Trichotillomania Treatment Update. / Actualización en el tratamiento de la tricotilomanía.

Trichotillomania (TTM) is an obsessive-compulsive disorder in which affected individuals recurrently pull-out hair from any region of the body, causing hair loss or alopecia. The management of TTM is a therapeutic challenge for dermatologists and consists of a combination of pharmacological and non-pharmacological alternatives. Cognitive-behavioral therapy has successfully been used to treat TTM. However, not all patients are willing to follow this treatment strategy. Unconventional support tools are proposed, such as electronic devices, internet therapies and microneedling. N-acetylcysteine and memantine are considered suitable first-line therapies thanks to their favorable safety and efficacy profile, low risk of adverse effects, and significant benefits. The use of other drugs, including fluoxetine, clomipramine, olanzapine, and naltrexone has limited evidence of variable efficacy. The present review illustrates the current treatment modalities for the management of TTM.

Mattering and parental presence in systemic therapy using nonviolent resistance: The utilization of imaginary methods.

An empowered sense of "self" is crucial for emotional well-being and positive relationships. Certain family interaction patterns can disrupt the adult's sense of "mattering" to the child, eroding their perceived self-efficacy. Mattering can be understood as a felt sense of relational agency which is necessary for experiencing one's interactions as meaningful, effective, and self-determined. When parents generate more positive future narratives in co-creation with their therapist, their sense of relevance to a child can be restored. In this way, more constructive forms of interaction can emerge with their child which has hitherto eschewed their care. This article aims to provide a conceptual basis for addressing an absence of reciprocity, where children demonstrate harmful or self-destructive behavior and refuse to cooperate in therapy. In such instances, one-sided parental action, utilizing nonviolent resistance methods, can influence relational dynamics. Imaginary methods can then facilitate shifts to psychological states in which the parent internally experiences efficacy and mattering more often without requiring validation from the "physical child" in the here and now. We introduce examples of specific imaginary techniques, which in our clinical practice have shown to facilitate such shifts in parents. We discuss neuroscientific theories that may account for their powerful impact we witness in our clinical experience.

Una sensación fortalecida del yo es fundamental para el bienestar emocional y las relaciones positivas. Ciertos patrones de interacción familiar pueden alterar la sensación del adulto de importarle al niño, deteriorando su autoeficacia percibida. La sensación de importarles a los demás puede entenderse como una percepción sentida de voluntad relacional que es necesaria para vivir las interacciones propias como significativas, eficaces y autodeterminadas. Cuando los padres generan narrativas futuras más positivas junto con su terapeuta, se puede recuperar su sensación de importancia para un niño. De esa manera, pueden surgir formas más constructivas de interacción con su hijo que hasta el momento ha eludido su cuidado. Este artículo tiene como finalidad ofrecer una base conceptual para abordar una ausencia de reciprocidad, donde los niños demuestran una conducta perjudicial o autodestructiva y se niegan a cooperar en la terapia. En esos casos, la acción de uno de los padres mediante el uso de métodos de resistencia no violenta puede influir en la dinámica relacional. Los métodos imaginarios pueden entonces facilitar cambios a estados psicológicos en los cuales el padre siente internamente su eficacia y tiene la sensación de importarle al niño con más frecuencia sin necesitar confirmación del niño físico en el aquí y ahora. Presentamos ejemplos de técnicas imaginarias específicas que en nuestra práctica clínica han demostrado facilitar dichos cambios en los padres. Comentamos las teorías neurocientíficas que pueden explicar el enorme efecto que observamos en nuestra experiencia clínica.

The Discursive Performance of Change Process in Systemic and Constructionist Therapies: A Systematic Meta-Synthesis Review of In-Session Therapy Discourse.

