Therapists' professional and personal characteristics as predictors of outcome in short- and long-term psychotherapy

Development of the Psychotherapist Character Virtues (PCV) Interview

OBJECTIVE

To develop an interview-based rating method for assessing therapists' beneficial character traits and evaluate its reliability and validity.

METHOD

The semi-structured Psychotherapist Character Virtues (PCV) interview and evaluation method, based on Erik Erikson's and Heinz Kohut's writings on 16 virtues or abilities and achievements of an adult self, was administered to 68 psychodynamic and solution-focused therapists. Inter-rater reliability was assessed based on 20 videorecorded interviews, rated by two evaluators. In a mixed-methods design, validity was investigated against (i) therapist's questionnaire-based self-reported professional and personal background characteristics and (ii) a qualitative content analysis of emotional atmosphere in the interview.

RESULTS

Interrater reliability for individual 16 virtues was acceptable (median correlation .72). From individual virtues, three principal components (Creative Will, Empathy, and Love/Care) emerged with good/excellent internal consistency (component determinacies .95, .85, and .90, respectively) and criterion validity with self-reported professional and personal characteristics. Cluster analysis of therapists' component scores yielded six different therapist character profiles. In qualitative analysis, character profiles meaningfully differed in their impact on the interview's emotional atmosphere.

CONCLUSION

PCV appears promising for evaluating therapists' character virtues, posited to undergird therapists' sensitive attunement and responsiveness. Further research is needed on PCV's predictive validity for therapeutic relationships and outcomes.

The effect of individual short- and long-term psychotherapy on perceived social support: analysis of secondary outcomes of a randomized clinical trial

PURPOSE

Social support is important for maintaining and restoring psychological well-being but the effects of individual psychotherapies on perceived social support are not well known. In this analysis of secondary outcomes from a randomized clinical study, we compared the effects of long-term psychotherapy and two short-term psychotherapies on social support during a 5-year follow-up.

MATERIALS AND METHODS

Altogether 326 adult outpatients suffering from depressive and/or anxiety disorders were randomly assigned to long-term psychodynamic psychotherapy (LPP, n = 126), short-term psychodynamic psychotherapy (SPP, n = 101) and solution-focused therapy (SFT, n = 97). Outcome was measured by the global index and six subscores of the self-reported Brief Inventory of Social Support and Integration scale (BISSI) at baseline and at 1, 2, 3, 4 and 5 years after the beginning of the therapy.

RESULTS

Social support improved in all therapy groups and the improvement was relatively stable, lasting several years after the end of therapy. Little difference in improvement was observed either between therapy orientations or durations.

CONCLUSIONS

While no major differences were observed between treatment groups, the slight differences call for further research to verify these findings and to better understand how different therapies may improve perceived social support.

The Therapist's Intuition and Responsiveness: What Makes the Difference between Expert and in Training Gestalt Psychotherapists

This study aims to investigate the presence of intuition and responsiveness in early students and in experienced students and psychotherapists, which is understood as the ability to integrate bodily sensitivity and cognition of what is experienced with the patient (aesthetic relational knowing-ARK). The study compares how the therapist's felt sense of the phenomenological intersubjective field and aesthetic relational competence differs between a group of experienced students and psychotherapists and a group of beginners. The sample consisted of 128 participants (20 M; 108 F), finally divided into two groups: "experienced students and psychotherapists" and "beginners". The Aesthetic Relational Knowledge Scale (ARKS), a questionnaire consisting of 58 items targeting three factors (empathy, body awareness, and resonance), was administered. Statistical analyses were conducted to assess (i) differences between the two groups (through Student's t and Cohen's d for effect sizes), (ii) the influence of the level of training for each ARK factor using analyses of covariance for testing the possible influence of demographic variables, and (iii) logistic regressions to compare the influence of the three factors of the ARK model on the group variable with groups as a categorical variable. Significant differences between the two groups were found in body awareness and resonance. Body awareness was found to be the variable best discriminating between the beginners and the experienced students and psychotherapists. Despite being non-significant, there is a tendency suggesting that empathy appears more relevant at the beginning of training. The study shows the importance of training for the development of the therapist's intuition and responsiveness, especially in the factors of body awareness and resonance. The results indicate the importance of assessing and supporting the aesthetic and field resonance of therapists in training, increasing quality and depth of the therapist's responsiveness. This study is limited by a correlational design using self-report and on a limited sample, but it shows that the ARKS can monitor the effectiveness of training related to Gestalt therapeutic competencies.

Determinants of patient-reported outcome trajectories and symptomatic recovery in Improving Access to Psychological Therapies (IAPT) services

BACKGROUND

Despite evidence for the general effectiveness of psychological therapies, there exists substantial heterogeneity in patient outcomes. We aimed to identify factors associated with baseline severity of depression and anxiety symptoms, rate of symptomatic change over the course of therapy, and symptomatic recovery in a primary mental health care setting.

METHODS

Using data from a service evaluation involving 35 527 patients in England's psychological and wellbeing [Improving Access to Psychological Therapies (IAPT)] services, we applied latent growth models to explore which routinely-collected sociodemographic, clinical, and therapeutic variables were associated with baseline symptom severity and rate of symptomatic change. We used a multilevel logit model to determine variables associated with symptomatic recovery.

RESULTS

Being female, younger, more functionally impaired, and more socioeconomically disadvantaged was associated with higher baseline severity of both depression and anxiety symptoms. Being older, less functionally impaired, and having more severe baseline symptomatology was associated with more rapid improvement of both depression and anxiety symptoms (male gender and greater socioeconomic disadvantage were further associated with rate of change for depression only). Therapy intensity and appointment frequency seemed to have no correlation with rate of symptomatic improvement. Patients with lower baseline symptom severity, less functional impairment, and older age had a greater likelihood of achieving symptomatic recovery (as defined by IAPT criteria).

