Relating therapeutic process to outcome: are there predictors for the short-term course in anorexic patients?

Between-Session Homework in Clinical Training and Practice: A Transtheoretical Perspective

Background

This paper defines and illustrates the ways in which Between-Session Homework (BSH) may be integrated into clinical work with clients across various treatment approaches. In line with the focus of this special issue, we explore how clinical training and supervision can enhance therapist skills and competence in the use of BSH.

Method

After providing a brief historical overview and an integrative perspective on BSH, along with a review of empirical research supporting its efficacy, we delve into the discussion of BSH as a transtheoretical clinical method with heuristic value across different treatment approaches, such as cognitive-behavioral, psychodynamic, and humanistic-experiential therapies.

Results

There exists diversity in how BSH is incorporated into distinct treatment approaches. Furthermore, we emphasize the significance of therapist skills and competence in utilizing BSH to facilitate client engagement and achieve positive treatment outcomes. Finally, we address how clinical training and supervision contribute to the development of these essential skills and competence.

Conclusions

Our findings highlight three main points: (1) substantial empirical support for the integration of BSH within cognitive-behavioral therapies, (2) the potential of BSH as a promising transtheoretical clinical method, even though research beyond cognitive-behavioral therapies remains limited, and (3) the imperative need for further research into how clinical training and supervision can effectively enhance therapist skills and competence in implementing BSH.

Intersession experiences and internalized representations of psychotherapy: A scoping review

INTRODUCTION

Between-session processes outside the therapy room and beyond the direct interaction between a therapist and client can play an important role in the psychotherapeutic process and outcome. These processes are called intersession experiences and can be seen as internalized mental representations of therapy and/or therapists. Due to the COVID-19 pandemic, different digital forms of treatment have successfully been implemented and could be relevant even after the end of the COVID-19 pandemic. Therefore, patients' internalized mental representations may become highly relevant in the future.

RATIONALE

The aim of this study was to conceptually delineate the current state of research on internalized mental representations of therapy or therapists in the period between sessions and to provide an overview of the evidence. In addition, we aimed to identify research gaps to provide a baseline for further research.

METHODS

For this purpose, we conducted a scoping review to obtain a comprehensive overview of the evidence and to identify the relevant research gaps. We searched PsycArticles, Medline, PsycINFO, and PSYNDEX for publications on internalized mental representations.

RESULTS

The final sample comprised 30 publications published from 1989 to 2021. Based on the individual study results, it can be assumed that intersession experiences are of central importance for psychotherapeutic treatment. However, the scoping review showed that there was a large gap in knowledge in the research of intersession experiences. All previous research was barely comparable, and therefore, a generalized statement is not possible.

CONCLUSION

Future research should provide sufficient information about relevant aspects, such as the setting, therapists, and patients, as these factors are likely to have a significant impact on the outcome. Furthermore, better measurements for the assessment of these processes should be developed.

Long-term psychodynamic psychotherapy in a face-to-face versus videoconferencing setting: A single case study

OBJECTIVE

Due to the coronavirus pandemic and crisis, psychotherapists around the world were forced to switch to video- or tele-based treatments overnight. To date, only a few studies on the effectiveness of video-based psychodynamic psychotherapy via the Internet exist. Therefore, the goal of the present study was to examine symptom improvement, therapeutic relationship, nonverbal synchrony processes, and intersession processes within a systematic single case design and compare face-to-face to video-based approaches in long-term psychodynamic-oriented psychotherapy.

METHODS

We examined 85 sessions of a client with major depression whose psychodynamic psychotherapy changed from a face-to-face setting to a video-based setting. Video recordings were analyzed using motion energy analysis, and nonverbal synchrony was computed using a surrogate synchrony approach. Time series analyses were performed to analyze changes in symptom severity, therapeutic relationship, and intersession processes.

RESULTS

The results showed that symptom severity improved descriptively, but not significantly, across the entire course of psychotherapy. There were significant differences, however, in the therapeutic relationship, intersession experiences, and synchronous behavior between the face-to-face and video-based settings.

CONCLUSION

The results indicate that the presented methodology is well situated to investigate the question whether psychodynamic psychotherapy in video-based setting works in the sameway as in a face-to-face setting.