Despite the emphasis of systemic and constructionist approaches on discourse and interaction, to date there has been no comprehensive overview of how change process is performed within in-session therapeutic dialogue. In this paper, we present a qualitative meta-synthesis of 35 articles reporting systemic and constructionist therapy process data from naturally occurring therapeutic dialogue. The studies were selected following the screening against eligibility criteria of a total sample of 2,977 studies identified through a systematic search of PsycINFO and MEDLINE databases. Thematic analysis of the 35 studies' findings identified four main themes depicting change process performance: (a) shifting to a relational perspective, (b) shifting to non-pathologizing therapeutic dialogue, (c) moving-forward dialogue, and (d) the dialogic interplay of power. Findings highlight the interactional and discursive matrix within which systemic and constructionist change process occurs. Findings illuminate the value of qualitative research studies sampling naturally occurring therapeutic discourse in bringing this matrix forth, particularly when utilizing discursive methodologies like conversation or discourse analysis.

A pesar del énfasis de los enfoques sistémicos y construccionistas sobre el discurso y la interacción, hasta ahora no se ha hecho una descripción general completa de cómo se lleva a cabo el proceso de cambio dentro del diálogo terapéutico en la sesión. En este artículo presentamos una metasíntesis cualitativa de 35 artículos que informan datos del proceso de terapia sistémica y construccionista obtenidos del diálogo terapéutico que se produce naturalmente. Los estudios se eligieron siguiendo los criterios de evaluación por elegibilidad de una muestra total de 2977 estudios detectados mediante una búsqueda sistemática en las bases de datos PsycINFO y MEDLINE. El análisis temático de los resultados de los 35 estudios identificó cuatro temas principales que describen la representación del proceso de cambio; (a) el cambio a una perspectiva relacional, (b) el cambio a un diálogo terapéutico no patologizante, (c) el diálogo de avance, y (d) la interacción dialógica del poder. Los resultados destacan la matriz interactiva y discursiva dentro de la cual se produce el proceso de cambio sistémico y construccionista. Los resultados ilustran el valor de los estudios de investigación cualitativa que muestrean el discurso terapéutico producido naturalmente a la hora de presentar esta matriz, particularmente cuando se utilizan metodologías discursivas, como el análisis de la conversación o el discurso.

Developing Reflexivity through Group Processes in Psychotherapy Training: An Interpretative Phenomenological Analysis of Systemic Family Therapy Trainees' Experience.

Constructionist approaches in the field of systemic family therapy prioritize reflexivity to promote personal development within training, often leaning on group processes. Drawing from a qualitative study we conducted to address the lack of related research, we present how systemic family therapy trainees experience reflexivity development through group processes. Ten systemic family therapy trainees participated in semi-structured interviews, transcribed and analyzed with interpretative phenomenological analysis. Analysis presented here reports three superordinate themes: Developing reflexivity through challenges and rewards, A conditional reflexive space within the training group, and Encountering the dynamics of identity via reflexive group processes. Our findings suggest that trainees experience reflexivity development as a complex relational process of personal development, highlighting the training group's critical role, nonetheless depending on certain preconditions. The importance of further exploring group processes' potential for reflexivity development in psychotherapy training is underscored.

Lo enfoques construccionistas en el ámbito de la terapia familiar sistémica priorizan la reflexividad para promover el desarrollo personal dentro de la capacitación, generalmente apoyándose en procesos grupales. Valiéndonos de un estudio cualitativo que realizamos para abordar la falta de investigaciones relacionadas, presentamos la manera en la que los practicantes de la terapia familiar sistémica experimentan el desarrollo de la reflexividad mediante procesos grupales. Diez practicantes de terapia familiar sistémica participaron en entrevistas semiestructuradas, transcriptas y analizadas con el análisis fenomenológico interpretativo. Los análisis presentados aquí informan tres temas superordinados: el desarrollo de la reflexividad mediante desafíos y recompensas, un espacio reflexivo condicional dentro del grupo de capacitación, el encuentro de la dinámica de identidad mediante procesos grupales reflexivos. Nuestros hallazgos sugieren que los practicantes experimentan el desarrollo de la reflexividad como un proceso complejo de desarrollo personal relacional que destaca el papel fundamental del grupo de capacitación, pero que depende de ciertas precondiciones. Se subraya la importancia de analizar con mayor profundidad la posibilidad de desarrollo de la reflexividad en los procesos grupales durante la capacitación en psicoterapia.

