Change motivation and mindfulness in individual psychotherapy: Examining a sample of adult outpatients with depression and/or anxiety.

OBJECTIVES: Existing literature has demonstrated that both motivation to change and mindfulness are associated with therapy outcomes in samples with mental disorders. Between the constructs of mindfulness and motivation to change occurs some theoretical-related and empirical overlap. However, it is still little known about the association of these two constructs. For this reason, we investigated the relationship of motivation to change and mindfulness in a sample of 116 adult outpatients with a primary diagnosis of depression or anxiety. METHODS: An outpatient sample of 116 depressive and/or anxious patients filled in the German short version of the University of Rhode Island Change Assessment (URICA-S) and the German version of the Kentucky Inventory of Mindfulness Skills (KIMS) before the start of cognitive-behavioral therapy (pre) and after the 25th cognitive-behavioral therapy session (post). To assess the association between change motivation and mindfulness, we calculated correlations, hierarchical regressions and cross-lagged panel models (CLPM). RESULTS: Several positive and negative significant correlations at the premeasurement time point, at the postmeasurement time point, and over time (from pre to postmeasurement time point) demonstrated a relation between the KIMS and the URICA-S. Hierarchical regression analyses and CLPM pointed towards relations between mindfulness and change motivation over time and in both directions for some subscales of the KIMS and the URICA-S. CONCLUSION: A bidirectional relation between motivation to change and mindfulness was supported in our naturalistic psychotherapy setting for several subscales. For a better understanding of the interconnection between the two constructs, future research should focus on the application of interventions to improve either mindfulness or motivation to change in psychotherapy. Additionally, the interactional effects of mindfulness and change motivation on therapy outcomes should be investigated.

Comparing Cognitive Behavioral Therapy and Systemic Therapy for Social Anxiety Disorder: Randomized Controlled Pilot Trial (SOPHO-CBT/ST).

This randomized controlled trial (RCT) aimed to pilot the newly developed manualized and monitored systemic therapy (ST) for social anxiety disorder (SAD), as compared to manualized and monitored cognitive behavioral therapy (CBT). We conducted a prospective multicenter, assessor-blind pilot RCT on 38 outpatients (ICD F40.1; Structured Clinical Interview for DSM (SCID); Liebowitz Social Anxiety Scale, LSAS-SR >30). The primary outcome was level of social anxiety (LSAS-SR) at the end of treatment. A total of 252 persons were screened, and 38 patients were randomized and started therapy (CBT: 20 patients; ST: 18 patients; age: M = 36 years, SD = 14). Within-group, simple-effect intent-to-treat analyses (ITT) showed significant reduction in LSAS-SR (CBT:d = 1.04; ST:d = 1.67), while ITT mixed-design ANOVA demonstrated the advantage of ST (d = 0.81). Per-protocol analyses supported these results. Remission based on reliable change indices also demonstrated significant difference (LSAS-SR: 15% in CBT; 39% in ST;h: 0.550), supported by blind diagnosticians' ratings of those who completed therapy (SCID; 45% in CBT, 78% in ST,p = .083). No adverse events were reported. CBT and ST both reduced social anxiety, supporting patient improvement with the newly developed ST for SAD; this has yet to be verified in a subsequent confirmatory RCT.

Este ensayo controlado aleatorizado tuvo como finalidad probar la terapia sistémica (TS) estandarizada y monitoreada recientemente desarrollada para el trastorno de ansiedad social en comparación con la terapia cognitivo-conductual (TCC) estandarizada y monitoreada. Realizamos un ensayo controlado aleatorizado prospectivo, multicentro y con enmascaramiento para el evaluador en 38 pacientes ambulatorios (CIE F40.1; Entrevista Clínica Estructurada para los trastornos del DSM (SCID); Escala de Ansiedad Social de Liebowitz, LSAS-SR > 30). El resultado principal fue el nivel de ansiedad social (LSAS-SR) al final del tratamiento. Se evaluó a un total de 252 personas, 38 pacientes fueron aleatorizados y comenzaron la terapia (TCC: 20 pacientes; TS: 18 pacientes; edad: promedio= 36 años, desviación estándar = 14). Los análisis intragrupales, de efecto simple, con intención de tratar demostraron una reducción significativa del LSAS-SR (TCC: d = 1.04; TS: d = 1.67), mientras que el análisis de varianza de diseño mixto con intención de tratar demostró la ventaja de la TS (d = 0.81). Los análisis por protocolo respaldaron estos resultados. La remisión basada en los índices de cambio fiable también demostró una diferencia significativa (LSAS-SR: 15% en la TCC; 39% en la TS; h: 0.550), respaldada por diferencias casi significativas en las valoraciones con enmascaramiento para los evaluadores de aquellos que completaron la terapia (SCID; 45% en la TCC, 78% en la TS, p = 0.083). No se informaron efectos adversos. Tanto la TCC como la TS reducen la ansiedad social y respaldan la mejora de los pacientes con la terapia sistémica recientemente desarrollada para los trastornos de ansiedad social; esto aun debe verificarse en un ensayo controlado aleatorizado confirmatorio posterior.

