Clinical factors and early life experiences associated with therapeutic alliance development in treatment for depression or binge eating

OBJECTIVE

This study examines childhood and clinical factors theorized to impact therapeutic alliance development over the course of psychotherapy.

METHOD

Raters assessed the therapeutic alliance of 212 client-therapist dyads, participating in two randomized controlled trials of schema therapy and cognitive behavioural therapy for binge eating or major depression, at three time points. Linear mixed models were used to characterize therapeutic alliance development over time and assess the influence of childhood trauma, perceived parental bonding, diagnosis and therapy type on scores.

RESULTS

Participants differed in initial alliance ratings for all subscales but had similar growth trajectories in all but the patient hostility subscale. A diagnosis of bulimia nervosa or binge eating disorder predicted greater initial levels of client distress, client dependency and overall client contribution to a strong therapeutic alliance, compared with a diagnosis of depression. Therapy type, childhood trauma and perceived parental bonds did not predict alliance scores.

CONCLUSION

Findings highlight the potential influence of clinical and personal characteristics on alliance strength and development, with implications for maximizing treatment outcomes through anticipating and responding to these challenges.

Trajectories of depression in psychotherapy: How client characteristics predict clinical improvement

OBJECTIVE

The current study aims to ascertain the trajectories of psychotherapy clients' symptom change and identify client factors that predict treatment outcome.

METHOD

We conducted a latent growth mixture model (LGMM) to identify the change trajectories of 44 clients' depression scores during psychotherapy. Client characteristics were then explored to determine whether any were associated with change trajectories. We examined whether the number of physician visits and/or client self-concealment scores predict 63 clients' improvement after controlling for initial symptom severity.

RESULTS

Two trajectories of clients' symptom change were identified: nonimprovers (52.3%) and improvers (47.7%). Nonimprovers had higher levels of self-concealment and baseline depression than improvers. The number of physician visits was associated with higher depression scores at baseline and greater clinical improvement during psychotherapy.

CONCLUSION

Clients showed distinct trajectories of symptom change in psychotherapy. Early identification of clients at risk for treatment failure may increase the probability of therapeutic success.

How much therapy is enough? The dose-response effect and its moderators in a psychology training clinic

OBJECTIVE

The current study aims to sharpen the understanding of the psychotherapy dose-response effect and its moderators in a psychology training clinic.

METHOD

Data were extracted from 58 client records. Weekly Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7, as well as Outcomes Questionnaire-45.2, administered every fifth session, assessed whether clients achieved reliable change (RC) and clinically significant and reliable change (CSR) during treatment. Survival analyses were conducted to determine the sessions required for 50% of the sample to achieve these outcomes. Multilevel Cox frailty regressions were used to investigate client-and-therapy-based moderators.

RESULTS

The median time for 50% of the sample to achieve RC was 8-10 sessions and 11 sessions to achieve initial CSR. Past treatment history was a significant moderator of time to achieve RC.

CONCLUSIONS

From a population perspective, psychotherapy is most beneficial to patients early in treatment. Sharper understanding of the number of sessions required to achieve meaningful change can inform practice in training settings.

Insight into conflictual relationship patterns: Development and validation of an observer rating scale

Objective: This study aimed to develop an observer-rated measure of Insight into Conflictual Relationship Patterns (ICR) applicable to audio- or videotapes of psychotherapy sessions and conduct a first psychometric evaluation. Method: We investigated the item properties, principal components, reliability, and validity of the ICR in a naturalistic sample of N = 125 outpatients in psychodynamic psychotherapy. Results: The ICR consists of 12 items that showed adequate item discrimination and item difficulty indices. All items represent one principal component. Using item response theory, discrimination parameters and item characteristic curves revealed that the ability of all items to differentiate patients was adequate to very good. The scale demonstrated good interrater reliability (ICC(3,1) = .76-.93), adequate internal consistency (Cronbach's α = .84), and high retest reliability (r = .91). Regarding validity, the ICR was significantly associated with insight according to the Achievement of Therapeutic Objectives Scale and patient-perceived session depth. Insight at session five predicted a symptomatic increase from session five to session ten. Conclusion: The ICR is an observer-rated measure to assess insight from psychotherapy session recordings that has demonstrated several aspects of reliability and validity. Future studies are needed to clarify the impact of ICR-assessed insight for symptomatic outcome.

Does feedback improve psychotherapy outcomes compared to treatment-as-usual for adults and youth?

Objective: Client-informed outcome feedback has consistently been shown to enhance psychotherapy outcomes for adults, particularly for clients at risk of treatment failure. However, there is a paucity of studies examining feedback in youth psychotherapy. Specifically, there is no research examining the feedback effect of the Youth-Outcome Questionnaire [Burlingame, G. M., Wells, M. G., & Lambert, M. J. (1996). The youth outcome questionnaire. Stevenson, MD: American Professional Credentialing Services.], despite the dominance of the adult version of the measure (Outcome Questionnaire-45 [Lambert, M. J., & Burlingame, G. M. (1996). Outcome questionnaire 45.2. Wilmington, DE: American Professional Credentialing Services.]) in adult feedback studies. Method: The effectiveness results for adult (N = 398) and youth clients (N = 397) attending psychotherapy at two psychology training clinics are presented and benchmarked against treatment-as-usual (for adults and youth) and feedback (for adults). Results: Psychotherapy with a feedback-informed approach was more effective than treatment-as-usual benchmarks, with 50% of adults and 64% of youth significantly improving after psychotherapy. Rates of adult improvement were similar to feedback-informed benchmarks, although the current sample had a higher rate of deterioration. There are no previously identified feedback-informed benchmarks for the Y-OQ, making this sample the first benchmark for future studies. Conclusions: Results support the benefits of feedback at enhancing psychotherapy outcomes for adults, and replicate this finding in a youth sample. Results also replicate that trainee psychotherapists can be as effective as licenced psychotherapists.