How is Systemic and Constructionist Therapy Change Process Narrated in Retrospective Accounts of Therapy? A Systematic Meta-synthesis Review.

Despite the considerable potential of qualitative approaches for studying the systemic and constructionist therapy process due to shared theoretical and epistemological premises, to date there is lack of a comprehensive qualitative synthesis of how change process is experienced and conceptualized by clients and therapists. To address this evidence gap, we performed a systematic meta-synthesis review of 30 studies reporting clients' and therapists' retrospective narratives of change process across systemic and constructionist models and across a range of client configurations, including individuals, couples, families, and groups. The studies were identified following a systematic search in PsycINFO and MEDLINE resulting in 2,977 articles, which were screened against eligibility criteria. Thematic analysis led to the identification of four main themes: (1) navigating through differences, (2) toward nonpathologizing construction of problems, (3) navigating through power imbalances, and (4) toward new and trusting ways of relating. Findings illustrate the multifaceted aspects of systemic and constructionist change process, the importance for their reflexive appraisal, and the need for further research contributing to the understanding of the challenges inherent in the systemic and constructionist therapeutic context.

A pesar del potencial considerable de los enfoques cualitativos para estudiar el proceso de la terapia sistémica y construccionista debido a premisas teóricas y epistemológicas compartidas, hasta la fecha hay una escasez de síntesis cualitativas completas de cómo los pacientes y los terapeutas viven y conceptualizan el proceso de cambio. Para abordar esta falta de datos, realizamos una revisión sistemática de la metasíntesis de 30 estudios que informan historias retrospectivas de los pacientes y los terapeutas del proceso de cambio entre modelos sistémicos y construccionistas y entre una variedad de configuraciones de pacientes, entre ellas, individuos, parejas, familias y grupos. Los estudios se identificaron después de una búsqueda sistemática en PsycINFO y MEDLINE, de donde se obtuvieron 2,977 artículos, que se analizaron según los criterios de elegibilidad. El análisis temático condujo a la identificación de cuatro temas principales: 1) orientarse entre las diferencias, 2) hacia una construcción no patologizante de los problemas, 3) orientarse entre los desequilibrios de poder, 4) hacia formas nuevas y confiables de relacionarse. Los resultados ilustran los aspectos multifacéticos del proceso de cambio sistémico y construccionista, la importancia para su valoración reflexiva y la necesidad de más investigaciones que contribuyan a la comprensión de los desafíos inherentes en el contexto terapéutico sistémico y construccionista.

Principle-Based Integrative Therapy with Couples: Theory and a Case Example.

The Principle-Based Integrative Therapy (PBIT) framework harnesses the principles of change underlying each theoretical model within integrative couple therapy treatments. PBIT has commonalities with other integrative approaches, and additional advantages stemming from its four tenets that guide therapists in combining strengths across models and overcoming each of their deficiencies. Tenet 1 advises that each model adds a core principle or mechanism of action that other models do not automatically address. Tenet 2 focuses on how techniques of one model may actualize the principles of other models. Tenet 3 ensures complementarity and a lack of conflict across principles. A case study and common case considerations are presented to illustrate how Tenets 1-3 can work in integrating Cognitive-Behavioral, Multicultural, and Emotionally Focused Therapy models in working with a couple. Finally, Tenet 4 advocates for the use of models and empirically supported principles that also have received empirical support with diverse populations. Prerequisites and training implications for PBIT, and future clinical and research directions to further the utility of PBIT are discussed.

