted the absence thereof. Conclusion: Children and adolescents with high scores of CAs show significant associations with child psychiatric symptoms (d = 0.35; including all ICD-diagnosis such as, e.g., Asperger Syndrome, ADHD etc. with a higher rate of genetic etiology). Early life stressors, however, do not trigger an irreversible fate, as psychotherapy with young people with high numbers of risk factors does help to reduce psychopathological symptoms significantly (range of five outcome parameters: d = 0.31-0.72).
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Objective: The present study validates the Multi-Problem Family (MPF)-Collaboration Scale), which measures the progress of goal directed collaboration of patients in the treatment of families with MPF and its relation to drop-out rates and treatment outcome. Method: Naturalistic study of symptom and competence-related changes in children of ages 4-18 and their caregivers. Setting: Integrative, structural outreach family therapy. Measures: The data of five different groups of goal directed collaboration (deteriorating collaboration, stable low collaboration, stable medium collaboration, stable high collaboration, improving collaboration) were analyzed in their relation to treatment expectation, individual therapeutic goals (ITG), family adversity index, severity of problems and global assessment of a caregiver's functioning, child, and relational aspects. Results: From N = 810 families, 20% displayed stable high collaboration (n = 162) and 21% had a pattern of improving collaboration. The families with stable high or improving collaboration rates achieved significantly more progress throughout therapy in terms of treatment outcome expectancy (d = 0.96; r = 0.43), reaching ITG (d = 1.17; r = 0.50), family adversities (d = 0.55; r = 0.26), and severity of psychiatric symptoms (d = 0.31; r = 0.15). Furthermore, families with stable high or improving collaboration maintained longer treatments and had a bigger chance of finishing the therapy as planned. The odds of having a stable low or deteriorating collaboration throughout treatment were significantly higher for subjects who started treatment with low treatment expectation or high family-related adversities. Conclusion: The positive outcomes of homebased interventions for multi-problem families are closely related to "stable high" and an "improving" collaboration as measured with the MPF-Collaboration Scale. Patients who fall into these groups have a high treatment outcome expectancy and reduce psychological stress. For therapeutic interventions with multi-problem families it seems beneficial to maintain a stable high collaboration or help the collaboration, e.g., by fostering treatment expectation.
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Objective: The aim of this case report is to demonstrate the feasibility of a systemic procedure (synergetic process management) including modeling of the idiographic psychological system and continuous high-frequency monitoring of change dynamics in a case of dissociative identity disorder. The psychotherapy was realized in a day treatment center with a female client diagnosed with borderline personality disorder (BPD) and dissociative identity disorder. Methods: A three hour long co-creative session at the beginning of the treatment period allowed for modeling the systemic network of the client's dynamics of cognitions, emotions, and behavior. The components (variables) of this idiographic system model (ISM) were used to create items for an individualized process questionnaire for the client. The questionnaire was administered daily through an internet-based monitoring tool (Synergetic Navigation System, SNS), to capture the client's individual change process continuously throughout the therapy and after-care period. The resulting time series were reflected by therapist and client in therapeutic feedback sessions. Results: For the client it was important to see how the personality states dominating her daily life were represented by her idiographic system model and how the transitions between each state could be explained and understood by the activating and inhibiting relations between the cognitive-emotional components of that system. Continuous monitoring of her cognitions, emotions, and behavior via SNS allowed for identification of important triggers, dynamic patterns, and psychological mechanisms behind seemingly erratic state fluctuations. These insights enabled a change in management of the dynamics and an intensified trauma-focused therapy. Conclusion: By making use of the systemic case formulation technique and subsequent daily online monitoring, client and therapist continuously refer to detailed visualizations of the mental and behavioral network and its dynamics (e.g., order transitions). Effects on self-related information processing, on identity development, and toward a more pronounced autonomy in life (instead of feeling helpless against the chaoticity of state dynamics) were evident in the presented case and documented by the monitoring system.
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OBJECTIVE: The feasibility of a high-frequency real-time monitoring approach to psychotherapy is outlined and tested for patients' compliance to evaluate its integration to everyday practice. Criteria concern the ecological momentary assessment, the assessment of therapy-related cognitions and emotions, equidistant time sampling, real-time nonlinear time series analysis, continuous participative process control by client and therapist, and the application of idiographic (person-specific) surveys. METHODS: The process-outcome monitoring is technically realized by an internet-based device for data collection and data analysis, the Synergetic Navigation System. Its feasibility is documented by a compliance study on 151 clients treated in an inpatient and a day-treatment clinic. RESULTS: We found high compliance rates (mean: 78.3%, median: 89.4%) amongst the respondents, independent of the severity of symptoms or the degree of impairment. Compared to other diagnoses, the compliance rate was lower in the group diagnosed with personality disorders. CONCLUSION: The results support the feasibility of high-frequency monitoring in routine psychotherapy settings. Daily collection of psychological surveys allows for the assessment of highly resolved, equidistant time series data which gives insight into the nonlinear qualities of therapeutic change processes (e.g., pattern transitions, critical instabilities).