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Fuhr K, Werle D, Batra A. How does early symptom change predict subsequent course of depressive symptoms during psychotherapy? Psychol Psychother 2022; 95:137-154. [PMID: 34676660 DOI: 10.1111/papt.12370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 09/28/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Previous studies reported about the influence of early changes on treatment response. However, the question of whether early changes can predict the subsequent course of depressive symptoms during treatment with psychotherapy has not yet been clearly answered. We aimed to investigate whether symptom course in the first weeks at the level of individual session can predict the further symptom progression on a session to session level during psychotherapy treatment in patients with Major Depression (MD). DESIGN Monocentric randomized controlled trial with psychotherapeutic treatment either with cognitive-behavioural therapy (CBT) or hypnotherapy (HT). The longitudinal course of weekly depressive symptoms during the six months treatment period was examined. METHODS In this RCT with 152 randomized patients suffering from current mild-to-moderate MD, depressive symptoms were assessed on a weekly basis during the 20 sessions' treatment with individual psychotherapy. We only included patients for which sufficient data for our analysis were available. Three different linear and quadratic mixed model analyses with random effects for each patient were tested: Early change was defined as the individual percentage symptom change during the first two, three, four and five weeks. Symptoms from session four, five, six and seven onward were predicted using different models, with early change added to the model in a final step. Calculating all models separately for CBT and HT lead to comparable results. RESULT A slow symptom decrease after session four, five, six, seven onward to the end of the treatment was found. However, adding early change to the model, had no effect on the further symptom course in all models. CONCLUSION Symptom changes at early stages of psychotherapy should not be considered as being predictive for further symptom course. PRACTITIONER POINTS The individual early symptom change in a treatment with psychotherapy in the first two, three, four, or five weeks of treatment does not predict the subsequent symptom course from session four, five, six, or seven onward at a session to session level. Symptom changes at early stages of psychotherapy should not be considered as being predictive for further symptom course. We found a symptom reduction ranging from 3% to 16% in the first two, three, four, or five weeks. Treatment response between the first and last therapy session was found in 54.5%, the number of remitted patients (with PHQ-9 scores < 5) was 44.7%. A small symptom improvement of between 0.21 and 0.42 points in the PHQ-9 scores per week in later stages of psychotherapy is likely in all patients (with and without early symptom improvement).
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Affiliation(s)
- Kristina Fuhr
- Department of Psychiatry and Psychotherapy, University Hospital of Tuebingen, Germany
| | - Dustin Werle
- Clinical Psychology and Psychotherapy, Department of Psychology, University of Tuebingen, Germany
| | - Anil Batra
- Department of Psychiatry and Psychotherapy, University Hospital of Tuebingen, Germany
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Rozen N, Aderka IM. The effect of depression on treatment outcome in social anxiety disorder: an individual-level meta-analysis. Cogn Behav Ther 2021; 51:185-216. [PMID: 34617874 DOI: 10.1080/16506073.2021.1966089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Social anxiety disorder (SAD) is highly comorbid with depression. In the present meta-analysis, we conducted the first individual-level examination of the association between pre-treatment depression and improvement in social anxiety symptoms during treatment. We identified eligible studies on cognitive behavior therapy (CBT) and pharmacotherapy for SAD and contacted authors to obtain individual-level data. We obtained these data from 41 studies, including 46 treatment conditions (n = 4,381). Our results showed that individuals who had high levels of depression at pre-treatment experienced greater decreases in social anxiety symptoms from pre- to post-treatment, but not at follow-up. When analyzing treatment modalities (individual CBT, group CBT, internet-delivered CBT, and pharmacotherapy), we found that depressive symptoms were associated with better post-treatment outcomes for individual CBT and internet-delivered CBT, but not for pharmacotherapy or group CBT. Our findings suggest that depression does not negatively affect treatment outcome in SAD and may even lead to improved outcomes in some treatment formats. Clinical implications of these findings are discussed.