CONCLUSIONS

We must continue to investigate how best to tailor psychotherapeutic interventions to fit patients' needs. Patients who begin therapy with more severe depression and/or anxiety symptoms and poorer functioning merit special attention, as these characteristics may negatively impact recovery.

Psychedelics, placebo effects, and set and setting: Insights from common factors theory of psychotherapy

Psychedelic-assisted treatment is at first glance markedly different in structure and approach from mainstream forms of psychotherapy in the West. A major criticism of clinical psychedelic research rests on the difficulty of executing placebo-controlled studies and distinguishing drug effects from those of the psychotherapeutic container in which psychedelics are typically presented. Detractors also tend to find fault in spiritual or mystical themes that often arise in the context of psychedelic use. Common factors theory of psychotherapy is a useful and extensively studied framework that can help make sense of these issues, and has much to contribute to our understanding of contextual effects that are often discussed in psychedelic literature as "set and setting." In this article, we examine four major contextual "common factors" shared by various healing traditions: 1) the therapeutic relationship; 2) the healing setting; 3) the rationale, conceptual scheme, or myth; and 4) the ritual. We explain how these factors show up in psychedelic-assisted treatment and how they may contribute to therapeutic effects. Lastly, we discuss the implications of these factors for the concept of placebo, and for future research.

What Works for Whom: Patients' Psychological Resources and Vulnerabilities as Common and Specific Predictors of Working Alliance in Different Psychotherapies

Background

Across different types of psychotherapy, one of the most robust predictors of better therapeutic outcomes is a good working alliance between patient and therapist. Yet there is little comparative research on whether particular patients more likely achieve a better alliance in certain treatments which represent particular therapeutic approaches or durations.

Methods

326 patients suffering from depressive and/or anxiety disorder were randomized into two short-term (solution-focused or psychodynamic) and one long-term (psychodynamic) therapy models. Treatments lasted ~7 and 36 months, respectively. Before randomization, patients were assessed with the interview-based Suitability for Psychotherapy Scale and filled Childhood Family Atmosphere and Life Orientation Test questionnaires. Patients filled Working Alliance Inventory after 3rd therapy session and at end of treatment; the long-term therapy patients, additionally, at 7 months' time point. Linear regression models were used.

Results

Greater psychological resources (e.g., capacity for self-reflection, affect regulation, flexible interaction) had little effect on alliance during the course of the short-term therapies. However, they did predict better working alliances at end of long-term as opposed to short-term therapy. Childhood adversities impacted alliances already at 7 months.

Conclusions

Although patients with certain qualities achieve better alliances in long-term as opposed to short-term therapies, apparently the theoretical orientation of therapy makes little difference. For patients with childhood adversities, differences between long-term (psychodynamic) treatment vs. various brief therapy models may be particularly salient.

Schema therapists' perceptions of the influence of their early maladaptive schemas on therapy

Objective: This qualitative survey aimed to explore schema therapists' perceptions of how their early maladaptive schemas are activated in their therapeutic work, and how they manage their reactions.Method: An online qualitative survey was conducted with 22 schema therapists. Following brief demographic questions, participants were asked three open-ended questions about their schema activation and associated reactions. An inductive-deductive hybrid thematic analysis of the qualitative responses identified four superordinate themes and 12 subthemes.Results: Participants described several negative impacts on their therapeutic work, including avoiding limit setting, becoming argumentative or aggressive, detaching or avoiding, and over-functioning. An array of strategies for managing schema and countertransference reactions were identified, including refocusing on the client's vulnerability, caring for one's own vulnerability and connecting with one's healthy adult self, and engaging in supervision, training, personal therapy, and self-care. Notably, several participants described how their internal reactions can be used advantageously to conceptualize and support clients, and to facilitate therapists' personal development.Conclusion: The findings highlighted that although schema and associated countertransference experiences can be challenging, awareness and effective management of therapists' reactions can benefit treatment and promote personal growth.

Person-Centered Psychiatry as Dialogical Psychiatry: The Significance of the Therapeutic Stance

In this article, we present holistic and person-centered perspectives in psychiatry, with the aim of better understanding what a focus on personhood might really mean and what clinical implications it might have. We first introduce classical and philosophical concepts of personhood, in order to then outline person-centered approaches in psychiatry, which mainly focus on the person of the patient. We then argue that, for it to really be person-centered, psychiatry must necessarily also focus on the person of professionals. We thus explore the notion of stance, as the expression of the therapist's personhood. By unpacking the effects that a professional's stance can have on patients, we finally turn to a consideration of the interpersonal sphere. More specifically, we propose clinical considerations on a therapeutic stance that strives to support and to help the person of the patient unfold. Such a stance must - we argue - necessarily be a dialogical one. Drawing on these considerations, we thus claim that a truly person-centered approach in psychiatry must necessarily and automatically be interperson-centered and dialogical. In the concluding remarks, we finally discuss broader societal implications and outline future research perspectives.

Poor suitability for psychotherapy - a risk factor for treatment non-attendance?

BACKGROUND

Patient suitability has been suggested to predict treatment non-attendance but information on its effect is limited.

AIM

To study the prediction of the Suitability for Psychotherapy Scale (SPS), on occurrence of treatment non-attendance.

METHODS

Altogether 326 outpatients, with depressive or anxiety disorder, were randomized to short-term psychodynamic psychotherapy (SPP), long-term psychodynamic psychotherapy (LPP), and solution-focused therapy (SFT). SPS was based on seven components from three suitability domains: nature of problems, ego strength, and self-observing capacity. Treatment non-attendance was defined as refusal of engaging therapy and of premature termination. The Cox model and logistic regression were used.

RESULTS

Treatment non-attendance was significantly more common in LPP patients with poor SPS (RR = 2.76, 95% CI = 1.45-5.26). This was mainly due to poor flexibility of interaction, poor self-concept, and poor reflective ability. Premature termination in SFT showed a similar trend but due to other SPS components: absence of a circumscribed problem, poor modulation of affects, and poor response to trial interpretation. On the contrary, individuals with good values of SPS were more prone to premature termination in SPP.