[Change Mechanisms in Group Therapy: A Questionnaire to Measure Therapeutic Perspectives]. / Wirkfaktoren in der Gruppentherapie: Fragebogen zur Messung der therapeutischen Perspektive.

Group therapy was shown to be an effective and economic intervention. To date few instruments exist to empirically assess mechanisms of therapeutic change in group therapy. The Group Therapy Process Questionnaire for Therapists (FEPiG-T) measuring change mechanisms in group therapy as viewed from the perspectives of therapists was developed and validated in this study based on the conceptualizations of Grawe,Yalom and Bordin and in reference to the previously developed measure for patients. The FEPiG-T subscales show good internal consistencies and small to large correlations with convergent measures. Subscales at beginning of therapy correlated with improvement of interpersonal problems over time. Further associations with symptom scales remained more vague. However, intersections with the established version for patients allow routinely implemented evaluation of the 2 perspectives in clinical practice, but inevitably need careful interpretation where the instruments differ in their factor structure.

[Mindfulness in Trainee Psychotherapies with Children and Adolescents]. / Achtsamkeit in Ausbildungspsychotherapien bei Kindern und Jugendlichen.

Mindfulness in Trainee Psychotherapies with Children and Adolescents The implementation of mindfulness-based interventions (MBIs) in cognitive-behavioral therapy has greatly increased over the past few years. However, there is little research about the implementation of MBIs in individual child and adolescent psychotherapy. The present paper gives an overview of current MBIs and their efficacy in children and adolescents. A depiction of the implementation of MBIs in individual therapy and a description of the "Mindfulness and Relaxation Study - Children and Adolescents" (MARS-CA) is given. The study aims to examine the effects of short session-introducing interventions with mindfulness elements on juvenile patients' psychopathological symptomatology and therapeutic alliance. For this reason, the authors compare session-introducing interventions with mindfulness elements with session-introducing relaxation interventions and no session-introducing intervention. Qualitative results of the pre-study show that both interventions with mindfulness elements and relaxation interventions work well with juvenile patients.

Targeting parental motivation for change in childhood obesity: development and validation of the PURICA-S scale.

BACKGROUND: The high prevalence of overweight and obesity in childhood and adolescence call for effective and sustainable intervention strategies. Parental motivation for change may be a key factor in sustained behavioral improvement towards a healthy weight status of their offspring. In this study, we developed a new short instrument to assess parental motivation for change to facilitate motivation-tailored family interventions that promise improved effectiveness. METHODS: The preexisting gold-standard instrument to assess motivational stages for change was adapted from the self to the parental perspective in a structured multistep Delphi procedure. The new instrument to assess parental motivation for change related to a health problem of their children was psychometrically evaluated in a sample (N = 193) of parents of children or adolescents with overweight or obesity. Confirmatory factor analysis, internal consistency, construct, and criteria validity were analyzed to test the psychometric properties of the new instrument. RESULTS: As a result of the Delphi procedures, all 16 items were successfully transferred to the parental perspective. The hypothesized four-factor structure of the new instrument was approved, and internal consistency and criteria validity were good to very good (albeit with inconsistent findings for the subscale precontemplation). DISCUSSION: In our investigated target group of parents with children with overweight or obesity, the new instrument to assess parental motivation for change proved to be a practicable, valid, and time-efficient short measure. The new instrument will enable more specific motivational stage-directed interventions that promise higher effectiveness of family-based interventions to fight childhood obesity. However, the subscale precontemplation seemed not fully suitable for the population investigated here and needs to be applied very carefully in future studies.

Heart Rate Variability in Individual Psychotherapy: Associations With Alliance and Outcome.