El marco de la Terapia Integrativa Basada en Principios (PBIT) aprovecha los principios de cambio que subyacen a cada modelo teórico dentro de los tratamientos de la terapia integrativa de pareja. La PBIT tiene similitudes con otros enfoques integrativos y otras ventajas que surgen de sus cuatro principios que guían a los terapeutas en la combinación de los puntos fuertes de los distintos modelos y en la superación de cada una de sus deficiencias. El primer principio recomienda que cada modelo agregue un principio o mecanismo fundamental de acción que otros modelos no aborden automáticamente. El segundo principio se centra en cómo las técnicas de un modelo pueden actualizar los principios de otros modelos. El tercer principio garantiza la complementariedad y la falta de conflictos entre los principios. Se presentan las consideraciones de un caso práctico y de casos comunes para ilustrar cómo estos tres principios pueden funcionar en la integración de los modelos de terapia congnitivo-conductual (CB), multicultural (MC) y centrada en las emociones (EFT) a la hora de trabajar con una pareja. Finalmente, el cuarto principio propone el uso de modelos y principios factuales que también hayan recibido apoyo empírico con diversas poblaciones. Se debaten los prerrequisitos y las consecuencias de la capacitación para la PBIT, así como las futuras direcciones clínicas y de investigación para impulsar la utilidad de la PBIT.

The role of attachment style in interpersonal psychotherapy for depressed adolescents.

OBJECTIVE(S): This study examined changes in depressed adolescents' reports of attachment anxiety and avoidance with interpersonal psychotherapy (IPT-A), and the relationship between attachment style and change in depression with IPT-A. METHOD: Forty adolescents (aged 12-17) participated in a 16-week randomized clinical trial of 4 adaptive treatment strategies for adolescent depression that began with IPT-A and augmented treatment for insufficient responders (n = 22) by adding additional IPT-A sessions (n = 11) or the antidepressant medication, fluoxetine (n = 11). Adolescents were 77.5% female and 22.5% male (mean age = 14.8, SD = 1.8). Ten percent of adolescents were Latino. Racial composition was 7.5% Asian, 7.5% American Indian/Alaska Native, 80.0% white, and 5.0% biracial. Measures of attachment style (Experience in Close Relationships Scale-Revised [ECR-R]) and depression (Children's Depression Rating Scale-Revised [CDRS-R]) were administered at baseline and Weeks 8 and 16. RESULTS: Attachment Anxiety and Avoidance (ECR-R) decreased significantly from baseline to Week 16. Baseline Avoidance positively predicted greater reductions in depression (CDRS-R), controlling for fluoxetine. Reductions in Anxiety and Avoidance were also significantly associated with reductions in CDRS-R, controlling for fluoxetine. CONCLUSIONS: Adolescents' reports of attachment anxiety and avoidance are amenable to intervention with IPT-A. IPT-A may be particularly beneficial for adolescents who report a high level of avoidant attachment. Clinical or methodological significance of this article Our findings suggest that attachment anxiety and avoidance are constructs that are amenable to intervention during adolescence, and therefore viable targets of treatment. IPT-A was found to be an effective intervention for addressing problems in attachment style, and decreases in attachment anxiety and avoidance were associated with reductions in depression. This provides support for selecting IPT-A as a treatment option for adolescents who are depressed and describe difficulty with attachment security. IPT-A appears to be particularly effective for adolescents with an avoidant attachment style, who experience discomfort with and have a tendency to avoid intimacy.

Psychotherapy for eating disorders: A meta-analysis of direct comparisons.

Objective: We conducted a meta-analysis of randomized controlled trials (RCTs) of bona fide psychotherapy for adults with eating disorders (EDs). Method: Thirty-five RCTs with 54 direct comparisons were included. The majority of RCTs included participants with bulimia nervosa and/or binge-ED, while only two RCTs included participants with anorexia nervosa, and three RCTs included participants with an ED not otherwise specified. Results: There was a clear advantage of bona fide psychotherapy over wait-list controls. Bona fide psychotherapy was superior to non-bona fide treatment; however, the majority of results were not stable. There were no significant differences between bona fide cognitive-behavioral therapy (CBT) and bona fide non-CBT, with the exception of bona fide CBT resulting in greater reductions in ED psychopathology assessed by the ED Examination, which primarily assesses maintenance factors according to the CBT model. Conclusions: Generally, the results indicate that any bona fide psychotherapy will be equally effective. While the number of trials remains modest, we hope that as more research becomes available, treatment guidelines can be updated, and more evidence-based treatment options will be available for treating EDs.