LIMITATIONS

The prediction of suitability on refusal could only be studied in the LPP group due to few refusals in the short-term therapy groups. The sample consisted of patients who participated in a trial. Thus the findings may not be directly generalized to unselected patients in the public mental health setting.

CONCLUSIONS

Poor suitability, apparently, predicts non-attendance in LPP and SFT, but not in SPP. More studies on large cohorts are needed.

Psychotherapists' perception of their clinical skills and in-session feelings in live therapy versus online therapy during the COVID-19 pandemic: a pilot study

During the coronavirus disease 2019 (COVID-19) pandemic, many psychotherapists who were used to seeing their patients in face-toface setting adapted to providing therapies online. In the present pilot study, we investigated therapist current experiences of online therapy compared to live therapy. Twenty-nine therapists completed Clinical Skills, Difficulties in Practice, and in-sessions feelings of Flow, Boredom and Anxiety of the Trainee Current Progress Report, giving a score for each item in two different conditions: Live Therapy and Online Therapy. Compared to Live Therapy, in Online Therapy therapists reported significantly less Clinical Skills, whereas Difficulties in Practice did not differ in the considered conditions. With regard to in-sessions feeling, therapists reported significantly lower scores of Boring and higher scores of Flow in Live Therapy compared to Online Therapy, whereas Anxiety did not differed in the considered conditions.

What is the appropriate time to measure outcome and process factors in psychodynamic psychotherapy?

INTRODUCTION

Different instruments and methods for measuring factors related to the progress and effectiveness of psychodynamic psychotherapy (PDT) have been widely discussed in the literature. However, there are no established guidelines on the most appropriate time to perform these measurements.

OBJECTIVES

The aim of this study is to problematize what is the appropriate time to measure the initial outcomes (symptoms, interpersonal relationships, quality, and social role) and process factors (alliance) in the early stages of PDT.

METHODS

A naturalistic cohort study was conducted, following 304 patients during the first six months of psychotherapy. The therapeutic alliance was evaluated after four sessions; symptoms, interpersonal relationships, and social role were evaluated at intake and after 12 and 24 sessions.

RESULTS

Our results indicate that four sessions were sufficient to measure the bond dimension of the therapeutic alliance, while more time is probably needed to adequately measure other aspects of the therapeutic alliance, such as tasks and goals. However, 12 sessions of treatment proved sufficient to detect improvements in all dimensions of the outcome instruments with moderate effect sizes, and those gains were stable at the 24th session.

CONCLUSION

According to our findings, 12 sessions seem to be sufficient to assess initial gains in PDT, although more studies are needed to evaluate the appropriate time to assess all aspects of the therapeutic alliance. Further studies are also required to evaluate the appropriate time to assess intermediate and long-term progress with regard to symptoms, interpersonal relations, social role and personality reorganization.

The professional and personal characteristics of effective psychotherapists: a systematic review

Objective: Psychotherapists differ notably in the outcomes their patients achieve, and the characteristics that may explain these differences have attracted increasing interest. We systematically review studies on therapist pre-treatment characteristics predicting patient outcomes. Method: Systematic searches on databases for psychotherapy research, clinical psychology, and medical science for the years 2000-2018 identified published research examining therapist characteristics and psychotherapy outcomes. Of 2041 studies, 31 met inclusion criteria. Results: Findings show a few direct effects of therapist intrapersonal variables (e.g., self-relatedness, attachment) and several interaction effects with other constructs (e.g., patient pathology) on outcome. There is little support for the relevance of self-rated social skills. However, more consistent evidence has recently emerged for performance-based measurements of professional interpersonal skills, especially when elicited in challenging situations. Patient outcomes were also predicted by therapists' self-rated professional characteristics, such as their experienced difficulties in practice, coping mechanisms, and attitudes towards therapeutic work, indicating that therapist self-perception also matters, although not always in the direction expected. Conclusions: More effective therapists seem characterized by professionally cultivated interpersonal capacities, which are likely rooted in their personal lives and attachment history. Research guidelines are proposed for moving this field forward (including larger samples, multilevel modeling, and in-depth qualitative work).

Relations among psychotherapists’ epistemic orientation, personal style and emotion regulation

Abstract The main objective of this study was to examine the relations among psychotherapists’ epistemic orientation (i.e., intuitive, empiricist, and rationalist), personal style and emotion regulation strategies. Participants in the study were 674 psychotherapists of different theoretical approaches, who completed an online questionnaire containing measures of epistemic orientation, personal style, and emotion regulation strategies. Psychotherapists profiled as predominantly intuitive tended towards broader attention and greater emotional closeness as compared to those profiled as predominantly rationalist or empiricist. Furthermore, they also reported using more strategies for increasing the effects of positive emotions than rationalists. Implications for training, practice and therapist well-being are discussed.

Effect of Rational Emotive Health Therapy on Alcohol Use Among Community-dwelling, HIV-positive Patients

BACKGROUND

Patients who have tested positive for the human immunodeficiency virus (HIV) and who also experience alcohol use disorder (AUD) symptoms have worse clinical outcomes when compared with those who do not have AUD symptoms. The objective of the present study was to determine the effect of rational emotive health therapy (REHT) on AUD among community-dwelling, HIV-positive patients in the Southeastern region of Nigeria.

METHODS

The research design included a pretest/post-test control group with a total of 124 community-dwelling, HIV-positive patients with AUD symptoms participating in the study. The measures employed for data collection included Alcohol-related Irrational Beliefs Scale (AIBS) and Alcohol Use Disorder Scale (AUDS). Repeated measures analysis of variance was used for statistical analysis.