Level of Structural Integration and Its Association with Intersession Experiences and Outcomes: A Pilot Study

The level of structural integration (LSI), a psychodynamic/psychoanalytic concept originally developed by the Operationalized Psychodynamic Diagnosis (OPD), provides a promising empirical approach that is recognized beyond the boundaries of psychoanalysis and is highly relevant for therapy and research. The aim of our study was to investigate the intersession experiences of patients in psychotherapy with different levels of structural integration. The sample consisted of 69 inpatients who were undergoing psychotherapeutic treatment. The patients were asked to complete the German version of the Intersession Experience Questionnaire (IEQ), the short version of the OPD Structure Questionnaire (OPD-SQS) and the Brief-Symptom Inventory (BSI). LSI is associated with the situations, contents and negative emotions in the intersession experiences of patients, as well as their symptom distress over the course of therapy. Furthermore, the level of structural integration is a significant predictor of outcomes. Patients with different LSI had different intersession experiences.

Intersession-Online: A Smartphone Application for Systematic Recording and Controlling of Intersession Experiences in Psychotherapy

Mobile health technologies have become more and more important in psychotherapy research and practice. The market is being flooded by several psychotherapeutic online services for different purposes. However, mobile health technologies are particularly suitable for data collection and monitoring, as data can be recorded economically in real time. Currently, there is no appropriate method to assess intersession experiences systematically in psychotherapeutic practice. The aim of our project was the development of a smartphone application framework for systematic recording and controlling of intersession experiences. Intersession-Online, an iOS- and Android-App, offers the possibility to collect data on intersession experiences easily, to provide the results to therapists in an evaluated form and, if necessary, to induce or interrupt intersession experiences with the primary aim to improve outcome of psychotherapy. In general, the smartphone application could be a helpful, evidence-based tool for research and practice. Overall speaking, further research to investigate the efficacy of Intersession-Online is necessary.

The role of self-esteem in the treatment of patients with anorexia nervosa - A systematic review and meta-analysis

OBJECTIVE

We aimed to provide a comprehensive overview of the role of self-esteem in the treatment of patients with anorexia nervosa (AN). Specifically, our objectives were to investigate the differences in self-esteem between individuals with AN and healthy controls, or individuals with other eating disorders, and to examine self-esteem as an outcome, predictor, moderator, and mediator in AN treatment.

METHOD

The databases PsycINFO, PSYNDEXplus, Ovid MEDLINE®, and ProQuest were searched for studies published from 1990 to 2018. To estimate aggregated effect sizes, we performed random-effects meta-analyses.

RESULTS

A screening of 1,596 abstracts and 203 full-texts identified 68 relevant publications. Results suggest a significantly lower global self-esteem in individuals with AN than in healthy controls (d = -1.90, p < .001). In contrast, global self-esteem of AN and bulimia nervosa (BN) patients was found to be comparable (d = 0.05, p = .529). It might be specific to AN patients that negative self-evaluations may not affect scholastic and professional abilities. Significantly moderate self-esteem increases were observed in treated AN patients at the end of treatment (d = 0.56, p < .001), short-term (d = 0.50, p < .001), and long-term (d = 0.75, p < .001) follow-up. Self-esteem did not predict end of treatment remission-or weight-related outcome and treatment dropout. However, small to moderate predictive effects were detected on short-term (r = .15, p = .007) and long-term remission or weight (r = .33, p = .017). Finally, first indications point to self-esteem as a mediator in adult AN inpatient treatment.

DISCUSSION

The review provides insights relevant for theory, research, and practice. Implications concern the overall support for transdiagnostic approaches and the recommendation to consider low initial self-esteem for decisions on after-care.

Clients' perceptions of the therapeutic relationship in the treatment of anorexia nervosa: qualitative findings from an online questionnaire

The therapeutic relationship plays a unique and pivotal role in the treatment and recovery of individuals with mental illness. The aim of the questionnaire was to understand clients’ perceptions of the factors affecting the formation of the therapeutic relationship during treatment or recovery from self-reported anorexia nervosa. Former or current individuals diagnosed with anorexia nervosa, 18 years and over, were invited to participate in an online questionnaire developed by the researchers. Eating disorder organisations in Australia and the United Kingdom advertised the study and provided the link to the online questionnaire. The questionnaire collected both quantitative and qualitative data, with quantitative data analysed using descriptive statistics and qualitative data using conventional content analysis. Findings revealed only 25% of participants (n=33) believed treatment providers listened and understood (to a great extent) their concerns during treatment and 30.08% (n=40) did not have sufficient trust or confidence in providers. The four qualitative themes identifying factors affecting therapeutic relationships are described. Healthcare providers working in acute and primary health settings should persevere with the development and maintenance of the therapeutic relationship in adults with anorexia nervosa. An investment in this relationship will be the catalyst driving motivation to change.