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Affiliation(s)
- Naama Rozen
- School of Psychological Sciences, University of Haifa, Haifa, Israel
| | - Idan M Aderka
- School of Psychological Sciences, University of Haifa, Haifa, Israel
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3
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Meng Y, Li H, Wang J, Xu Y, Wang B. Cognitive behavioral therapy for patients with mild to moderate depression: Treatment effects and neural mechanisms. J Psychiatr Res 2021; 136:288-295. [PMID: 33631654 DOI: 10.1016/j.jpsychires.2021.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 01/29/2021] [Accepted: 02/08/2021] [Indexed: 11/18/2022]
Abstract
In this study, we combined clinical assessment and magnetic resonance imaging (MRI) techniques to investigate the brain mechanisms in mild to moderate depression (MMD) patients following cognitive behavioral therapy (CBT). Data were collected from 30 MMD patients and 18 healthy controls, and we divided patients into two treatment periods (4 weeks, 8 weeks). Clinical assessment indicated that depression characteristics, as quantified by Hamilton Depression Rating Scale (HAMD), were significantly higher in MMD patients than in healthy controls. At the baseline, MRI data revealed abnormalities in the hippocampus and nucleus accumbens (NAc) of patients with MMD, e.g., smaller gray matter volumes of the hippocampus and nucleus accumbens (NAc), as well as weaker functional connectivity between NAc and the posterior cingulate cortex/precuneus. Moreover, the hippocampus and NAc volumes were negatively correlated with the HAMD scores in MMD patients. After CBT intervention, the HAMD scores decreased, and the structural and functional characteristics of NAc in MMD patients obtained at 8-week were improved; e.g., no significant differences in NAc volume or NAc-based functional connectivity between the two groups. Taken together, our results provided evidence suggesting that CBT is an effective treatment for MMD patients. Alterations of gray matter volume and resting-state functional connectivity after 8 weeks of CBT indicated a potential modulation mechanism in brain structural modifications and functional connectivity plasticity within the NAc in MMD patients.
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Affiliation(s)
- Yanjun Meng
- Nursing College, Shanxi Medical University, Taiyuan, China; Nursing College, Shanxi University of Chinese Medicine, Taiyuan, China
| | - Hong Li
- CAS Key Laboratory of Behavioral Science, Institute of Psychology, Beijing, China; Department of Psychology, University of Chinese Academy of Sciences, Beijing, China; Department of Psychiatry, First Hospital/First Clinical Medical College of Shanxi Medical University, Taiyuan, China
| | - Junjie Wang
- Department of Psychiatry, First Hospital/First Clinical Medical College of Shanxi Medical University, Taiyuan, China
| | - Yong Xu
- Department of Psychiatry, First Hospital/First Clinical Medical College of Shanxi Medical University, Taiyuan, China
| | - Binquan Wang
- Nursing College, Shanxi Medical University, Taiyuan, China; Department of Otolaryngology, Head and Neck Surgery, First Hospital of Shanxi Medical University, Taiyuan, China.
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Rozen N, Aderka IM. Do depressive symptoms affect the outcome of treatments for SAD? A meta analysis of randomized controlled trials. Clin Psychol Rev 2020; 80:101874. [PMID: 32653699 DOI: 10.1016/j.cpr.2020.101874] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/17/2020] [Accepted: 05/30/2020] [Indexed: 01/05/2023]
Abstract
Individuals with social anxiety disorder (SAD) typically have elevated depressive symptoms. In the present meta-analysis, we reviewed the treatment outcome literature in SAD and examined whether depressive symptoms predict treatment outcome. We focused on randomized controlled trials of cognitive behavior therapy (individual face-to-face, group format, and internet-delivered format) and randomized controlled trials of pharmacotherapy. After implementing exclusion criteria, 108 studies with 133 treatment conditions (n = 12,913 participants) were included in the meta-analysis. Our findings indicated that treatments for SAD were efficacious and significantly reduced social anxiety symptoms across all treatment modalities. Exclusion of individuals with MDD or high levels of depression did not affect outcome at post-treatment or at follow-up. However, we found that elevated depressive symptoms were associated with greater reductions in social anxiety symptoms from pre-treatment to post-treatment. Importantly, this effect was above and beyond pre-treatment levels of social anxiety. Finally, analyzing treatment modalities separately, we found that depressive symptoms were associated with better post-treatment outcomes in individual face-to-face CBT but not in other modalities. Clinical and research implications of these findings are discussed.