Therapeutic Agency Inventory: Development and psychometric validation of a patient self-report.

Objectives: Therapeutic agency is defined as a patient's intentional influence over the process of psychotherapeutic change. However, there is a lack of conceptually sound self-report measures with adequate psychometric properties. The aim of this study was to develop and psychometrically evaluate the patient-rated Therapeutic Agency Inventory (TAI).Method: Based on the literature, we developed items related to therapeutic agency and investigated their psychometric properties in a naturalistic study with a sample of 334 psychotherapy participants. We assessed changes in TAI scores in a subsample of 58 patients over the course of inpatient psychotherapy and related TAI scores to therapeutic improvement.Results: The TAI consists of 15 items. We performed exploratory factor analyses, and the following three factors were extracted: In-session activity, therapy-related processing, and therapist-oriented passivity. Internal consistency was .84 for the total score and ranged between .73 and .80 for each of the factors. The TAI was significantly associated with other psychotherapy process factors, self-efficacy expectations, control beliefs, lower overall psychological distress, and lower depression scores. Changes in agency during psychotherapy predicted therapy outcome, even after controlling for baseline distress.Conclusions: The TAI is a reliable, valid, and change-sensitive self-report instrument that can be used to assess agency in psychotherapy.

Dropout from interpersonal psychotherapy for mental health disorders: A systematic review and meta-analysis.

Objective: Dropout is one factor that might limit the effectiveness of interpersonal psychotherapy (IPT). Improved understanding of IPT dropout is an important research priority. This meta-analysis examined dropout rates from IPT in randomized controlled trials. Method: Seventy-two trials met inclusion criteria. Results: The weighted mean dropout rate from IPT was 20.6% (95% CI = 17.4-24.2). Dropout rates were similar for depressive (20.9%; 95% CI = 17.2-25.2), anxiety (16.1%; 95% CI = 11.1-22.9), and eating disorders (18.7%; 95% CI = 11.6-28.8). Dropout was highest when more stringent definitions of dropout were applied (e.g., failure to complete the entire IPT protocol versus failure to complete at least 50% of sessions) and was lowest when adolescent patients were sampled. There was some evidence that IPT was associated with significantly lower rates of dropout than both CBT and non-specific supportive therapies. These effects were generally replicated when analysing trials that provided a clear definition of treatment (rather than study) dropout. Conclusions: Overall, findings provide preliminary evidence to suggest that IPT may be an accepted and tolerated treatment option for patients with common mental health disorders. This review also highlights the need for future trials to rigorously report detail pertaining to patient dropout.

"It was like having half of the patient in therapy": Therapists of nonimproved patients looking back on their work.

Objective: To explore therapists' experiences of therapeutic process in psychoanalytic psychotherapy with nonimproved young adults. Method: Eight nonimproved cases were identified according to the criterion of reliable and clinically significant change in self-rated symptoms. Transcripts of therapist interviews (8 at baseline and 8 at termination) were analyzed applying grounded-theory methodology. Results: A tentative conceptual process model was constructed around the core category Having Half of the Patient in Therapy. Initially, the therapists experienced collaboration as stimulating, at the same time as the therapeutic relationship was marked by distance. At termination negative processes predominated: the patient reacted with aversion to closeness and the therapist experienced struggle and loss of control in therapy. The therapists described therapy outcome as favorable in form of increased insight and mitigated problems, while core problems remained. Conclusions: This split picture was interpreted as a sign of a pseudo-process emerging when the therapist one-sidedly allied herself with the patient's capable and seemingly well-functioning parts. The therapists' experiences could be compared to the nonimproved patients' "spinning one's wheels" in therapy. The therapists seem not to have succeeded in adjusting their technique to their patients' core problems, despite attempts to meta-communicate.

