The therapeutic alliance in different mental disorders: A comparison of patients with depression, somatoform, and eating disorders

A Novel Blended Transdiagnostic Intervention (eOrygen) for Youth Psychosis and Borderline Personality Disorder: Uncontrolled Single-Group Pilot Study

BACKGROUND

Integrating innovative digital mental health interventions within specialist services is a promising strategy to address the shortcomings of both face-to-face and web-based mental health services. However, despite young people's preferences and calls for integration of these services, current mental health services rarely offer blended models of care.

OBJECTIVE

This pilot study tested an integrated digital and face-to-face transdiagnostic intervention (eOrygen) as a blended model of care for youth psychosis and borderline personality disorder. The primary aim was to evaluate the feasibility, acceptability, and safety of eOrygen. The secondary aim was to assess pre-post changes in key clinical and psychosocial outcomes. An exploratory aim was to explore the barriers and facilitators identified by young people and clinicians in implementing a blended model of care into practice.

METHODS

A total of 33 young people (aged 15-25 years) and 18 clinicians were recruited over 4 months from two youth mental health services in Melbourne, Victoria, Australia: (1) the Early Psychosis Prevention and Intervention Centre, an early intervention service for first-episode psychosis; and (2) the Helping Young People Early Clinic, an early intervention service for borderline personality disorder. The feasibility, acceptability, and safety of eOrygen were evaluated via an uncontrolled single-group study. Repeated measures 2-tailed t tests assessed changes in clinical and psychosocial outcomes between before and after the intervention (3 months). Eight semistructured qualitative interviews were conducted with the young people, and 3 focus groups, attended by 15 (83%) of the 18 clinicians, were conducted after the intervention.

RESULTS

eOrygen was found to be feasible, acceptable, and safe. Feasibility was established owing to a low refusal rate of 25% (15/59) and by exceeding our goal of young people recruited to the study per clinician. Acceptability was established because 93% (22/24) of the young people reported that they would recommend eOrygen to others, and safety was established because no adverse events or unlawful entries were recorded and there were no worsening of clinical and social outcome measures. Interviews with the young people identified facilitators to engagement such as peer support and personalized therapy content, as well as barriers such as low motivation, social anxiety, and privacy concerns. The clinician focus groups identified evidence-based content as an implementation facilitator, whereas a lack of familiarity with the platform was identified as a barrier owing to clinicians' competing priorities, such as concerns related to risk and handling acute presentations, as well as the challenge of being understaffed.

CONCLUSIONS

eOrygen as a blended transdiagnostic intervention has the potential to increase therapeutic continuity, engagement, alliance, and intensity. Future research will need to establish the effectiveness of blended models of care for young people with complex mental health conditions and determine how to optimize the implementation of such models into specialized services.

Therapeutic alliance with psychotherapist versus dietician: a pilot study of eating disorder treatment in a multidisciplinary team during the COVID-19 pandemic

Little is known about the therapeutic alliance (TA) formed with different professionals in multidisciplinary eating disorder (ED) treatment, particularly in the context of online treatment during the COVID-19 pandemic. We aimed to conduct a pilot study during the COVID-19 pandemic examining characteristics of patients' TA with their dieticians and psychotherapists, associations between patients' and therapists' views of the TA, and relationships between psychological characteristics and TAs. Sixty-three patients with EDs and their treating psychotherapists and dieticians were surveyed during the COVID-19 pandemic using the Working Alliance Inventory (WAI-S). Spearman correlation tests were used to examine associations between variables. Positive associations were found between the TAs examined. Concordance was stronger in patient-dietician dyads than in patient-psychotherapist dyads. Severe ED psychopathology was associated with weaker TA (bond subscale). General psychopathology was associated with weaker TA with the dietician (task subscale). Given that several differences were found between the TAs of treatment dyads, further longitudinal studies are needed to validate our pilot findings and to investigate multidisciplinary TAs and their impact on treatment outcomes in online ED treatment settings during the COVID-19 pandemic, as well as in other treatment settings (e.g., in-person settings). This study will contribute to a deeper understanding of the dynamics of TAs in multidisciplinary ED treatment and inform the development of more effective interventions.