RESULTS

The result obtained at the initial assessment indicated that AUD was severe. Furthermore, REHT intervention led to a significant reduction in AUD symptoms, as shown by a reduction in AUDS and AIBS scores with time in the treatment group compared to those in the waitlist control group after the intervention. Also, the effect of REHT was positively maintained in the treatment group participants at follow-up assessment.

CONCLUSION

The presence of HIV symptoms alone does not cause HIV-positive patients to be dependent on alcohol; rather, irrational beliefs about the infection may contribute to unhealthy feelings and abuse of alcohol. Rational emotive health therapy is an effective approach that can be employed by therapists and health counselors in helping HIV-positive patients to think rationally about themselves and work to be able to overcome HIV-related, as well as alcohol-related, irrational beliefs.

Childhood adversities as predictors of improvement in psychiatric symptoms and global functioning in solution-focused and short- and long-term psychodynamic psychotherapy during a 5-year follow-up

BACKGROUND

Childhood adversities are frequent among adults who seek treatment for depression or anxiety. These disorders are commonly treated by psychotherapy. Yet it is not known if specific types or durations of psychotherapy are particularly suited for patients who have suffered various early adversities.

METHODS

221 depressed and anxious adult outpatients from community, student, occupational, and private healthcare services filled the Childhood Family Atmosphere Questionnaire. They were randomly assigned to short- (solution-focused or psychodynamic) or long-term (psychodynamic) psychotherapy. Outcome was assessed via patient questionnaires and clinician interviews of psychiatric symptoms and global functioning during a 5-year follow-up. Linear regression analyses were conducted.

RESULTS

Less separations from caregivers expectedly predicted better outcomes in all therapies; unexpectedly, so did greater abuse. Family unhappiness and parental problems predicted faster or greater improvement when patients were assigned to a short- or long-term psychodynamic therapy model.

LIMITATIONS

As patients with psychotic, substance abuse, and severe personality disorders were screened out, findings might not generalize to these patient groups.

CONCLUSIONS

Patients with certain childhood adversities appear to respond with faster or greater improvement when the psychotherapy model is explicitly focused on working through the potential connections between past and current problems. If confirmed by in-depth studies, the findings may help match psychotherapeutic models with given patient complaints, as well as fine-tune different psychosocial interventions to individual needs for optimizing treatment outcomes.

"It's both a strength and a drawback." How therapists' personal qualities are experienced in their professional work

Objective: The aim of this study was to gain knowledge about how the integration of personal and professional experiences affects therapeutic work. Method: Therapists (N = 14) who had been recommended by their leaders at their individual workplaces were interviewed twice with semi-structured qualitative interviews, which were then subjected to thematic and Interpretative Phenomenological Analysis. Results: All the therapists in the sample described their personal qualities as an experienced tension between their personal strengths and vulnerabilities in the therapeutic setting. This tension came to expression through four subordinate themes: (a) The tension between perceiving oneself as a helper while dealing with one's own needs for attention and care; (b) The tension between the ability for embodied listening to the patient while tuning into oneself; (c) The tension between staying present while handling aggression and rejection from clients; and (d) The tension in striving for a constructive balance between closeness and distance. Conclusion: The results point to ways in which the personal selves of the therapists may affect their professional role performance. Drawing upon previous research and literature on the topic, the paper discusses how therapists' personal qualities are experienced as affecting their work and suggests several implications for psychotherapy training and practice.

Assessing the Confidence of Australian Mental Health Practitioners in Delivering Therapy to People With Intellectual Disability

Research supports the use of psychological therapies among people with mild to moderate intellectual disability (ID). One barrier to people with ID accessing psychological treatments is the confidence of mental health practitioners. This article explores the confidence of Australian clinicians in providing therapy to people with ID. One hundred and fifty-two psychologists and counselors in Australia completed a survey exploring self-reported confidence when working with clients who have ID and mental health difficulties. Clinicians were most confident with generic counseling skills, but less confident with elements of assessments and interventions. The use of treatment protocols was endorsed as helpful particularly among those with low confidence. This highlights the need for dissemination of treatment guides and training to help increase clinician confidence.

Do therapists' subjective variables impact on psychodynamic psychotherapy outcomes? A systematic literature review

BACKGROUND

Despite growing attention to the general therapist effects in a wide range of clinical settings, little is known about the individual, cross-situational, and therapy-nonspecific variables that impact on the differential effectiveness of clinicians. The current study is a systematic review of the evidence relating to the influence of therapist's subjective characteristics on outcomes of psychodynamic psychotherapies.

METHOD

A multistage and systematic search of articles published between 1987 and 2017 identified 30 relevant studies, which were organized into 6 areas according to the specific therapist's variable considered.

RESULTS

Therapists' interpersonal functioning and skills showed the strongest evidence of a direct effect on treatment outcomes. Furthermore, there were preliminary evidence that therapists' attachment styles, their interpersonal history with caregivers, and their self-concept might affect outcomes through interaction effects with other constructs, such as technical interventions, patient's pathology, and therapeutic alliance. The high variability between studies on therapists' overall reflective or introspective abilities and personality characteristics suggested the need for more systematic research in these areas, whereas therapists' values and attitudes showed small effects on therapeutic outcome.

CONCLUSIONS

The present review clarifies how a deep examination of the contribution of therapists' subjective characteristics can help elucidate the complex association between relational and technical factors related to the outcome of psychodynamic treatments.

The prediction of the level of personality organization on reduction of psychiatric symptoms and improvement of work ability in short- versus long-term psychotherapies during a 5-year follow-up

OBJECTIVES

How level of personality organization (LPO) predicts psychiatric symptoms and work ability in short- versus long-term psychotherapies is poorly known. We investigated the importance of the LPO on the benefits of short-term versus long-term psychotherapies.

DESIGN

A cohort study based on 326 outpatients with mood or anxiety disorder was allocated to long-term (LPP) and short-term (SPP) psychodynamic psychotherapy, and solution-focused therapy (SFT).