A comparison between the clinical significance and growth mixture modelling early change methods at predicting negative outcomes.

Objective: Routine outcome monitoring benefits treatment by identifying potential no change and deterioration. The present study compared two methods of identifying early change and their ability to predict negative outcomes on self-report symptom and wellbeing measures. Method: 1467 voluntary day patients participated in a 10-day group Cognitive Behaviour Therapy (CBT) program and completed the symptom and wellbeing measures daily. Early change, as defined by (a) the clinical significance method and (b) longitudinal modelling, was compared on each measure. Results: Early change, as defined by the simpler clinical significance method, was superior at predicting negative outcomes than longitudinal modelling. The longitudinal modelling method failed to detect a group of deteriorated patients, and agreement between the early change methods and the final unchanged outcome was higher for the clinical significance method. Conclusions: Therapists could use the clinical significance early change method during treatment to alert them of patients at risk for negative outcomes, which in turn could allow therapists to prevent those negative outcomes from occurring.

Towards the recovery of a sense of self: An interpretative phenomenological analysis of patients' experience of body-oriented psychotherapy for schizophrenia.

OBJECTIVE: Increasing evidence supports the efficacy of body-oriented psychotherapy (BPT) for schizophrenia. Yet, so far no research has investigated outcome in relation to therapy process: Why and how BPT is effective. In this study, we qualitatively explore participants' experience of a manualized BPT for schizophrenia to shed light on the process of therapeutic change. METHOD: We conducted in-depth interviews with 6 participants who completed a 10-week BPT group intervention. Interviews explored participants' experience of change and helpful aspects of therapy and were analysed using interpretative phenomenological analysis. FINDINGS: We identified six master themes across the interviews: (i) Being a whole: body-mind connection; (ii) Being agentic and being able; (iii) Being unique and worthy: Being accepted for who one is; (iv) Changing interactions: Engaging in authentic interpersonal contact; (v) Being part of a group: Feeling integrated; and (vi) Hope and investing in the future. CONCLUSION: We discuss the clinical implications for each theme and bring the findings together by describing therapeutic change in schizophrenia as a recovery of sense of self at different but interlocked levels. Moreover, we put forward recommendations for both specific and common factors for schizophrenia therapy. Clinical or methodological significance of this article: The clinical significance of this study is twofold. On the one hand, the findings of this analysis might inform the theory and practice of BPT and might directly feedback into a further development of the manual guidelines. On the other hand, common helpful factors have been identified thatmight also be relevant for the more general clinical practice concerning patients with schizophrenia. Here, we summarize our key messages for the clinical practitioner emerging from the findings: The inclusion of bodily aspects and a focus on pre-reflective experience in psychotherapy can help persons with schizophrenia recover the sense of being a body-mind unity. Empowering persons with schizophrenia, instead of instructing them, seems to foster a sense of agency and self-confidence, which are crucial to the recovery process. A twofold therapeutic stance characterized by openness towards the other and authenticity was experienced by patients as facilitating the rapport building. This might help persons with schizophrenia engage in the relation. Social inclusion might enhance therapeutic change and recovery in schizophrenia. Group therapy might be helpful for fostering a feeling of social belonging, but the inclusion in the wider social and community context remains a critical issue. The experience of joyful moments in psychotherapy might positively contribute to therapeutic change in that it fosters a sense of hope for the future. Overall our paper contributes to the literature aiming at expanding the range of therapeutic modalities, focussing on the creation and use of mixed models of therapy within and beyond talking practices.

"Just like talking to someone about like shit in your life and stuff, and they help you": Hopes and expectations for therapy among depressed adolescents.