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Affiliation(s)
- Naama Rozen
- School of Psychological Sciences, University of Haifa, Israel
| | - Idan M Aderka
- School of Psychological Sciences, University of Haifa, Israel.
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5
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Shalom JG, Aderka IM. A meta-analysis of sudden gains in psychotherapy: Outcome and moderators. Clin Psychol Rev 2020; 76:101827. [PMID: 32036232 DOI: 10.1016/j.cpr.2020.101827] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 01/27/2020] [Accepted: 01/30/2020] [Indexed: 10/25/2022]
Abstract
Sudden gains have been shown to be a common phenomenon and an important predictor of outcome in psychotherapy (Tang & DeRubeis, 1999). The present meta-analysis examined the growing literature on sudden gains in psychotherapy, their effects on outcome, and moderators of these effects. We searched PsycINFO, PubMed, ProQuest Dissertations & Theses, Scholar and Web of Science databases for articles between January 1st 1999 and May 31st 2019 and included 50 studies (n = 6355) in the meta-analysis. Sudden gains were found to significantly predict outcome at post-treatment (g = 0.68) and follow up (g = 0.61) above and beyond treatments, disorders and settings. Studies using Tang and DeRubies's (1999) criteria for identification of sudden gains had smaller effect sizes compared to studies using altered criteria. Pretreatment severity levels did not significantly predict the effects of sudden gains and neither did treatment setting (randomized controlled trials vs. naturalistic settings). Finally, number of sessions and sudden gains' reversal rates were both negatively associated with the effect sizes of sudden gains. These findings suggest that sudden gains are a ubiquitous phenomenon in psychotherapy but their effects may be moderated by a number of factors. Research and clinical implications are discussed.
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Affiliation(s)
- Jonathan G Shalom
- Department of Psychology, University of Haifa, Mount Carmel, Haifa 3498838, Israel
| | - Idan M Aderka
- Department of Psychology, University of Haifa, Mount Carmel, Haifa 3498838, Israel.
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Schiller M, Pinus M, Hammen CC, Shahar G. Effects of Psychological Distress and Exposure to Terror-Related Stress on the Self in Emerging Adulthood. Int J Cogn Ther 2019. [DOI: 10.1007/s41811-019-00053-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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7
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Beard JIL, Delgadillo J. Early response to psychological therapy as a predictor of depression and anxiety treatment outcomes: A systematic review and meta-analysis. Depress Anxiety 2019; 36:866-878. [PMID: 31233263 DOI: 10.1002/da.22931] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 05/10/2019] [Accepted: 05/25/2019] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Previous studies indicate that early symptomatic improvement, typically observed during the first 4 weeks of psychological therapy, is associated with positive treatment outcomes for a range of mental health problems. However, the replicability, statistical significance, and magnitude of this association remain unclear. AIM The current study reviewed the literature on early response to psychological interventions for adults with depression and anxiety symptoms. METHODS A systematic review and random effects meta-analysis were conducted, including studies found in Medline, PsychINFO, SCOPUS, Web of Science, and through reference lists and reverse citations. RESULTS Twenty-five eligible studies including 11,091 patients measured early response and examined associations with posttreatment outcomes. It was possible to extract and/or calculate effect size data from 15 studies to conduct a meta-analysis. A large pooled effect size (g = 0.87 [95% confidence interval: 0.63-1.10], p < .0001) indicated that early responders had significantly better posttreatment outcomes compared to cases without early response, and this effect was larger in anxiety (g = 1.37) compared to depression (g = 0.76) measures. Most studies were of good quality and there was no evidence of publication bias. The main limitations concerned insufficient statistical reporting in some studies, which precluded their inclusion in meta-analysis, and it was not possible to examine effect sizes according to different outcome questionnaires. CONCLUSION There is robust and replicated evidence that early response to therapy is a reliable prognostic indicator for depression and anxiety treatment outcomes.