METHODS

The LPO was assessed by interview at baseline and categorized into neuroses and higher level borderline. Outcome was assessed at baseline and 4-9 times during a 5-year follow-up, using self-report and interview-based measures of symptoms and work ability.

RESULTS

For patients receiving SPP, improvement in work ability, symptom reduction, and the remission rate were more considerable in patients with neuroses than in higher level borderline patients, whereas LPP or SFT showed no notable differences in effectiveness in the two LPO groups. In patients with neuroses, improvement was more considerable in the short-term therapy groups during the first year of follow-up, and in higher level borderline patients LPP was more effective after 3 years of follow-up. The remission rate, defined as both symptom reduction and lack of auxiliary treatment, was higher in LPP than in SPP for both the LPO groups considered.

CONCLUSIONS

In neuroses, short-term psychotherapy was associated with a more rapid reduction of symptoms and increase in work ability, whereas LPP was more effective for longer follow-ups in both LPO groups. Further large-scale studies are needed.

PRACTITIONER POINTS

Level of personality organization is relevant for selection between short- and long-term psychotherapies. Short-term therapy gives faster benefits for neurotic patients but not for patients with higher level borderline personality organization. Sustained remission from symptoms is more probable after long-term than short-term therapy.

Patients' pre-treatment interpersonal problems as predictors of therapeutic alliance in long-term psychodynamic psychotherapy

Information on how the patient's interpersonal problems predict alliance development during long-term therapy is lacking. The aim of this study was to explore how the patient's pre-treatment interpersonal problems predict the development of alliance in long-term psychotherapy. Altogether 128 adult outpatients experiencing mood or anxiety disorder were assigned to long-term psychodynamic psychotherapy in the Helsinki Psychotherapy Study. The Inventory of Interpersonal Problems (IIP) total score and the eight octant scores, assessed at baseline, were used as predictors. The trajectories of change in patient- and therapist-rated Working Alliance Inventory (WAI) were used as outcome measures at 7, 12, and 36 months of follow-up after baseline. Study of the changes by time showed that the patient-rated alliance was significantly improved by the 36-month follow-up, i.e. the most usual end-point of therapy, in persons with higher pre-treatment level of the IIP total score. Low total IIP score and low to moderate level of hostile type problems showed no slope of improvement of patient-rated alliance during follow-up. The therapist-rated alliance showed a similar course as the patient-rated alliance with the exception of a faster improvement for higher IIP scores. In conclusion, a higher level of patients' interpersonal problems predicted favorable alliance development.

Psychotherapy Outcome Research: Issues and Questions

Emphasis on identifying evidence-based therapies (EBTs) has increased markedly. Lists of EBTs are the rationale for recommendations for how psychotherapy provider training programs should be evaluated, professional competence assessed, and licensure and reimbursement policies structured. There are however methodological concerns that limit the external validity of EBTs. Among the most salient is the circularity inherent in randomized control trials (RCTs) of psychotherapy that constrains the manner in which the psychological problems are defined, psychotherapy can be practiced, and change evaluated. RCT studies favor therapies that focus of specific symptoms and can be described in a manual, administered reliably across patients, completed in relatively few sessions, and involve short-term evaluations of outcome. The epistemological assumptions of a natural science approach to psychotherapy research limit how studies are conducted and assessed in ways that that advantage symptom-focused approaches and disadvantage those approaches that seek to bring broad recovery-based changes. Research methods that are not limited to RCTs and include methodology to minimize the effects of "therapist allegiance" are necessary for valid evaluations of therapeutic approaches that seek to facilitate changes that are broader than symptom reduction. Recent proposals to adopt policies that dictate training, credentialing, and reimbursement based on lists of EBTs unduly limit how psychotherapy can be conceptualized and practiced, and are not in the best interests of the profession or of individuals seeking psychotherapy services.

Exploring physiotherapists' personality traits that may influence treatment outcome in patients with chronic diseases: a cohort study

Background

During treatment of patients with Chronic Diseases (CD) the therapist-patient interaction is often intense, and the strategies used during treatment require physiotherapists to assume a coaching role. Uncovering therapist factors that explain inter-therapist variation might provide tools to improve treatment outcome and to train future therapists. The purpose of this study was to explore the so-called ‘therapist-effect’, by looking at the influence of intrinsic therapist factors, specifically personality traits, on treatment outcome in patients with CD.

Methods

A cohort study was performed using data from the NIVEL Primary Care Database (NPCD) in 2011–2012 and an additional questionnaire. Patients with CD (n = 393) treated by Dutch physiotherapists working in outpatient practices (n = 39) were included. Patient and treatment outcome variables were extracted from NPCD. The course of complaint was measured using the Numeric Rating Scale. Therapist variables were measured using a questionnaire consisting of demographics and the Big Five traits: Extraversion, Neuroticism, Agreeableness, Conscientiousness and Openness to experiences. Data were analysed using multilevel linear regression.

Results

Only Neuroticism was found to be significant (Neuroticism F = 0.71, P = 0.01; therapist gender F = 0.72, P = 0.03; life events F = −0.54, P = 0.09; patient gender F = −0.43, P = 0.10; patient age F = 0.01, P = 0.27). Subgroup analyses of 180 patients with Osteoarthritis and 30 therapists showed similar results.

Conclusions

There are indications that patients with CD who are treated by therapists who tend to be calmer, more relaxed, secure and resilient have a greater reduction in severity of complaints compared to patients treated by therapists who show less of these traits. Being a male therapist and having experienced life events influence outcome positively. However, more extensive research is needed to validate the current findings.

Peer Support Workers in Health: A Qualitative Metasynthesis of Their Experiences

OBJECTIVE

Peer support models, where an individual has a specific illness or lifestyle experience and supports others experiencing similar challenges, have frequently been used in different fields of healthcare to successfully engage hard-to-reach groups. Despite recognition of their value, the impact of these roles on the peer has not been systematically assessed. By synthesising the qualitative literature we sought to review such an impact, providing a foundation for designing future clinical peer models.