A Retrospective Chart Review Suggests That Coordinated, Multidisciplinary Treatment for Patients with Anorexia Nervosa Improves Odds of Weight Restoration

Purpose

The objective of this study was to conduct a secondary data analysis of clinical information documented in the electronic medical record to assess the clinical outcomes of patients who received three different treatment approaches on clinical outcomes for treatment of patients with anorexia nervosa (AN).

Patients and methods

Historical electronic medical record (EMR) data on patients aged 6 to 80 years diagnosed with AN seen in a healthcare system between 2007 and 2017 were stratified, according to services received, into three groups: Group A (n = 48) received hospital-based services; Group B (n = 290) saw one or two provider types; Group C (n = 26) received outpatient coordinated multidisciplinary care from three provider types. Clinical outcomes [body mass index for adults (BMI), body mass index percentile (BMI%ile) for pediatric patients] defined AN severity and weight restoration. EMR data were analyzed using a generalized mixed-effects model and a Markov Transition model to examine the odds of weight restoration and the change in odds of weight restoration across the number of provider visits, respectively.

Results

Patients receiving coordinated multidisciplinary care had significantly higher odds of weight restoration compared with patients receiving hospital-based services only (OR = 3.76, 95% CI [1.04, 13.54], p = 0.042). In addition, patients receiving care from 1 to 2 providers (OR = 1.006, 95% CI [1.003, 1.010], p = 0.001) or receiving coordinated multidisciplinary care (OR = 1.005, 95% CI [1.001, 1.011], p = 0.021) had significantly higher odds of weight restoration per provider visit day compared with patients receiving hospital-based services only.

Conclusion

This retrospective chart review supports the coordinated, multidisciplinary care model for the weight restoration in patients with AN in an outpatient setting.

Conceptualizing the digital therapeutic alliance in the context of fully automated mental health apps: A thematic analysis

Fully automated mental health apps provide a promising opportunity for increasing access to mental health care and resources. Given this opportunity, continued research into the utility and effectiveness of mental health apps is crucial. Therapeutic alliance (TA) refers to the relationship between a client and a healthcare professional, and has been shown to be an important predictor of clinical outcomes in face-to-face therapy. Given the significance of TA in traditional therapy, it is important to explore whether the notion of a digital therapeutic alliance (DTA) in the context of fully automated mental health apps also plays an important role in clinical outcomes. Current evidence shows that the conceptualization of DTA in the context of fully automated mental health apps can be potentially different to TA in face-to-face therapy. Thus, a new DTA conceptual model is necessary for comprehensively understanding the mechanisms underpinning DTA for fully automated mental health apps. To the best of our knowledge, this is the first study that qualitatively explored the dimensions of a DTA in the context of fully automated mental health apps. We conducted interviews with 20 users of mental health apps to explore the key dimensions comprising DTA in the context of fully automated mental health apps. We found that although conceptualizations of DTA and TA have shared dimensions, flexibility and emotional experiences are unique domains in DTA. On the other hand, although agreement on goals between a therapist and a client is important in face to face therapy, we found that users can have an alliance with an app without a goal. The importance of goal needs further investigations.

Patient perspectives on premature termination of eating disorder treatment: a systematic review and qualitative synthesis

BACKGROUND

High rates of premature treatment termination are a well-reported issue in eating disorder treatment, and present a significant barrier for treatment effectiveness and longer term health outcomes of patients with eating disorders. Understanding patient perspectives on this phenomenon is essential in improving treatment completion rates and informing research and intervention development. The aim of this review is to synthesise qualitative literature on patient perspectives of premature termination of eating disorder treatment and to summarise the key issues leading to discontinuation of treatment.

METHODS

A systematic review of 1222 articles was conducted to identify studies using qualitative methods to investigate patient experiences of prematurely terminating eating disorder treatment. Ten articles were included in the review, with thematic synthesis used to analyse the primary research and develop overarching analytical themes.