Heart rate variability (HRV) can be conceptualized as a marker of an individual's capability to adaptively respond to its environment and has been linked with mental health. Although conceptually and empirically linked to social behavior and thus relevant in the therapeutic setting, HRV is seldom investigated directly within therapy sessions. In the present examination, we aimed at addressing this research gap by assessing patients' and therapists' HRVs both ambulatory within therapy sessions and under resting conditions. Drawing on polyvagal theory, we hypothesized that higher in-session HRV is accompanied with higher therapeutic alliance ratings. Further, we expected baseline HRV to predict symptomatic outcome and to increase over the course of therapy. In a sample of 53 outpatients receiving 25 sessions of cognitive behavioral therapy, we measured HRV, therapeutic alliance and depressive symptoms on four occasions. Multilevel modeling analyses demonstrated that patients with higher in-session high-frequency HRV rated the therapeutic alliance higher. Baseline HRV predicted symptomatic outcome and increased over the course of therapy. Possible explanations involve a link between in-session HRV and in-session behavior and should be investigated in future studies. The results highlight the usefulness of in-session HRV as a promising process variable in psychotherapy research.

Mindfulness and progressive muscle relaxation as standardized session-introduction in individual therapy: A randomized controlled trial.

OBJECTIVE: There is scarce research on the effects of mindfulness in individual therapy. As many practitioners integrate mindfulness exercises into individual therapy, empirical evidence is of high clinical relevance. METHOD: We investigated the effects of a session-introducing intervention with mindfulness elements (SIIME) in a randomized, controlled design. The effects of SIIME on therapeutic alliance and symptomatic outcome were compared with progressive muscle relaxation (PMR) and treatment-as-usual (TAU) control conditions. The sample comprised 162 patients with anxiety and depression. RESULTS: Multilevel modeling revealed a significant symptom reduction and significant increase of alliance over the course of therapy. There were no significant time-condition interactions on outcome and alliance, indicating the comparable efficiency of all three treatment conditions. CONCLUSIONS: We found no advantage of SIIME versus PMR and TAU. Add-on mindfulness might not improve individual therapy related to alliance and outcome.

[Questionnaire on the Experience of the Art Therapy Group in Psychosomatics from Patient View (FEKTP) - Construction and Validation of a Measuring Instrument]. / Fragebogen zum Erleben der Kunsttherapiegruppe in der Psychosomatik aus Patientensicht (FEKTP).

Art therapy is a clinically accepted method of therapy, but there are still very few studies that deal with the efficacy, change factors or mode of action of art therapy. In particular, there is a dearth of research instruments and psychometrically verified research tools specially fitted for art therapy which measures the experience dimensions of the art therapy group from the patient's point of view. Hence, it provides evidence of its effectiveness, better understands the art therapy group processes and serves quality assurance. The aim of the present study was to develop and validate the questionnaire on the experience of the art therapy group from patient view (FEKTP). This questionnaire is based on Grawe's and Yalom's conceptions of change factors in group therapy. 133 patients participated in the study and completed the FEKTP directly after the 6th art therapy session. Patients additionally received established questionnaires concerning clinical symptoms and experience processes at the beginning and end of treatment. Factor analysis demonstrated a clear factor structure of the FEKTP, which corresponded to the theoretically predicted subscales to the greatest extent. The test psychometric main quality criteria of the FEKTP (reliability, validity and objectivity) can be classified as acceptable to good range. The criterion validity appear to be given, but should be examined more exactly in future studies. Thus, a valid instrument for the systemic detection of general change factors for art therapy is now available. The questionnaire can be recommended for research as well as clinical contexts.

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.

Mind-Body Practices and the Self: Yoga and Meditation Do Not Quiet the Ego but Instead Boost Self-Enhancement.

Mind-body practices enjoy immense public and scientific interest. Yoga and meditation are highly popular. Purportedly, they foster well-being by curtailing self-enhancement bias. However, this "ego-quieting" effect contradicts an apparent psychological universal, the self-centrality principle. According to this principle, practicing any skill renders that skill self-central, and self-centrality breeds self-enhancement bias. We examined those opposing predictions in the first tests of mind-body practices' self-enhancement effects. In Experiment 1, we followed 93 yoga students over 15 weeks, assessing self-centrality and self-enhancement bias after yoga practice (yoga condition, n = 246) and without practice (control condition, n = 231). In Experiment 2, we followed 162 meditators over 4 weeks (meditation condition: n = 246; control condition: n = 245). Self-enhancement bias was higher in the yoga (Experiment 1) and meditation (Experiment 2) conditions, and those effects were mediated by greater self-centrality. Additionally, greater self-enhancement bias mediated mind-body practices' well-being benefits. Evidently, neither yoga nor meditation fully quiet the ego; to the contrary, they boost self-enhancement.