METHODS

Systematic review and qualitative metasynthesis of studies found in Medline, CINAHL or Scopus documenting peer worker experiences.

RESULTS

1,528 papers were found, with 34 meeting the criteria of this study. Findings were synthesised to reveal core constructs of reframing identity through reciprocal relations and the therapeutic use of self, enhancing responsibility.

CONCLUSIONS

The ability of the Peer Support Worker to actively engage with other marginalised or excluded individuals based on their unique insight into their own experience supports a therapeutic model of care based on appropriately sharing their story. Our findings have key implications for maximising the effectiveness of Peer Support Workers and in contributing their perspective to the development of a therapeutic model of care.

Randomized trial on the effectiveness of long- and short-term psychotherapy on psychosocial functioning and quality of life during a 5-year follow-up

Knowledge is incomplete on whether long-term psychotherapy is more effective than short-term therapy in treating mood and anxiety disorder, when measured by improvements in psychosocial functioning and life quality. In the Helsinki Psychotherapy Study, 326 outpatients with mood or anxiety disorder were randomized to solution-focused therapy (SFT), short-term psychodynamic psychotherapy (SPP), or long-term psychodynamic psychotherapy (LPP), and followed up for 5 years from the start of treatment. The outcome measures comprised 4 questionnaires on psychosocial functioning, assessing global social functioning (Social Adjustment Scale (SAS-SR), sense of coherence (Sense of Coherence Scale (SOC)), perceived competence (Self-Performance Survey), dispositional optimism (Life Orientation Test (LOT)), and 1 questionnaire assessing quality of life (Life Situation Survey (LSS)). Short-term therapies improved psychosocial functioning and quality of life more than LPP during the first year. The only exceptions were LOT and perceived competence, which did not differ between SPP and LPP. Later in the follow-up, SOC and perceived competence showed significantly more improvement in LPP than in the short-term therapy groups. No direct differences between SFT and SPP were noted. Short-term therapy has consistently more short-term effects on psychosocial functioning and quality of life than LPP, whereas LPP has some additional long-term benefits on psychosocial functioning.

Psychotherapists Growing Older: A Study of Senior Practitioners

A sample of 1,102 psychotherapists aged 60 years and older was selected from the multinational database of the Society for Psychotherapy Research Collaborative Research Network. These older therapists were first described in terms of gender, generation, years in practice, civil status, professional background, and theoretical orientation. To compare them on practice-related characteristics with cohorts of younger therapists, the following age-based taxonomy was developed: young adult (21 < 30); prime adult (30 < 45); mature adult (45 < 60); senior adult (60 to 90). Senior adults were further differentiated into young old (60 to 66), mid old (67 to 74), and long old (75 to 90). Comparisons between therapist age groups were made regarding practice setting, quality of therapeutic involvement, current use of supervision and personal therapy, currently experienced professional growth, personal life quality, and perceived aspects of self in close personal relationships. Given a series of positive results favoring senior adults as a group, and even long old compared to young old, it is suggested that these hardy "surviving" therapists typically have succeeded in mastering the developmental tasks of previous phases of professional development.

Investigating the relationship between competence and patient outcome with CBT

Little is understood about the relationship between therapist competence and the outcome of patients treated for common mental health disorders. Understanding the relationship between competence and patient outcome is of fundamental importance to the dissemination and implementation of Cognitive Behavioural Therapy (CBT). The current study extends existing literature by exploring the relationship between CBT competence and patient outcome in routine clinical practice within the framework of the British Government's Improving Access to Psychological Therapies (IAPT) programme. Participants comprised 43 therapists treating 1247 patients over a training period of one year. Results found little support of a general association between CBT competence and patient outcome; however significantly more patients of the most competent therapists demonstrated a reliable improvement in their symptoms of anxiety than would be expected by chance alone, and fewer experienced no reliable change. Conversely, significantly more patients treated by the least competent therapists experienced a reliable deterioration in their symptoms than would be expected. The implications of these results for the dissemination and implementation of CBT are discussed.

The effectiveness of short- and long-term psychotherapy on personality functioning during a 5-year follow-up

BACKGROUND

Only few randomized trials comparing sustained effects of short- and long-term psychotherapies in personality functioning are available. In this study we compared the effects of two short-term therapies and long-term psychodynamic psychotherapy on patients' personality functioning during a 5-year follow-up.

METHODS

Altogether 326 patients of the Helsinki Psychotherapy Study, with anxiety or mood disorder, were randomly assigned to either short-term psychotherapy of about six months (solution-focused therapy (SFT, n=97) or short-term psychodynamic psychotherapy (SPP, n=101)), or to long-term psychodynamic psychotherapy (LPP, n=128), lasting on average three years. Outcomes in personality functioning (i.e., self-concept, defense style, interpersonal problems, and level of personality organization) were assessed five to seven times using, respectively, questionnaires (SASB, DSQ, IIP) and interview (LPO) during the 5-year follow-up from randomization.

RESULTS

Personality functioning improved in all therapy groups. Both short-term therapies fared better than LPP during the first year of follow-up, by faster improvement in self-concept and decrease in immature defense style. SFT also showed more early reduction of interpersonal problems. However, LPP thereafter showed larger and more sustained benefits than SFT and SPP, through greater changes in self-concept. Additionally, LPP outperformed SFT at the end of the follow-up in IIP and LPO, after adjustment for auxiliary treatment. No differences were noted between the short-term therapies at any measurement point.

LIMITATIONS

Auxiliary treatment was used relatively widely which limits generalization to exclusive use of short- or long-term therapy.

CONCLUSIONS

LPP seems to be somewhat more effective than short-term therapies in facilitating longterm changes in personality functioning.