OBJECTIVE: To explore hopes and expectations for therapy among a clinical population of depressed adolescents. METHOD: As part of a randomized clinical trial, 77 adolescents aged 11-17, with moderate to severe depression, were interviewed using a semi-structured interview schedule. The interviews were analysed qualitatively using framework analysis. RESULTS: The findings are reported around five themes: "the difficulty of imagining what will happen in therapy," "the 'talking cure,'" "the therapist as doctor," "therapy as a relationship," and "regaining the old self or developing new capacities." CONCLUSIONS: Differing expectations are likely to have implications for the way young people engage with treatment, and failure to identify these expectations may lead to a risk of treatment breakdown.

The influence of diagnosis on psychotherapy missed opportunities in a veteran population.

OBJECTIVE: Canceled or unattended psychotherapy sessions are a source of concern for patients, providers, and health-care systems. Veterans are particularly likely to experience mental health problems, and yet they are also especially susceptible to variables leading to premature termination of services. METHOD: This study examined a large (n = 2285) sample of veterans receiving psychotherapy services to determine if mental health diagnosis had an impact upon missed psychotherapy opportunities. RESULTS: There were differential cancelation rates for individuals with different classes of disorder, and the total number of appointments a person scheduled changed the nature of the effect. CONCLUSIONS: Health-care administrators and treatment providers should consider the specific effects of individuals with differing diagnoses when planning courses of treatment and coordinating care.

The relationships between adult attachment, theoretical orientation, and therapist-reported alliance quality among licensed psychologists.

OBJECTIVE: Attachment anxiety has been depicted as an undesirable therapist characteristic based on findings that preoccupied therapists, relative to those with other attachment styles, report more ruptures in the therapeutic alliance. What has not been considered, however, is the extent to which attachment dynamics are related to theoretical orientations and how attachment styles and theoretical orientations combine to predict therapists' perceptions of the quality of their alliances. METHOD: The present surveyed 290 licensed psychologists nationally. RESULTS: Results revealed that even within a sample of primarily secure psychologists, higher 15 levels of attachment anxiety correlated positively with the endorsement of psychodynamic orientations, and negatively with the endorsement of cognitive-behavioral orientations and self-reported alliance quality. Endorsement of cognitive-behavioral orientations, in turn, correlated positively with therapist-reported alliance quality. CONCLUSION: The results are discussed in terms of the extent to which attachment dimensions should be considered in therapists' understandings of their therapeutic alliances.

A theoretical and methodological proposal for the descriptive assessment of therapeutic interactions.

OBJECTIVE: The goal of this study is to show the development of a strategy for a descriptive assessment of the therapeutic interaction. METHOD: In this study, we develop an observational methodology to analyze the dialogues that took place during 92 sessions conducted in a psychological center in Madrid, Spain, in which 19 adults were treated for various psychological problems by 9 behavioral therapists. A system was developed to codify vocal behavior of both the therapists and the clients; the software The Observer XT was used for recording. Therapeutic interactions were analyzed using sequential analysis. RESULTS: There are three main sequences that synthesize the therapist-client interaction: first, an utterance by the client preceded by a therapist's verbalization, specifically a question (discriminative morphology) and followed by an expression of approval (reinforcement morphology); second, verbalizations of failure or discomfort uttered by the client, followed most often by verbalizations of disapproval (punishing morphology) uttered by the therapist; and third, verbalizations uttered by the client that are discriminated by the therapist after an in-depth explanation and followed by different therapist's utterances (expressions of approval, technical information, etc.). CONCLUSIONS: Depending on how the client responds the results in this study present a starting point for the study of the functional sequences that form the basis of therapeutic change.

Measuring change in relating and interrelating during the early stages of psychotherapy: Comparison with a nonpatients' sample.