A meta-analysis of the relation between therapeutic alliance and treatment outcome in eating disorders.

The therapeutic alliance has demonstrated an association with favorable psychotherapeutic outcomes in the treatment of eating disorders (EDs). However, questions remain about the inter-relationships between early alliance, early symptom improvement, and treatment outcome. We conducted a meta-analysis on the relations among these constructs, and possible moderators of these relations, in psychosocial treatments for EDs. Twenty studies met inclusion criteria and supplied sufficient supplementary data. Results revealed small-to-moderate effect sizes, ßs = 0.13 to 0.22 (p < .05), indicating that early symptom improvement was related to subsequent alliance quality and that alliance ratings also were related to subsequent symptom reduction. The relationship between early alliance and treatment outcome was partially accounted for by early symptom improvement. With regard to moderators, early alliance showed weaker associations with outcome in therapies with a strong behavioral component relative to nonbehavioral therapies. However, alliance showed stronger relations to outcome for younger (vs. older) patients, over and above the variance shared with early symptom improvement. In sum, early symptom reduction enhances therapeutic alliance and treatment outcome in EDs, but early alliance may require specific attention for younger patients and for those receiving nonbehaviorally oriented treatments.

Increasing the treatment motivation of patients with somatic symptom disorder: applying the URICA-S scale.

BACKGROUND: Therapeutic intervention programs for somatic symptom disorder (SSD) show only small-to-moderate effect sizes. These effects are partly explained by the motivational problems of SSD patients. Hence, fostering treatment motivation could increase treatment success. One central aspect in SSD patients might be damage to motivation because of symptomatic relapses. Consequently, the aim of the present study was to investigate associations between motivational relapse struggle and therapeutic outcome in SSD patients. METHODS: We assessed 84 inpatients diagnosed with SSD in the early, middle and late stages of their inpatient treatment. The maintenance subscale of the University of Rhode Island Change Assessment-Short (URICA-S) was applied as a measure to assess motivational relapse struggle. Additionally, patients completed measures of treatment outcome that focus on clinical symptoms, stress levels and interpersonal functioning. RESULTS: The results from multiple regression analyses indicate that higher URICA-S maintenance scores assessed in early stages of inpatient treatment were related to more negative treatment outcomes in SSD patients. CONCLUSIONS: SSD patients with ambivalent treatment motivation may fail in their struggle against relapse over the course of therapy. The URICA-S maintenance score assessed at therapy admission facilitated early identification of SSD patients who are at greater risk of relapse. Future studies should incorporate randomized controlled trials to investigate whether this subgroup could benefit from motivational interventions that address relapse.

[Change Factors in Group Therapy: Development and Validation of a Questionnaire]. / Wirkfaktoren in der Gruppentherapie: Entwicklung und Validierung eines Fragebogens.

While the efficacy of group therapy is sufficiently confirmed, there is a research gap concerning relevant therapeutic processes. Particularly, there is a dearth of integrative instruments that assess a broad spectrum of group therapeutic change factors. Hence, the aim of the current investigation was the validation of the newly developed "Scale for the assessment of therapeutic processes in group therapy (FEPiG)" based on Grawe's general psychotherapy and Yalom's conception of change factors in group therapy. 303 Patients (110 outpatients, 193 inpatients) participated in the study and completed the FEPiG as well as established measures concerning group processes. The outpatients additionally received established questionnaires concerning clinical symptomatology and filled out all instruments at the beginning and end of treatment. Factor analysis demonstrated an excellent factor structure of the FEPiG, which corresponded to the theoretically predicted subscales. Internal consistencies of the FEPiG were good to excellent and correlated with established process measures, which indicated convergent validity. While the FEPiG change factors subscales at the beginning of therapy were not correlated with outcome, associations between increases in change factors across the course of therapy and symptom reduction could be demonstrated.

The individual therapy process questionnaire: development and validation of a revised measure to evaluate general change mechanisms in psychotherapy.