Factors related to psychotherapists' self-assessment when treating anxiety and other disorders

The aim of the study was to replicate and extend recent findings regarding therapists' self-assessment biases. This study examined clinicians' estimates of their abilities when working with general clinical groups and with anxious patients, and of the recovery/improvement rates of their clients. It also considered what clinician personality traits and clinical practice elements were associated with such estimates. A total of 195 out 801 clinicians completed a survey regarding self-ratings, team ratings, therapy outcomes for their clients, and their own personality traits. The great majority of clinicians rated themselves and their teams as being better clinicians than their peers, though not to as extreme a level as in the previous study. They also reported exceptionally positive therapy outcomes. Due to the large proportion of non-responders, it is possible that these findings do not reflect actual self-assessment bias, but a greater willingness to participate among clinicians who are more skilled and with particular personality styles. However, the data suggest that perceptions of skill and therapy outcome might be associated with clinician personality characteristics, though not with other clinical practice variables. These interpretations should be treated with caution due to the limited response rate. Different possible explanations for these patterns of self-assessment are outlined, including conscious and unconscious processes. Methods for enhancing accurate skill perception are discussed, including self-monitoring and supervision.

Limitations of Randomized Control Designs in Psychotherapy Research

Despite the growing influence of lists of empirically supported therapies (ESTs) there are concerns about the design and conduct of this body of research. These concerns include limitations inherent in the requirements of randomized control trials (RCTs) that favor those psychotherapies that define problems and outcome in terms of uncomplicated symptoms. Additional concerns have to do with criteria for patient selection, lack of integration with research on psychotherapy process and effectiveness studies, limited outcome criteria, and lack of controls for experimenter bias. RCT designs have an important place in outcome research; however it is important to recognize that these designs also place restrictions on what and how psychotherapy can be studied. There is a need for large scale psychotherapy outcome research based on designs that allow for inclusion of process variables and the study of the effects of those idiographic approaches to therapy that do not lend themselves to RCT designs. Interpretative phenomenological analysis may provide a useful method for the evaluation of the effectiveness of idiographic approaches to psychotherapy where outcome is not understood solely in terms of symptom reduction.

The Development of a Measure of Confidence in Delivering Therapy to People with Intellectual Disabilities

Current policy in UK health services emphasizes that, where possible, people with intellectual disabilities should access the same services as people without intellectual disabilities. One of the barriers to this is the confidence of clinicians and therapists. In this paper, we report on the development of a scale to describe the confidence of therapists in working with people with intellectual disabilities (the Therapy Confidence Scale-Intellectual Disabilities [TCS-ID]). One-hundred and eighty-one therapists who provided talking therapies but who did not work primarily with people with intellectual disabilities completed the scale; 43 people completed the scale twice for test-retest reliability purposes. One-hundred and seven people also completed a scale of general therapy self-efficacy. The TCS-ID has a single factor structure accounting for 62% of the variance, Cronbach's alpha for the scale is 0.93 and test-retest reliability is 0.83. There are significant differences in confidence based upon participants experience in working with people with intellectual disabilities and their therapeutic orientation, and there is a significant association between the TCS-ID and the General Therapy Self-efficacy Scale. Sixty clinicians working in mainstream mental health services received training on adapting their therapeutic approaches to meet the needs of people with intellectual disabilities. The TCS-ID was used pre-training and post-training and demonstrated a significant increase in confidence for all group. We suggest that the scale has good psychometric properties and can be used to develop an understanding of the impact of training for mainstream therapist in working with people with intellectual disabilities.

KEY PRACTITIONER MESSAGE

There is increasing emphasis on people with intellectual disabilities receiving services from mainstream mental health services. There is no research describing the experiences and outcomes of people with intellectual disabilities receiving mainstream talking therapy services. The confidence that clinicians have in working with people with intellectual disabilities may be a barrier to them receiving mainstream services. The Therapy Confidence Scale-Intellectual Disabilities is a psychometrically sound scale for measuring the confidence of therapists in working with people with intellectual disabilities and is a useful outcome measure for training clinicians to work with people with intellectual disabilities.

Social support as a predictor of the outcome of depressive and anxiety disorder in short-term and long-term psychotherapy

Social support is known to be important for well-being of individuals, but it is not clear how it predicts psychotherapy outcome in patients suffering from depressive or anxiety disorders. The aim of the present study was to study the prediction of social support on the outcome of short-term and long-term psychotherapy. In the Helsinki Psychotherapy Study, 326 psychiatric outpatients, aged 20-46 years, and suffering from depressive or anxiety disorders, were randomly assigned to short-term psychotherapy (short-term psychodynamic or solution-focused) or long-term psychodynamic psychotherapy. The level of social support at baseline was assessed using the Brief Inventory of Social Support and Integration (BISSI). Psychiatric symptoms were assessed with the Symptom Check List, Global Severity Index (SCL-90-GSI) at baseline and four times during a 3-year follow-up. Patients with a high level of social support before treatment benefitted more from long-term than short-term therapy at the 3-year follow-up, whereas patients with a low level of social support experienced no such benefit. Pretreatment social support seems to predict differentially short- and long-term psychotherapy and thus needs to be acknowledged when evaluating patient's resources and treatment options. More research is needed to verify these findings.

Self-concept and quality of object relations as predictors of outcome in short- and long-term psychotherapy

BACKGROUND

Quality of object relations and self-concept reflect clinically relevant aspects of personality functioning, but their prediction as suitability factors for psychotherapies of different lengths has not been compared. This study compared their prediction on psychiatric symptoms and work ability in short- and long-term psychotherapy.

METHODS

Altogether 326 patients, 20-46 years of age, with mood and/or anxiety disorder, were randomized to short-term (solution-focused or short-term psychodynamic) psychotherapy and long-term psychodynamic psychotherapy. The Quality of Object Relations Scale (QORS) and the Structural Analysis of Social Behavior (SASB) self-concept questionnaire were measured at baseline, and their prediction on outcome during the 3-year follow-up was assessed by the Symptom Check List Global Severity Index and the Anxiety Scale, the Beck Depression Inventory and by the Work Ability Index, Social Adjustment Scale work subscale and the Perceived Psychological Functioning scale.