The study examined whether the relative short time period of two months of individual psychotherapy improved patients' psychiatric symptoms, their negative relating (i.e., destructive and undesirable interpersonal attitudes and behavior to others) and their negative interrelating (i.e., destructive and undesirable relationship with their partners). A sample of 60 outpatients, reportedly suffering mainly from a mood or anxiety disorder, were compared with a sample of 48 nonpatients and their partners, over a comparable time span. It was shown that the patients' psychopathology scores dropped significantly. Significant changes in some relating and interrelating scores also occurred, even though the therapy had not specifically addressed these issues. Unexpectedly, the partners demonstrated some degree of deterioration both in their relating and their interrelating scores.

Psychotherapeutic and psychosocial interventions for managing stress in multiple sclerosis: the contribution of mindfulness-based interventions.

Depression or anxiety in multiple sclerosis (MS) has been linked to a more severe course of the disease and higher numbers of relapses, in addition to poorer treatment adherence and exacerbated immune system dysregulation. Recent investigations indicate that psychotherapeutic interventions for stress management, such as mindfulness-based interventions (MBIs), could improve quality of life, depression, anxiety, and fatigue in MS patients. Mindfulness fosters the ability to slow down and observe experiences as they truly are, which improves affect regulation. Mindfulness is acquired through training; its advantage over other psychotherapeutic interventions is that effects may remain over time, since cultivating mindfulness depends on regular practising of abilities learned during training. The objective of this article is to review the current evidence of psychotherapeutic and psychosocial interventions, including MBIs for stress management, and their beneficial effects on MS patients.

Improvements of complex post-traumatic stress disorder symptoms during a multimodal psychodynamic inpatient rehabilitation treatment - results of an observational single-centre pilot study.

Background: Complex post-traumatic stress disorder (CPTSD) describes chronic disturbances in self-organization (i.e. affect dysregulation; negative self-concept; severe difficulties in relationships) which are frequently observed in survivors of prolonged, repeated or multiple traumatic stressors. So far, evidence of psychodynamic treatment approaches for CPTSD is scarce.Methods: In this single-centre observational pilot study, symptom change during a 6-week psychodynamic inpatient treatment in a multimodal psychosomatic rehabilitation centre was evaluated using repeated measures analyses of variance (ANOVAs). Patients completed questionnaires on PTSD and CPTSD symptoms (ITQ), anxiety, depression and somatization (BSI-18), functional impairment (WHODAS) and epistemic trust, mistrust and credulity (ETMCQ) before (T1) and at the end of treatment (T2). A hierarchical linear regression analysis was calculated to identify factors associated with improved CPTSD symptoms.Results: A total of n = 50 patients with CPTSD were included in the study, of whom n = 40 (80%) completed treatment. Patients reported a significant reduction of CPTSD symptoms during treatment with a large effect size (-3.9 points; p < .001; η2 = .36), as well as a significant reduction of psychological distress (p < .001; η2 = .55) and functional impairment (p < .001; η2 = .59). At the end of treatment, 41.0% of patients no longer fulfilled the diagnostic criteria for CPTSD. Changes in epistemic stance included improved epistemic trust (ß = -.34, p = .026) and decreased epistemic credulity (ß = .37, p = .017), which together with lower age (ß = .43, p = .012) and lower depression levels at baseline (ß = .35, p = .054) were significantly associated with baseline adjusted mean change of CPTSD symptoms during therapy and explained 48% of its variance.Discussion: In our study, patients reported a significant reduction of CPTSD symptoms and comorbid symptoms during a multimodal psychodynamic inpatient rehabilitation treatment. Improved epistemic trust may facilitate the establishment of a trusting therapeutic relationship, thus fostering an environment of openness for knowledge transfer (i.e. social learning) and the exploration of diverse viewpoints and perspectives in the therapeutic process.

Complex post-traumatic stress disorder (CPTSD) is a condition often found in individuals who have experienced severe trauma, such as childhood abuse or torture.A study involving 50 patients with CPTSD showed significant improvements in symptoms and overall quality of life after undergoing a 6-week integrative multimodal psychodynamic inpatient rehabilitation treatment.The study also highlighted that improvement in epistemic trust could be a potential mechanism of change contributing to the positive therapeutic outcomes.