There is a dearth of measures specifically designed to assess empirically validated mechanisms of therapeutic change. To fill in this research gap, the aim of the current study was to develop a measure that covers a large variety of empirically validated mechanisms of change with corresponding versions for the patient and therapist. To develop an instrument that is based on several important change process frameworks, we combined two established change mechanisms instruments: the Scale for the Multiperspective Assessment of General Change Mechanisms in Psychotherapy (SACiP) and the Scale of the Therapeutic Alliance-Revised (STA-R). In our study, 457 psychosomatic inpatients completed the SACiP and the STA-R and diverse outcome measures in early, middle and late stages of psychotherapy. Data analyses were conducted using factor analyses and multilevel modelling. The psychometric properties of the resulting Individual Therapy Process Questionnaire were generally good to excellent, as demonstrated by (a) exploratory factor analyses on both patient and therapist ratings, (b) CFA on later measuring times, (c) high internal consistencies and (d) significant outcome predictive effects. The parallel forms of the ITPQ deliver opportunities to compare the patient and therapist perspectives for a broader range of facets of change mechanisms than was hitherto possible. Consequently, the measure can be applied in future research to more specifically analyse different change mechanism profiles in session-to-session development and outcome prediction. Key Practitioner Message This article describes the development of an instrument that measures general mechanisms of change in psychotherapy from both the patient and therapist perspectives. Post-session item ratings from both the patient and therapist can be used as feedback to optimize therapeutic processes. We provide a detailed discussion of measures developed to evaluate therapeutic change mechanisms.

Inpatient and Day-Clinic Experience Scale (IDES) - a Psychometric Evaluation.

OBJECTIVES: The Inpatient and Day-Clinic Experience Scale (IDES) was developed to assess common factors in a multimodal psychotherapy setting from the patients' perspective. The questionnaire measures different aspects of therapeutic relationships, a positive self-view and a critical attitude towards therapy. METHODS: Three samples (total N = 821) were used to evaluate the psychometric properties and factor structure of the questionnaire. RESULTS: Confirmatory analyses show a good model fit and support the proposed structure with 25 items and seven scales. In addition, reliability indices were stable throughout multiple assessments over time. Concerning validity, early IDES process measures were moderately associated with symptomatic improvement. CONCLUSIONS: The IDES is a psychometrically reliable questionnaire for the evaluation of process factors in inpatient and day-clinic psychotherapy settings.

Associations between Grawe's general mechanisms of change and Young's early maladaptive schemas in psychotherapy research: a comparative study of change processes.

OBJECTIVE: The study aimed at analyzing associations between Grawe's general mechanisms of change and Young's early maladaptive schemas (EMS). METHOD: Therefore, 98 patients completed the Scale for the Multiperspective Assessment of General Change Mechanisms in Psychotherapy (SACiP), the Young Shema Questionnaire-Short Form Revised (YSQ S3R), and diverse outcome measures at the beginning and end of treatment. RESULTS: Our results are important for clinical applications, as we demonstrated strong predictive effects of change mechanisms on schema domains using regression analyses and cross-lagged panel models. CONCLUSIONS: Resource activation experiences seem to be especially crucial in fostering alterations in EMS, as this change mechanism demonstrated significant associations with several schema domains. Future research should investigate these aspects in more detail using observer-based micro-process analyses.

Stages of change, treatment outcome and therapeutic alliance in adult inpatients with chronic anorexia nervosa.

BACKGROUND: Anorexia nervosa (AN) is associated with high rates of chronicity and relapse risk is a considerable therapeutic challenge in the disorder. The aim of the present study was to investigate the association of stages of change and outcome with a focus on the relapse struggle in the maintenance stage in patients with predominantly chronic AN. Further, therapeutic alliance and stages of change associations were explored. METHODS: As an instrument measuring relapse struggle in the maintenance stage, we applied the short form of the University of Rhode Island Change Assessment-Short (URICA-S). We assessed stages of change in 39 patients with a predominantly chronic course of AN in early, middle, and late stages of inpatient psychotherapy. General symptom severity as assessed by the SCL-90-R and weight change were investigated as outcome measures. RESULTS: In-line with earlier evidence, contemplation significantly predicted therapeutic alliance. Further, we demonstrated that relapse risk as operationalized by URICA-S maintenance is an important predictor of general psychopathology. BMI change was not predicted by stages of change. CONCLUSIONS: The URICA-S maintenance scale might be applied to help identify patients at relapse risk. High URICA-S maintenance scores could be considered as one critical aspect of AN patients who might especially benefit from relapse-preventing aftercare programs.

Change mechanisms in psychotherapy: multiperspective assessment and relation to outcome.