RESULTS

Negative self-concept strongly and self-controlling characteristics modestly predicted better 3-year outcomes in long-term therapy, after faster early gains in short-term therapy. Patients with a more positive or self-emancipating self-concept, or more mature object relations, experienced more extensive benefits after long-term psychotherapy.

LIMITATIONS

The importance of length vs. long-term therapy technique on the differences found is not known.

CONCLUSIONS

Patients with mild to moderate personality pathology, indicated by poor self-concept, seem to benefit more from long-term than short-term psychotherapy, in reducing risk of depression. Long-term therapy may also be indicated for patients with relatively good psychological functioning. More research is needed on the relative importance of these characteristics in comparison with other patient-related factors.

Resistance to treatment and change in anorexia nervosa [corrected]: a clinical overview

BACKGROUND

Current literature on Eating Disorders (EDs) is devoid of evidence-based findings providing support to effective treatments, mostly for anorexia nervosa (AN). This lack of successful guidelines may play a role in making these disorders even more resistant. In fact, many individuals do not respond to the available treatments and develop an enduring and disabling illness. With this overview we aimed to highlight and discuss treatment resistance in AN--with an in-depth investigation of resistance-related psychological factors.A literature search was conducted on PubMed and PsychINFO; English-language articles published between 1990 and 2013 investigating the phenomenon of resistance to treatment in AN have been considered.

DISCUSSION

The selected papers have been then grouped into four main thematic areas: denial of illness; motivation to change; maintaining factors and treatment outcome; and therapeutic relationship. Eating symptomatology was found to only partially explain resistance to treatment. The role of duration of illness has been questioned whilst some maintaining factors seemed promising in providing a useful framework for this phenomenon. Emotive and relational aspects have been investigated on their role in resistance as well as therapists' countertransference.

SUMMARY

Remarkably there has been little research done on resistance to treatment in the ED field, in spite of its clinical relevance. Motivation, insight and subjective meaning of the illness can be useful tools to manage the resistance phenomenon when coupled with a wider approach. The latter enables the therapists to be aware of their role in the therapeutic alliance through countertransference aspects and to consider the EDs as disorders of the development of both personality and self, entailing severe impairments as regards identity and relationships.

Therapists' professional and personal characteristics as predictors of outcome in long-term psychodynamic psychotherapy and psychoanalysis

BACKGROUND

Whether long-term psychodynamic therapy (LPP) and psychoanalysis (PA) differ from each other and require different therapist qualities has been debated extensively, but rarely investigated empirically.

METHODS

In a quasi-experimental design, LPP was provided for 128 and PA for 41 outpatients, aged 20-46 years and suffering from mood or anxiety disorder, with a 5-year follow-up from start of treatment. Therapies were provided by 58 experienced therapists. Therapist characteristics, measured pre-treatment, were assessed with the Development of Psychotherapists Common Core Questionnaire (DPCCQ). General psychiatric symptoms were assessed as the main outcome measure at baseline and yearly after start of treatment with the Symptom Check List, Global Severity Index (SCL-90-GSI).

RESULTS

Professionally less affirming and personally more forceful and less aloof therapists predicted less symptoms in PA than in LPP at the end of the follow-up. A faster symptom reduction in LPP was predicted by a more moderate relational style and work experiences of both skillfulness and difficulties, indicating differences between PA and LPP in the therapy process.

CONCLUSIONS

Results challenge the benefit of a classically "neutral" psychoanalyst in PA. They also indicate closer examinations of therapy processes within and between the two treatments, which may benefit training and supervision of therapists.

Psychological predictors of the recovery from mood or anxiety disorder in short-term and long-term psychotherapy during a 3-year follow-up

Choice of optimal treatment length for psychiatric patients requires knowledge about the patients' pre-treatment suitability. This study compares the prediction of seven psychological suitability measures on changes in psychiatric symptoms in short- and long-term psychotherapy over a 3-year follow-up. The psychological suitability of 326 outpatients from the Helsinki Psychotherapy Study, aged 20-46 years, and suffering from mood or anxiety disorders, was assessed at baseline using the Suitability for Psychotherapy Scale (SPS) before randomly assigning them to solution-focused therapy, short-term or long-term psychodynamic psychotherapy. Psychiatric symptoms (Symptom Checklist-90 Global Severity Index) were assessed at baseline and seven times during follow-up. Three patient groups with different prognosis were found when a cumulative SPS score, summing up the values of the seven single suitability measures, was used to predict symptom development: patients with more good (4 or more) than poor values benefited more from short-term therapy, patients with more poor (4-6) than good values benefited more from long-term therapy, and patients with all seven values poor failed to benefit from either short- or long-term therapy. The SPS can apparently be applied before the start of treatment to predict the amount of therapy patients need to recover, although its suitability in therapies of different types needs to be confirmed.

Psychotherapists' personal identities, theoretical orientations, and professional relationships: elective affinity and role adjustment as modes of congruence

Research shows psychotherapists espousing different theoretical approaches differ in mentality (e.g., cognitive styles, beliefs and epistemologies) and personality (e.g., neuroticism). However, studies have not investigated the association between professional relational style prescribed by therapists' theoretical orientations and therapists' manner of relating in personal life. Analyses of over 4000 therapists of varied nationalities, professions and career levels having different theoretical preferences indicate: (i) therapists' self-experience in close personal relationships was significantly associated with the manner their theoretical orientations prescribed for relating with clients; (ii) therapists were less accepting, less tolerant and more demanding in their personal relationships than with clients; and (iii) therapists adjusted their professional relational manner in practice to meet the specific expectations of their preferred orientations.