Client characteristics and early working alliance development: A person-centered research approach.

OBJECTIVE: Certain client characteristics are associated with early working alliance difficulties in psychotherapy. However, there is limited quantitative evidence on whether combinations of these characteristics (e.g., intersectional identities, prior treatment experiences) are related to alliance development. The present study leveraged a person-centered research approach to examine profiles of early alliance development and differences in the latent class structure of client characteristics among alliance development profiles. METHOD: Individual psychotherapy clients (N = 2,579) rated the working alliance for their first four sessions and self-reported demographics, treatment history, and psychological distress. Therapists provided their assessment of clients' primary presenting concerns at baseline. RESULTS: Latent profile analysis revealed three profiles of working alliance development: high and stable, moderate and increasing, and low and stable. Follow-up person-centered analyses (multigroup confirmatory latent class analysis) indicated that clients in the alliance profiles differed in their combinations of clinical and demographic characteristics. For example, women of color with high baseline distress and a history of prior psychotherapy were over-represented in the low and stable alliance profile. CONCLUSION: These results are consistent with recommendations to holistically consider how clients' characteristics and experiences shape psychotherapy processes. Results also highlight the utility of person-centered quantitative methods in psychotherapy research.

Stigma and Intentions to Seek Psychotherapy Among Primary Care Providers During the COVID-19 Pandemic: A Mediational Analysis.

BACKGROUND: Medical personnel have reported increases in psychological distress and depression during the COVID-19 pandemic. Additionally, many providers, including primary care providers (PCPs), face significant stigma related to personal mental healthcare. However, the process by which stigma affects help-seeking among PCPs is unclear. METHOD: Between January and May 2020, 112 PCPs completed a survey of perceived public stigma, self-stigma, attitudes, intentions to seek psychotherapy for depression, and a clinical vignette on patient referrals to psychotherapy. RESULTS: Self-stigma and attitudes toward psychotherapy sequentially mediated the relationship between perceived public stigma and intentions to seek psychotherapy. PCPs were more likely to refer a depressed patient to psychotherapy than seek personal psychotherapy, but lower personal help-seeking intentions were associated with lower referral intentions. CONCLUSION: These results clarify processes by which stigma hinders PCPs' psychotherapy use and highlight interventions to encourage their help-seeking. Addressing cultural and practical barriers in the medical field is needed to reduce stigma.

Effort and effort discounting as predictors of seeking psychotherapy among individuals with depression.

OBJECTIVES: Many individuals who experience depression do not seek psychotherapy, and past research has had limited success in predicting help-seeking in this population. Accounting for behavioral characteristics of depression that affect help-seeking decisions, such as effort discounting (devaluation of rewards as a function of effort), may address this gap. METHODS: Individuals with moderate-severe depression symptoms who were not in psychotherapy (N = 253) reported their depression symptom severity and the amount of effort they anticipated seeking psychotherapy would require; they also completed a behavioral measure of effort discounting. At a 3-month follow-up, they reported whether they initiated psychotherapy during the follow-up period. RESULTS: Depression symptom severity was associated with perceptions that seeking psychotherapy would be more effortful. In turn, perceptions that seeking psychotherapy would be more effortful prospectively predicted a lower likelihood of initiating psychotherapy. Effort discounting was unrelated to psychotherapy use. CONCLUSIONS: These results suggest that differences in the anticipated effort required to seek psychotherapy can increase depressed individuals' risk of going untreated. Future research may test whether reducing the effort of seeking psychotherapy increases psychotherapy use among those with depression. For instance, streamlining insurance enrollment procedures, implementing patient decision aids, or offering telehealth treatment options may be beneficial.

Client and therapist agreement in moment-to-moment helpfulness ratings in psychotherapy: A microprocess approach.

METHOD: Clients (n = 16; Mage = 32.88 years; 81% female) and their therapists (n = 10; 80% female) from a training clinic provided moment-to-moment ratings while reviewing a video recording of a recent session. West and Kenny's Truth-and-Bias (T&B) model was used to examine agreement in ratings. Multilevel modeling was used to evaluate the agreement-alliance association while controlling for sessions completed. RESULTS: Consistent with the T&B model, client-therapist ratings were temporally congruent and were not discrepant overall. Greater congruence and smaller discrepancies were linked with stronger alliances. CONCLUSIONS: The within-session and between-dyad variability in helpfulness ratings highlight the utility of moment-to-moment rating methods. Findings suggest that therapists should attune to client perceptions on a within-session level and attunement may be a target for enhancing the alliance.