Process-symptom-bridges in psychotherapy: An idiographic network approach

AIM

real-time monitoring of psychotherapeutic processes was recently described as a promising, new way of tracking periods of change in ongoing treatments. This approach generates complex, multivariate datasets that have to be presented in an intuitive way for clinicians to aid their clinical decision-making. Using network modeling and new approaches in centrality analyses, we examine "bridge nodes" between symptom stress and aspects of the psychotherapeutic process between therapy session (intersession processes, ISP). Method:we recorded intersession processes as well as depressive and anxiety symptoms using daily questionnaires in ten cases. Regularized, thresholded intraindividual dynamic networks were estimated. We applied bridge centrality analysis to identify individual bridges between psychotherapeutic processes and symptoms in the resulting models. Case-wise interpretations of bridge centrality values are offered.

RESULTS

bridge centrality analysis revealed individual bridge nodes between intersession processes and symptom severity. Strength and direction of bridges varied substantially across individuals.

CONCLUSION

given current methodological challenges, idiographic network studies are feasible and offer important insights for psychotherapy process research. In this case, we demonstrated how patients deal with periods of increased symptom stress. In this case we have described how patients deal with their therapy under increased symptom load. Bridges between psychotherapeutic processes and symptom stress are a promising target for monitoring systems based on ISP. Future studies should examine the clinical utility of network-based monitoring and feedback in ongoing therapies. In the near future, process feedback systems based on idiographic models could serve clinicians to improve treatments.

Contingency Contracts for Weight Gain of Patients with Anorexia Nervosa in Inpatient Therapy: Practice Styles of Specialized Centers

The treatment of patients with anorexia nervosa (AN) is often challenging, due to a high degree of ambivalence towards recovery and weight gain these patients often express. One part of the multimodal treatment is the utilization of treatment contracts (i.e., contingency contracts) that aim to motivate patients to gain weight by applying positive and negative consequences for the (non-)achievement of weight goals. The main aim of this study is to assess and analyze current standards of contingency contracts’ utilization in German eating disorder centers. n = 76 mental health professionals of twelve specialized university centers in Germany that are currently or were formerly treating patients with AN in an inpatient setting participated. Most experts use contingency contracts in their clinic with weekly weight goals ranging between 500 and 700 g. Overall effectiveness and significance of contingency contracts for the inpatient treatment of patients with AN was rated high. Typical characteristics of a contingency contract in specialized German university hospital centers, such as the most frequent consequences, are described. The survey results assist the planning of further studies aiming to improve the multimodal treatment of patients with AN. For clinical practice, using external motivators such as contingency contracts as well as targeting internal motivation (e.g., by using motivational interviewing) is proposed.

Daily dynamic assessment and modelling of intersession processes in ambulatory psychotherapy: A proof of concept study

Background: the typical mode of assessment in studies on intersession processes (ISP) in psychotherapy is using cross-sectional or weekly measurements. Daily dynamics of intersession processes have not yet been studied. Method: intersession process data from 22 ambulatory psychotherapy cases were collected in a naturalistic study with high temporal resolution, resulting in a total of 1026 daily measurements. Multilevel vector autoregressive (VAR) modelling was applied to discover the temporal course and causal influences among intersession processes. Centrality analysis was applied to discover unique functions of various intersession process variables. Results: a group-level network structure was discovered, offering first insights on the role of different intersession processes during psychotherapy. Centrality analysis revealed unique roles for various aspects of the intersession process. Temporal distance from the last session had only weak influence on the ISP. Conclusions: using short, daily measures, the unique role of various aspects of the ISP were uncovered. Some aspects of the ISP, like recalling session contents or reflection on future session contents, are facilitators of overall ISP intensity. Other aspects like thoughts on payment or appointments or negative treatment-related emotions are likely to suppress ISP.

DynAMo: A Modular Platform for Monitoring Process, Outcome, and Algorithm-Based Treatment Planning in Psychotherapy

BACKGROUND

In recent years, the assessment of mental disorders has become more and more personalized. Modern advancements such as Internet-enabled mobile phones and increased computing capacity make it possible to tap sources of information that have long been unavailable to mental health practitioners.

OBJECTIVE

Software packages that combine algorithm-based treatment planning, process monitoring, and outcome monitoring are scarce. The objective of this study was to assess whether the DynAMo Web application can fill this gap by providing a software solution that can be used by both researchers to conduct state-of-the-art psychotherapy process research and clinicians to plan treatments and monitor psychotherapeutic processes.