The study aimed at constructing a reliable and valid post-session questionnaire measuring general change mechanisms of psychotherapy with correspondent versions for patient and therapist perspectives. Therefore, 253 inpatients in early, middle, and late stages of psychotherapy completed the newly developed Scale for the Multiperspective Assessment of General Change Mechanisms in Psychotherapy (SACiP) and diverse outcome measures. The psychometric qualities of the SACiP were excellent as shown by (a) exploratory factor analyses on patient and therapist ratings, (b) confirmatory factor analyses on later measuring times, and (c) high internal consistencies. Supporting construct validity, the SACiP predicted outcome, as shown by correlational analyses and mixed effects modeling. Patient evaluations of change mechanisms were better predictors of outcome than the corresponding therapist evaluations.

Change Mechanism of Cognitively-Based Compassion Training for Couples with Depression: An Exploratory Empirical Investigation of Process Variables.

Objective: Compassion training seems to be a promising intervention for couples to improve individual psychopathology and relationship quality. Beyond studying the efficacy of training such as Cognitively-Based Compassion Training for Couples (CBCT-fC), it is important to gain insights into the putative mechanisms along the process. Methods: Theoretically derived presumed mechanisms of compassion training (clarification of values, self-regulation, decentering, and exposure) and additional therapeutic factors (emotional bond, social learning, and clarification of meaning) were studied over the course of a 10-session-long group-based CBCT-fC among women with depressive disorders. Results: Dyadic growth curve models indicated that emotional bond, social learning, and clarification of meaning increase over time in both partners. In decentering and clarification of values, women who suffered from depression showed a larger increase than men, while men had higher values at the start of the training. Conclusions: Women with depression seem to benefit from CBCT-fC in terms of an increase in decentering and value clarification, important mechanisms of compassion training. This study is the first to show that theoretically derived mechanisms of compassion and additional therapeutic factors can describe the process along secular contemplative training sessions, which are increasingly implemented in the health care system. Future studies should explore the relationship of mechanisms and the outcome along the process of the training. Study Registration: Trial registration number NCT03080025.

The impact of session-introducing mindfulness and relaxation interventions in individual psychotherapy for children and adolescents: a randomized controlled trial (MARS-CA).

BACKGROUND: The investigation of mindfulness-based interventions (MBIs) in cognitive-behavioral therapy has greatly increased over the past years. However, most MBI research with youth focuses on structured, manualized group programs, conducted in school settings. Knowledge about the implementation and effects of MBIs in individual psychotherapy with children and adolescents is scarce. To fill this research gap, the "Mindfulness and Relaxation Study - Children and Adolescents" (MARS-CA) is designed. It aims to assess the effects of short session-introducing interventions with mindfulness elements on juvenile patients' symptomatic outcome and therapeutic alliance in individual child and adolescent psychotherapy. METHODS: MARS-CA is conducted at a university outpatient training center for cognitive-behavior therapy. Short session-introducing interventions with mindfulness elements will be compared to short session-introducing relaxation interventions and no session-introducing intervention to explore their effects on symptomatic outcome and therapeutic alliance. The session-introducing interventions will take place at the beginning of 24 subsequent therapy sessions. We hypothesize that patients' symptomatic outcome and therapeutic alliance improve more strongly in the mindfulness condition than in the other two conditions and that the mindfulness condition moderates the relationship between therapeutic alliance and symptomatic outcome. Patients and their trainee therapists will be randomized to one of the three treatment arms. Participants aged between 11 and 19 years and having a primary diagnosis of either a depressive disorder, an anxiety disorder, or a hyperkinetic disorder will be included. Therapeutic alliance will be assessed after every therapy session (therapy session 1 to therapy session 24), symptomatic outcome will be assessed before the start of treatment (pre), after the 3rd, the 10th, and the 17th therapy sessions, at the end of treatment (24th therapy session, post), and at a 6-month follow-up. Additionally, mindfulness and mindfulness-related measures as well as demographic data, adherence, allegiance, and therapeutic techniques will be assessed. It is our aim to assess a sample of 135 patients. We will conduct multilevel modeling to address the nested data structure. DISCUSSION: The study can provide information about how add-on MBIs, conducted by trainee therapists, influence therapeutic alliance and symptomatic outcome in individual psychotherapy in children and adolescents. TRIAL REGISTRATION: ClinicalTrials.gov NCT04034576. Registered on July 17, 2019.