Psychotherapy dose, clinical outcome, and academic withdrawal at university counseling centers.

Academic withdrawal from colleges and universities is a common occurrence, particularly among students with mental health concerns. Receiving a successful course of psychotherapy may reduce students' risk of academic withdrawal, but outcomes in university counseling centers (UCCs) could be hindered by strategies used to meet high service demands with limited resources, such as offering a low number or frequency of sessions. The present study examined associations among psychotherapy dose, clinical outcome, and academic withdrawal among students (N = 16,197) in short-term individual psychotherapy at 85 UCCs in the United States. Structural equation modeling results indicated that after controlling for baseline psychological distress, the number of psychotherapy sessions attended positively predicted, and the average number of days between sessions negatively predicted, clients' self-reported reductions in psychological distress. In turn, after controlling for pretreatment characteristics associated with academic withdrawal (prior psychiatric hospitalization, gender, academic distress) reductions in psychological distress negatively predicted therapists' report of clients voluntarily withdrawing from their academic institution during psychotherapy. This indicates that students who receive higher psychotherapy doses within a short-term context (i.e., 10 or fewer sessions) are less distressed by the end of treatment, which then predicts a lower likelihood of academic withdrawal during psychotherapy. UCC leadership and clinicians might enhance clinical and academic outcomes by providing flexibility in the number and frequency of psychotherapy sessions available to students. However, centers may need additional resources from their academic institutions to provide this flexibility. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Use of a Research as Intervention Approach to Explore Telebehavioral Health Services During the COVID-19 Pandemic in Southeastern Idaho.

INTRODUCTION: Since the inception of the COVID-19 pandemic, telebehavioral health services have been a key contributor to continuation of care in rural and underserved areas of southeastern Idaho. Providers of telebehavioral health services faced numerous challenges as they navigated rapidly shifting regulations, variable access to internet and their own personal understandings of practice. OBJECTIVE: This study aimed to characterize provider experiences, generate policy- and practice-level recommendations, and raise awareness among community stakeholders regarding telebehavioral health in southeastern Idaho. METHODS: Using a newly developed conceptual/analytical framework, a research-as-intervention strategy was employed to conduct and analyze semi-structured interviews, short writings, and photographs from 7 primary care and behavioral health providers in the region. RESULTS: Providers shared examples from practice that addressed technology and training, access-to-care, safety, changing provider roles, payment for services, treatments that are not well suited to telehealth and the nuances of living and working in newly forged spaces of care. CONCLUSIONS: Providers found promise in telebehavioral health's utility as a hybrid model of care, but it must be supported by flexible legislation and policy. For example, it would help to make reimbursement expansions permanent and to simplify inter-jurisdictional practice options. Cross-sharing of information between licensing boards could help providers from various disciplines understand the parameters within which their colleagues must work.

Client preference accommodation for religious/spiritual integration and psychotherapy outcomes in naturalistic practice settings.

The purpose of this practice-research network study was to examine client preferences for religious/spiritual (R/S) integration and test whether preference accommodation in this area is linked to positive treatment outcomes (i.e., less dropout and greater client change). Thirteen independent practice psychotherapists and their 175 clients completed measures of R/S integration preferences and use of R/S techniques and approaches throughout treatment. Psychotherapists also completed an assessment of treatment dropout and change for each participating client. Overall, participating clients expressed moderate preferences for R/S integration, time spent on R/S topics, and an R/S match with their psychotherapists. Preferences in each of these 3 areas were stronger for R/S identifying clients (compared with non-R/S clients) and when clients believed that R/S integration was more essential to produce positive treatment outcomes. Both client R/S identification and client R/S integration preferences predicted psychotherapist's use of R/S techniques in treatment sessions. Importantly, clients' ratings of R/S preference accommodation significantly predicted psychotherapists' ratings of client treatment completion and client change. Specifically, with each unit increase on a 5-point measure of client perceptions of R/S preference accommodation, clients were 1.63 times more likely to be rated as treatment completers and 1.83 times more likely to be identified as having improved while in treatment. Implications for R/S integration in psychotherapy and future research directions are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Religious microaggressions in psychotherapy: A mixed methods examination of client perspectives.