The dose-response effect in routinely delivered psychological therapies: A systematic review

The dose-response effect refers to the relationship between the dose (e.g., length, frequency) of treatment and the subsequent probability of improvement. This systematic review aimed to synthesize the literature on the dose-response effect in routine psychological therapies delivered to adult patients with mental health problems. Twenty-six studies were eligible for inclusion. Different methodological approaches have been used to examine the dose-response effect; including survival analysis, multilevel modelling and descriptive cluster analyses. Replicated and consistent support was found for a curvilinear (log-linear or cubic) relationship between treatment length and outcomes, with few exceptions such as eating disorders and severe psychiatric populations. Optimal doses of psychotherapy in routine settings range between 4 and 26 sessions (4-6 for low intensity guided self-help) and vary according to setting, clinical population and outcome measures. Weekly therapy appears to accelerate the rate of improvement compared to less frequent schedules. Most of the reviewed evidence is from university counselling centres and outpatient psychotherapy clinics for common mental health problems. There is scarce and inconclusive evidence in clinical samples with chronic and severe mental disorders.

Therapist-Specific Factors and Psychotherapy Outcomes of Adult and Youth Clients Seen in a Psychology Training Clinic

The current study investigated therapist demographic and level of experience in relation to psychotherapy outcomes for adult and child clients. The OQ-45 and Y-OQ 2.01 were used to assess outcomes for 199 adults and 169 youth clients seen for psychotherapy by graduate-level student therapists. Analyses included calculation of Pearson correlation coefficients for each therapist-specific factors (e.g., therapist age, sex) and total score change amount on the OQ-45/Y-OQ 2.01 by treatment outcome subgroup (e.g., clinically significant change, reliable improvement, no change, or deterioration). For adults, a statistically significant relationship was found between improved outcomes and therapist having previously obtained clinical master's degree (r = 0.276, p < .05) as well as female therapist gender (r = -0.295, p < .05). For youth, no statistically significant correlations were observed. Current findings are compared to nontraining settings and implications for student therapist training and training clinic policy are reviewed.

Impact of Self-Help Schema Therapy on Psychological Distress and Early Maladaptive Schemas: A Randomised Controlled Trial

Self-help cognitive behaviour therapy has been found helpful in treating anxiety and depression. Recent evidence suggests that self-help schema therapy may represent another treatment alternative. The present study aimed to provide a preliminary assessment of the efficacy of self-help schema therapy on psychological distress and early maladaptive schemas (EMSs) using a 6-week treatment protocol with minimal email contact. Method: Participants were recruited from the general population and randomly assigned to self-help schema therapy (n = 32) or a waitlist (n = 32). Intent-to-treat analyses and study completer analyses were conducted using repeated-measures analyses of variance (time × group). Results: Intent-to-treat analyses revealed that treatment produced a marginal improvement in distress, but no change in EMSs. Among study completers (n = 34), self-help schema therapy yielded large reductions in distress scores on the Outcome Questionnaire-45.2 (partial eta squared = .16). Compared to the waitlist, self-help schema therapy also produced a moderate decrease in EMSs (partial eta squared = .10). The majority of study completers showed reliable clinical change in distress and reported high levels of satisfaction with the intervention. Conclusion: Self-help schema therapy may be an effective treatment for those individuals who persist in treatment. Self-help schema therapy has the potential to help a large number of individuals who may not otherwise have access to services. More research is needed to determine variables associated with treatment adherence and successful outcome.

Baseline training in cognitive and psychodynamic psychotherapy during a psychologist training program. Exploring client outcomes in therapies of one or two semesters

This effectiveness study explored the outcomes of 187 clients seen by 187 students undergoing baseline training in psychotherapy. Clients reduced their symptoms (SCL-90) and increased their positive self-image (SASB introject) during the therapy. Multiple regression analyses showed no differences between the cognitive and the psychodynamic training approaches and no differences between one and two semesters duration of the therapies. However, 2-3% of variance in end states was accounted for by the interaction between the variables, indicating a moderating effect of duration in the two approaches. Outcomes for clients in the cognitive training approach were significantly better with two semesters than with one semester, while there was no such difference in the psychodynamic approach. Consequences for baseline training are discussed.

Can the Clinician–Researcher Gap be Bridged? Experiences from a Randomized Clinical Trial in Analytic/Dynamic Group Psychotherapy

This article describes how four seasoned clinicians and group analysts working in public mental health services, experience their participation in a randomized trial of short-term versus long-term analytic group psychotherapy (20 or 80 sessions). The design makes it possible to integrate the research with regular clinical practice, and participation gives the institutions the opportunity to fulfil obligations of doing research, that are imposed on the Community Mental Health Centres. The experiences are mainly described from the clinicians’ position, but some comments from the research director are included. The collaboration across approximately five years is found to be interesting and rewarding. Based on the assumption that further steps are made to strengthen and develop the qualitative aspects of such projects, the clinicians recommend such collaboration as a feasible and useful way to build and maintain a bridge across the gap that too often seems to separate researchers and clinicians. This is assumed to be profitable for everyone involved, not least the patients.