METHODS

In this paper, we report on the current state of a Web application that can be used for assessing the temporal structure of mental disorders using information on their temporal and synchronous associations. A treatment planning algorithm automatically interprets the data and delivers priority scores of symptoms to practitioners. The application is also capable of monitoring psychotherapeutic processes during therapy and of monitoring treatment outcomes. This application was developed using the R programming language (R Core Team, Vienna) and the Shiny Web application framework (RStudio, Inc, Boston). It is made entirely from open-source software packages and thus is easily extensible.

RESULTS

The capabilities of the proposed application are demonstrated. Case illustrations are provided to exemplify its usefulness in clinical practice.

CONCLUSIONS

With the broad availability of Internet-enabled mobile phones and similar devices, collecting data on psychopathology and psychotherapeutic processes has become easier than ever. The proposed application is a valuable tool for capturing, processing, and visualizing these data. The combination of dynamic assessment and process- and outcome monitoring has the potential to improve the efficacy and effectiveness of psychotherapy.

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, βs = 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.

How do patients with anorexia nervosa "process" psychotherapy between sessions? A comparison of cognitive-behavioral and psychodynamic interventions

OBJECTIVE

Patients' processing of psychotherapy between sessions ("inter-session process" (ISP)) has been repeatedly shown to be related to outcome. The aim of this study was to compare ISP characteristics of cognitive-behavioral vs. psychodynamic psychotherapy in the treatment of anorexia nervosa (AN) and their relation to outcome.

METHODS

Data of 106 patients participating in a randomized-controlled trial who received either 40 sessions of enhanced cognitive-behavioral therapy (CBT-E) or focal psychodynamic therapy (FPT) were analyzed. The ISP was measured with the Inter-session Experience Questionnaire (IEQ). Three outcome classes were distinguished: full recovery, partial recovery, and still fulfilling all AN criteria.

RESULTS

Patients receiving CBT-E reported more on "applying therapy" in the initial and the final treatment phase compared to FPT patients. In terms of process-outcome relations, higher levels of "recreating the therapeutic dialogue between sessions," "recreating the therapeutic dialogue with negative emotions" as well as "applying therapy with negative emotions" in the final phase of treatment predicted negative outcome in FPT, whereas overall higher levels of negative emotions predicted negative outcome in CBT-E.

CONCLUSIONS

In outpatient treatment in AN, the processing of therapy as measured by the IEQ showed surprisingly few differences between CBT-E and FPT. However, different ISP patterns were predictive of outcome, pointing to different mechanisms of change.

The therapeutic process in psychological treatments for eating disorders: a systematic review

OBJECTIVE

For eating disorders, a vast number of investigations have demonstrated the efficacy of psychological treatments. However, evidence supporting the impact of therapeutic process aspects on outcome (i.e., process-outcome research) has not been disentangled.

METHOD

Using the Generic Model of Psychotherapy (GMP) to organize various process aspects, a systematic literature search was conducted on psychological treatment studies for anorexia nervosa, bulimia nervosa, binge-eating disorder, and eating disorders not otherwise specified.

RESULTS

Improved outcomes resulted for family-based treatment compared to individual treatment, for individual compared to group treatment, booster sessions, and positive patient expectations (GMP contract aspect); for nutritional counseling and exercising but not exposure with response prevention as adjunct interventions (therapeutic operations); for highly motivated patients and, to a lesser extent, for therapeutic alliance (therapeutic bond); as well as for rapid response and longer overall treatment duration (temporal patterns). Regarding other GMP aspects, studies on self-relatedness were completely lacking and in-session impacts were rarely investigated.

DISCUSSION

As most studies assessed only a limited number of process aspects, the ability to draw conclusions about their overall impact regarding outcome is rather limited. Therefore, future process-outcome research is needed beyond investigations of treatment efficacy for eating disorders.

Preferred therapist characteristics in treatment of anorexia nervosa: the patient's perspective

OBJECTIVE

Previous research in eating disorders suggests that treatment satisfaction is closely related to the manner in which care is delivered. The present research is a systematic in depth study of health professional characteristics preferred by AN-patients.

METHOD

Thirty-eight women with AN aged 18-51 were interviewed in depth using a phenomenological study design. Interviews were tape-recorded, transcribed, and analyzed using the QSR-NVivo7 software program.

RESULTS

Four factors associated with patients' satisfaction with their therapists were identified: "acceptance," "vitality," "challenge," and "expertise." Patients' responses suggested that treatment of AN requires therapists who are capable of using a complex set of behaviors when interacting with their patients.