Ethical guidelines state that psychologists should consider clients' religion in their practice. However, some clients have reported negative experiences regarding clinicians' treatment of religion in psychotherapy. These experiences may constitute microaggressions, which have been negatively associated with the working alliance and treatment outcomes among clients with various identities (e.g., those of marginalized racial groups or sexual orientations). The present study used mixed methods to examine religious microaggressions among current and former psychotherapy clients identifying as religious (N = 396). Approximately 39% of participants indicated that at least one religious microaggression occurred during treatment; the most common was minimization or avoidance of religious issues. Religious microaggressions were negatively associated with the working alliance and outcomes. Additionally, the working alliance fully mediated the association between religious microaggressions and poorer outcomes. Thematic analysis of qualitative descriptions of religious microaggressions yielded seven themes: minimization/avoidance of religious issues, assumptions of religious homogeneity, pathologizing religion, unhelpful/inappropriate interventions, pressure to embrace religion, prioritization of therapist's religious beliefs, and lack of expertise. Limitations include a retrospective, cross-sectional design and a majority White, female, and Christian sample. These results provide initial evidence that a substantial minority of religious clients may experience religious microaggressions in psychotherapy, which could impede treatment progress via negative effects on the working alliance. As such, clinicians may be able to enhance client outcomes by increasing awareness of religious microaggressions in their work and addressing microaggression-related alliance ruptures openly when they do occur. Implications for training are also discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The effectiveness of the Collaborative Assessment and Management of Suicidality (CAMS) compared to alternative treatment conditions: A meta-analysis.

INTRODUCTION: This meta-analysis aimed to test the efficacy of the Collaborative Assessment and Management of Suicidality (CAMS) intervention against other commonly used interventions for the treatment of suicide ideation and other suicide-related variables. METHOD: Database, expert, and root and branch searches identified nine empirical studies that directly compared CAMS to other active interventions. A random effects model was used to calculate the effect size differences between the interventions; additionally, moderators of the effect sizes were tested for suicidal ideation. RESULTS: In comparison to alternative interventions, CAMS resulted in significantly lower suicidal ideation (d = 0.25) and general distress (d = 0.29), significantly higher treatment acceptability (d = 0.42), and significantly higher hope/lower hopelessness (d = 0.88). No significant differences for suicide attempts, self-harm, other suicide-related correlates, or cost effectiveness were observed. The effect size differences for suicidal ideation were consistent across study types and quality, timing of outcome measurement, and the age and ethnicity of participants; however, the effect sizes favoring CAMS were significantly smaller with active duty military/veteran samples and with male participants. CONCLUSIONS: The existing research supports CAMS as a Well Supported intervention for suicidal ideation per Center of Disease Control and Prevention criteria. Limitations and future directions are discussed.

A Behavioral Economic Model of Help-Seeking for Depression.

Findings from the clinical psychology literature indicate that many who experience depression do not seek treatment when needed. This may be due to help-seeking models and interventions failing to account for the behavioral characteristics of depression that affect decision making (e.g., altered sensitivity to punishment and reward). Behavioral economics can provide a framework for studying help-seeking among individuals with depression that explicitly considers such characteristics. In particular, the authors propose that depression influences help-seeking by altering sensitivity to treatment-related gains and losses and to the delays, effort, probabilities, and social distance associated with those gains and losses. Additional biases in decision making (e.g., sunk-cost bias, default bias) are also proposed to be relevant to help-seeking decisions among individuals with depression. Strengths, limitations, and future directions for research using this theoretical framework are discussed. Taken together, a behavioral economic model of help-seeking for depression could assist in identifying those who are at greatest risk of going untreated and in creating more effective help-seeking interventions.

Shared decision-making in mental and behavioural health interventions.

Elements of shared decision-making (ie, collaboration, patient preferences, and working alliance) have long been discussed and studied in the field of clinical psychology; however, research indicates that shared decision-making is not typically used in clinical practice. Instead, clinicians often rely on a paternalistic approach. In this article, we provide a narrative review of the existing research supporting shared decision-making for mental and behavioural health concerns, we discuss several barriers that impede its use in actual clinical practice, and we provide recommendations for increasing shared decision-making when working with patients.