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Affiliation(s)
- Jessica I L Beard
- Department of Psychology, University of Sheffield, Sheffield, United Kingdom
| | - Jaime Delgadillo
- Clinical Psychology Unit, Department of Psychology, University of Sheffield, Sheffield, United Kingdom
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Zang Y, Su YJ, McLean CP, Foa EB. Predictors for Excellent Versus Partial Response to Prolonged Exposure Therapy: Who Needs Additional Sessions? J Trauma Stress 2019; 32:577-585. [PMID: 31265187 DOI: 10.1002/jts.22412] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 01/20/2019] [Accepted: 01/30/2019] [Indexed: 11/09/2022]
Abstract
In practice, the duration of psychotherapy is determined by the patient's response to treatment. Identifying predictors for treatment responses is of great clinical utility to guide clinicians in their treatment planning. Demographic characteristics, trauma history, comorbidity, and early reduction of posttraumatic stress disorder (PTSD) symptoms were examined as predictors of excellent versus partial response to prolonged exposure therapy (PE) for PTSD. Participants were 96 female assault survivors with chronic PTSD who received at least eight PE sessions with or without cognitive restructuring. Participants were classified as excellent responders (n = 27) or partial responders (n = 69) based on whether they achieved at least 70% improvement in self-reported PTSD severity on the PTSD Symptom Scale-Self-Report at the end of Session 8. Excellent responders terminated therapy after Session 9, and partial responders were offered up to three additional sessions. Logistic regression was conducted to investigate predictors of response to PE. Results showed that prior interpersonal violence and comorbid alcohol use disorder were associated with partial response. Comorbid depressive disorder and early PTSD symptom reduction were associated with excellent response. Being treated by a cognitive behavioral therapy expert predicted higher excellent response for patients with a history of prior interpersonal violence. The model accounted for 56.6% of the variance in treatment response and correctly predicted responder status for 83.3% of the sample. These findings contribute to the field's understanding of factors that predict or moderate response to PE and have implications for treatment planning.
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Affiliation(s)
- Yinyin Zang
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yi-Jen Su
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Graduate Institute of Behavioral Sciences, Chang Gung University, Taoyuan, Taiwan, ROC.,Department of Psychiatry, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
| | - Carmen P McLean
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Edna B Foa
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Shahar G. The (Suicidal-) Depressive Position: A Scientifically Informed Reformulation. Psychodyn Psychiatry 2018; 46:265-293. [PMID: 29809115 DOI: 10.1521/pdps.2018.46.2.265] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Despite considerable progress in depression research and treatment, the disorder continues to pose daunting challenges to scientists and practitioners alike. This article presents a novel conceptualization of the psychological dynamics of depression which draws from Melanie Klein's notion of the positions, reformulated using social-cognitive terms. Specifically, Klein's notion of position, consisting of anxieties (persecutory vs. "depressive"), defense mechanisms ("primitive"/split based vs. neurotic/repression based), and object relations (part vs. whole) is reformulated to include (1) affect, broadly defined, (2) affect regulatory strategies (defense mechanisms, coping strategies, and motivation regulation), and (3) mental representations of self-with-others, all pertaining to the past, present, and future. I reformulate the depressive position to include-beyond sadness, anxiety, and anhedonia-also anger/agitation, shame, disgust, and contempt, all of which are down-regulated via diverse mechanisms. In the depressive position, the self is experienced as wronged and others as punitive, albeit seductive. Attempts to appease internal others (objects) are projected into the future, only to be thwarted by awkward and inept interpersonal behavior. This might propel the use of counter-phobic, counter-dependent, and "manic" affect regulatory mechanisms, potentially leading to suicidal depression.