RESULTS

Conflict around enmeshment of eating disorder with identity, and lack of support with reconstructing a sense of self without the eating disorder; challenges of managing pressures of social and clinical relationships while feeling unheard and misunderstood by both; expectations and disappointments around treatment; and dissatisfaction with progress were key themes behind premature termination of treatment.

CONCLUSIONS

The findings of this review demonstrate the key issues influencing the decision to end treatment early, highlighting the contribution of individual, environmental, and service-level factors. Implications of these factors are discussed and suggestions raised for future research and service development.

Digital Therapeutic Alliance With Fully Automated Mental Health Smartphone Apps: A Narrative Review

Fully automated mental health smartphone apps show strong promise in increasing access to psychological support. Therefore, it is crucial to understand how to make these apps effective. The therapeutic alliance (TA), or the relationship between healthcare professionals and clients, is considered fundamental to successful treatment outcomes in face-to-face therapy. Thus, understanding the TA in the context of fully automated apps would bring us insights into building effective smartphone apps which engage users. However, the concept of a digital therapeutic alliance (DTA) in the context of fully automated mental health smartphone apps is nascent and under-researched, and only a handful of studies have been published in this area. In particular, no published review paper examined the DTA in the context of fully automated apps. The objective of this review was to integrate the extant literature to identify research gaps and future directions in the investigation of DTA in relation to fully automated mental health smartphone apps. Our findings suggest that the DTA in relation to fully automated smartphone apps needs to be conceptualized differently to traditional face-to-face TA. First, the role of bond in the context of fully automated apps is unclear. Second, human components of face-to-face TA, such as empathy, are hard to achieve in the digital context. Third, some users may perceive apps as more non-judgmental and flexible, which may further influence DTA formation. Subdisciplines of computer science, such as affective computing and positive computing, and some human-computer interaction (HCI) theories, such as those of persuasive technology and human-app attachment, can potentially help to foster a sense of empathy, build tasks and goals and develop bond or an attachment between users and apps, which may further contribute to DTA formation in fully automated smartphone apps. Whilst the review produced a relatively limited quantity of literature, this reflects the novelty of the topic and the need for further research.

Work-directed rehabilitation or physical activity to support work ability and mental health in common mental disorders: a pilot randomized controlled trial

Objective:

To evaluate feasibility and potential effectiveness of work-directed rehabilitation in people with common mental disorders.

Design:

Pilot randomized controlled trial.

Setting:

Primary healthcare, Sweden.

Subjects:

Working adults ( n = 42) of mean age 46.2 ± 11.1 years with depression or anxiety disorder.

Interventions:

Eight weeks of work-directed rehabilitation ( n = 21) or physical activity ( n = 21). Work-directed rehabilitation included sessions with a physiotherapist and/or an occupational therapist, to develop strategies to cope better at work. Physical activity included a planning session and access to a local gym.

Main measures:

Feasibility: attendance, discontinuation and adverse events. Measurements were the Work Ability Index, the Global Assessment of Functioning, the Montgomery–Asberg Depression Rating Scale, the Beck Anxiety Inventory and the World Health Organization—Five Well-Being Index.

Results:

Attendance to rehabilitation sessions was 88% ( n = 147/167) and discontinuation rate was 14% ( n = 3/21). No serious adverse events were reported. Within both groups, there was a significant improvement in Work Ability Index score (mean change: 3.6 (95% confidence interval (CI): 0.45, 6.7) in work-directed rehabilitation and 3.9 (95% CI: 0.9, 7.0) in physical activity) with no significant difference between groups. For the other outcomes, significant improvements were found within but not between groups. Per-protocol analysis showed a trend toward the antidepressant effect of work-directed rehabilitation compared to physical activity (mean difference in depression score −3.1 (95% CI: −6.8, 0.4), P = 0.075).