DISCUSSION

There is accumulating evidence that across treatment modality, the manner in which treatment is delivered is critical to therapeutic change. Our findings increase the understanding of factors that may be associated with treatment retention, further help seeking, and overall treatment outcome. These exploratory and informant-centered results could guide clinicians in developing a strong therapeutic alliance with AN-patients and promote increased knowledge about the mechanisms that engage this population.

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.

Why are we waiting? The relationship between low admission weight and end of treatment weight outcomes

Inpatient eating disorder units are increasingly being asked to admit patients at lower BMI's, often delaying hospital treatment until medically unavoidable. This paper aims to explore the impact of this trend on treatment outcome. Eighty-two adults with anorexia nervosa admitted to a national inpatient eating disorder ward were assessed for BMI at admission, length of hospitalisation, discharge BMI and re-admission within 1-year post-treatment. In the current study, admission BMI was unrelated to amount of weight gain during treatment or to length of hospital stay. As such patients admitted at lower BMI's had significantly lower BMI's on discharge from treatment. Low admission BMI's were related to significantly higher likelihoods of re-admission within 1 year. This study provides strong evidence for the benefit of early treatment episodes and with more successful treatment outcomes being related to higher weights at start of treatment.

Anorexic self-control and bulimic self-hate: differential outcome prediction from initial self-image

OBJECTIVE

The study investigated initial self-image (structural analysis of social behavior) and its relation to 36-month outcome, among patients with anorexia nervosa and bulimia nervosa. Hypotheses were that degree of different aspects of self-image would predict outcome in the groups.

METHOD

Participants were 52 patients with anorexia and 91 with bulimia from a longitudinal naturalistic database, and outcome measures included eating disorder and psychiatric symptoms and a general outcome index. Stepwise regression was used to investigate which self-image variables were related to outcome, and multiple regression contrasted the groups directly on each obtained predictor.

RESULTS

Consistent with hypotheses, in bulimia degree of self-hate/self-love moderately predicted outcome, whereas self-control-related variables powerfully predicted outcome in anorexia.

DISCUSSION

It is important to focus on self-image in the treatment of both diagnostic groups, but especially in anorexia nervosa, where control-submission interactions between patient and therapist should be handled with care.

Family therapy in the treatment of adolescent anorexia nervosa: current research evidence and its therapeutic implications

From the outset, the systemic and family movement has expressed an interest in eating disorders, more specifically anorexia nervosa, establishing causal links between family functioning and aetiology and advocating family therapy as the treatment of choice for this disorder. Because of high consistency between its explanatory and therapeutic dimensions, this model continues to dominate our conceptualizations and clinical practice, in spite of a lack of empirical support. This article summarizes present empirical evidence concerning both family functioning (explanatory dimension) and the effectiveness of family therapy (therapeutic dimension) in anorexia nervosa, and describes resulting changes in theoretical and clinical perspectives. A model of evidence-based family therapy is presented and several unresolved issues are raised. Overall, this overview of the literature supports the use of therapeutic models that are more flexible and normative, less guilt-inducing, more diversified (eclectic and integrative), and more rooted in the empirical literature.

The quality of treatment of eating disorders: a comparison of the therapists' and the patients' perspective

OBJECTIVE

The aims of this study were to investigate the quality of treatment of eating disorders (EDs) from the therapists' and patients' perspective and to compare their views.

METHOD

The Questionnaire for Eating Problems and Treatment (QEPT) was administered to 73 therapists working with patients with ED, to 156 current ED and 148 former ED patients. The QEPT addresses the quality of treatment of EDs. ED diagnosis was assessed by the Eating Disorder Examination Questionnaire. Answers were analyzed quantitatively and qualitatively.

RESULTS

Both therapists and patients most often mentioned focus of treatment, therapeutic alliance, and communicational skills as important aspects of the quality of treatment. However, they valued similar topics differently. Therapists valued the focus on ED symptoms and behavioral change more highly, whereas patients underscored the importance of the therapeutic relationship and addressing underlying problems. Most therapists work from a cognitive behavioral orientation, but protocol-based treatment was not found important.

CONCLUSION

There is an avid need for dissemination of evidence-based treatment. Therapists' and patients' views supplement current evidence-based knowledge on treatment quality of EDs. Optimal treatment of EDs will be facilitated when these three bodies of knowledge-the available evidence and the therapists' and patients' views-are integrated.