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Affiliation(s)
- Golan Shahar
- The Stress, Self, and Health Lab (STREALTH), Department of Psychology, Ben-Gurion University of the Negev, and for the Israeli Psychodynamic Research Group (IPRG)
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McCarthy KL, Caputi P, Grenyer BFS. Significant change events in psychodynamic psychotherapy: Is cognition or emotion more important? Psychol Psychother 2017; 90:377-388. [PMID: 28261907 DOI: 10.1111/papt.12116] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 11/30/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Significant change events are helpful moments within a psychotherapy session that have been shown in previous research to relate strongly to outcome. They are special moments and therefore provide rich data for research into understanding therapeutic process. This study investigated clinical and linguistic features of these helpful moments using and comparing both human ratings and computerized text analysis strategies. METHOD Significant change events versus non-event passages were studied within 1195 word blocks of transcribed psychotherapy for 20 participants with diagnoses of comorbid depression and personality disorder. Significant events were determined manually by independent raters using the Helpful Aspects of Therapy (HAT) form linked to the Helpful Aspects of Experiential Therapy Content Analysis System (HAETCAS). Mergenthaler's Therapeutic Cycles Model (TCM)-computerized text analysis, identified significant events via linguistic markers. The Linguistic Inquiry and Word Count (LIWC) differentiated emotional and cognitive components. RESULTS Significant events included statements reflecting emotional and cognitive awareness and insight, and moments of alliance strengthening. These events were saturated with both positive and negative emotion words, particularly anger and sadness, and more cognitive insight words. CONCLUSIONS Significant moments of psychotherapeutic movement featured high therapeutic alliance. There was evidence of the integration or working through of positive and negative emotional content with cognitive insight - meaning both emotion and cognition were important in these interchanges. PRACTITIONER POINTS This study found that significant events in therapy were characterized by high levels of both emotional and cognitive language, and alliance strengthening. Linguistic analysis methods provide important data on psychotherapeutic processes which can be useful in guiding clinicians and improving treatment outcomes.
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Affiliation(s)
- Kye L McCarthy
- School of Psychology and Illawarra Health and Medical Research Institute, University of Wollongong, NSW, Australia
| | - Peter Caputi
- School of Psychology and Illawarra Health and Medical Research Institute, University of Wollongong, NSW, Australia
| | - Brin F S Grenyer
- School of Psychology and Illawarra Health and Medical Research Institute, University of Wollongong, NSW, Australia
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Collimore KC, Rector NA. Treatment of Anxiety Disorders With Comorbid Depression: A Survey of Expert CBT Clinicians. COGNITIVE AND BEHAVIORAL PRACTICE 2014. [DOI: 10.1016/j.cbpra.2014.01.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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McCarthy KL, Mergenthaler E, Grenyer BFS. Early in-session cognitive-emotional problem-solving predicts 12-month outcomes in depression with personality disorder. Psychother Res 2013; 24:103-15. [DOI: 10.1080/10503307.2013.826834] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Mergenthaler E. Resonating minds: a school-independent theoretical conception and its empirical application to psychotherapeutic processes. Psychother Res 2009; 18:109-26. [PMID: 18815969 DOI: 10.1080/10503300701883741] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
The resonating minds theory will be introduced as a means to describe psychotherapeutic processes and change. It builds on the mind-brain interface with psychotherapeutic interventions causing change in the brain, an altered brain causes changes in the emotional, cognitive, and behavioral regulation, and this again will change the types of subsequent therapeutic interventions. For the empirical assessment of this theory the therapeutic cycles model will be used. It is based on computer assisted analysis of verbatim transcripts using emotional tone, abstraction and narrative style as language measures. Sample applications and studies are shortly presented in order to provide evidence for the applicability and face validity of this approach.
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Barber JP. Issues and findings in investigating predictors of psychotherapy outcome: Introduction to the special section. Psychother Res 2007. [DOI: 10.1080/10503300601175545] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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