Conclusion:

Work-directed rehabilitation was feasible to persons with common mental disorders and improved their work ability and mental health. Comparable improvements were seen in the physical activity group. Suggested modifications for a larger trial include adding a treatment-as-usual control.

Therapeutic alliance in inpatients with severe anorexia nervosa

OBJECTIVE

Therapeutic alliance (TA) is a relevant aspect in anorexia nervosa (AN), but data on inpatients are lacking. We aimed to evaluate the influence of motivation to change, diagnostic subtypes, and duration of illness on TA at hospital discharge; we also investigated if baseline clinical characteristics were associated with discharge TA, and the TA-outcome association.

METHOD

We enrolled 137 adult inpatients with AN completing Eating Disorder Examination-Questionnaire, Beck Depression Inventory, State-Trait Anxiety Inventory, Anorexia Nervosa Stages of Change-Questionnaire, EuroQoL-Quality of Life Scale-Visual Analogue Scale, and Working Alliance Inventory-Short Revised.

RESULTS

Patients with different AN subtypes and duration of illness reported similar TA. Baseline depression, state anxiety, and motivation to change were statistically significantly associated with TA at discharge. After controlling for all these variables and duration of illness, only motivation to change remained statistically significant. Statistically significant correlations were also found between improvements in body mass index and quality of life and discharge TA.

CONCLUSIONS

Few data exist on TA in inpatients with AN and a long duration of illness. Our findings suggest that baseline motivation to change correlates with TA at discharge independently of other variables. Future studies should ascertain as to whether a causal link exists or not.

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

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

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

OBJECTIVE

There is scarce research on the effects of mindfulness in individual therapy. As many practitioners integrate mindfulness exercises into individual therapy, empirical evidence is of high clinical relevance.

METHOD

We investigated the effects of a session-introducing intervention with mindfulness elements (SIIME) in a randomized, controlled design. The effects of SIIME on therapeutic alliance and symptomatic outcome were compared with progressive muscle relaxation (PMR) and treatment-as-usual (TAU) control conditions. The sample comprised 162 patients with anxiety and depression.

RESULTS

Multilevel modeling revealed a significant symptom reduction and significant increase of alliance over the course of therapy. There were no significant time-condition interactions on outcome and alliance, indicating the comparable efficiency of all three treatment conditions.

CONCLUSIONS

We found no advantage of SIIME versus PMR and TAU. Add-on mindfulness might not improve individual therapy related to alliance and outcome.

Spezifische Techniken in kognitiv-verhaltenstherapeutischen Ausbildungstherapien

Zusammenfassung. Theoretischer Hintergrund: Zur Frage, was Psychotherapie wirksam macht, wurde in den letzten Jahren viel hinsichtlich Wirkfaktoren und Techniken geforscht. Allerdings besteht weiterhin eine Forschungslücke in der Untersuchung konkreter kognitiv-verhaltenstherapeutischer Interventionen in der Psychotherapieausbildung. Fragestellung: Ziel war die Validierung des Heidelberger Inventars Kognitiv-Behavioraler Interventionen (HIKBI), welches diesbezüglich Facetten zentraler Interventionen aus Sicht von Ausbildungstherapeut_innen erfasst. Methode: In 589 ambulanten Ausbildungstherapien wurden das HIKBI und etablierte Prozess- und Outcome-Fragebögen ausgefüllt. Ergebnisse: Es ergab sich beim HIKBI eine eindeutige Faktorenstruktur, die Subskalen wiesen eingeschränkt akzeptable bis gute Reliabilitäten (.59 ≤ α ≤ .82) auf. Hinweise für die konvergente Validität lagen durch signifikante Zusammenhänge mit allgemeinen Wirkfaktoren vor. Jedoch zeigten sich keine statistisch signifikanten Zusammenhänge mit symptomatischen Outcomes. Schlussfolgerung: Mit dem HIKBI liegt ein psychometrisch akzeptables Messinstrument zur Erfassung spezifischer KVT-Techniken in der verhaltenstherapeutischen Ausbildung vor.