Vanishing academics: On the importance of speed and becoming-imperceptible

Under the influence of neoliberalism, academic work faces mounting pressure to align with imperatives of visibility and perceptibility. Traditionally criticised for working in isolated 'ivory towers', academics are now compelled to showcase the societal value of their work through performance metrics and evaluations. Paradoxically, these efforts have unintentionally led to the rigidification and commodification of academic work, stifling the production of knowledge beyond predefined parameters. In this paper, we contend that academics should resist the imposition of this neoliberal 'grid' and instead seek a path of 'becoming-imperceptible', drawing inspiration from the insights of Deleuze and Guattari. Becoming-imperceptible does not entail silent disengagement; rather, it represents a creative form of resistance challenging prevailing modes of assessment rooted in visibility and perceptibility. By incorporating the concept of 'fast feminism' to subvert Paul Virilio's hypermasculine speed theory, we uncover the transformative potential of temporary absences. Leveraging these moments of absence, academics can intensify their affective connections with both their peers and their work, making them undiscernible to the confines of the academic establishment. We argue that these instances of imperceptibility create fertile ground for creative and inventive academic endeavours on the margins of established boundaries, where original scholarship can flourish. Such a subversive approach is particularly relevant in fields like nursing and the health sciences, where it can challenge the dominant discourses that typify neoliberal academia.

"You can't really have a relationship with them because they just ask you questions": understanding adolescent dropout - an empirical single case study

Introduction

High dropout rates are common in youth psychotherapy, including psychoanalytic psychotherapy, yet the reasons behind this trend remain obscure. A critical focus to enhance adolescent engagement could be the therapeutic alliance, particularly in resolving alliance ruptures. This study sought to clarify the complex relationships between the therapeutic alliance, encompassing alliance ruptures and resolutions, and dropout within the context of poor outcome. It investigated a single case of an adolescent with depression who dropped-out of Short-Term Psychoanalytic Psychotherapy, without showing clinical improvement.

Method

Data was garnered from diverse sources, including questionnaires, interviews, and session recordings, and analyzed through a mixed-method longitudinal framework. This encompassed views from the adolescent, therapist, parents, and external evaluators.

Results

The study identifies several factors impacting the decision to drop out, including initial profound distrust toward the therapist, a complex and difficult therapeutic relationship characterized by unresolved alliance ruptures, and sporadic attendance. External factors including minimal parental engagement with therapy were also seen as detrimental to the adolescent's involvement and progress.

Discussion

The research underscores the challenges in engaging adolescents, especially when there may be distrust of professionals, and in the absence of parental involvement with treatment.

Approaches to Engaging Men During Primary Healthcare Encounters: A scoping review

Gender-responsive healthcare is critical to advancing men's health given that masculinities intersect with other social determinants to impact help-seeking, engagement with primary healthcare, and patient outcomes. A scoping review was undertaken with the aim to synthesize gender-responsive approaches used by healthcare providers (HCPs) to engage men with primary healthcare. MEDLINE, PubMed, CINAHL, and PsycINFO databases were searched for articles published between 2000 and February 2024. Titles and abstracts for 15,659 citations were reviewed, and 97 articles met the inclusion criteria. Data were extracted and analyzed thematically. Thirty-three approaches were synthesized from across counseling/psychology, general practice, social work, nursing, psychiatry, pharmacy, and unspecified primary healthcare settings. These were organized into three interrelated themes: (a) tailoring communication to reach men; (b) purposefully structuring treatment to meet men's health needs, and (c) centering the therapeutic alliance to retain men in care. Strength-based and asset-building approaches focused on reading and responding to a diversity of masculinities was reinforced across the three findings. While these approaches are recommended for the judicious integration into health practitioner education and practice, this review highlighted that the evidence remains underdeveloped, particularly for men who experience health inequities. Critical priorities for further research include intersectional considerations and operationalizing gender-responsive healthcare approaches for men and its outcomes, particularly at first point-of-contact encounters.

Skill Use Mediates the Within-Person Effect of the Alliance on Session-to-Session Changes in Anxiety and Depression in the Unified Protocol

Objective

Both the therapeutic alliance and the specific skills taught in treatment are thought to contribute to change in cognitive-behavior therapy (CBT), but it is unclear if or how these processes influence each other and outcomes in treatment. We tested the hypothesis that the degree to which patients used CBT skills would mediate the relation between the alliance and session-to-session changes in anxiety and depression.

Method

Adult participants (N = 70; Mage = 33.74, 67% female, 70% White) with emotional disorders were randomized to receive 6 or 12 sessions of the Unified Protocol. Before each session, participants reported anxiety and depression severity and past-week skillfulness. After each session, participants rated the strength of the alliance. We tested whether greater within-person skillfulness mediated the relation between within-person alliance strength and session-to-session changes in anxiety and depression.

Results

Skillfulness significantly mediated the effect of the alliance on session-to-session changes in anxiety, ab = -.02, p = .04, and depression, ab = -.02, p = .02, such that a stronger alliance predicted greater next-session skillfulness, which predicted session-to-session decreases in anxiety and depression. When alliance subscales were examined separately, the strongest effect was observed for agreement on therapy tasks.

Conclusions

Improvements in the alliance may facilitate skill use and indirectly predict reductions in anxiety and depression through skill use in CBT. We encourage research on how to enhance both the alliance and skillfulness in CBT.

supportive-expressive treatment

OBJECTIVE

The available literature points to the potential therapeutic benefits of alliance strengthening during treatment. Both supportive and expressive techniques have been suggested to be associated with strengthening of the alliance. The present study investigates whether patients may show different effects of supportive vs. expressive techniques in improving alliance as a function of their pretreatment insight levels.

METHOD

Fifty-five patients were randomly assigned to either supportive treatment (ST) or supportive-expressive treatment (SET), as part of a larger randomized controlled trial. Clinical interviews were administered at pretreatment to evaluate the patients' level of insight. The working alliance was measured after each of the 16 sessions. A multilevel model, including a 3-way interaction of pretreatment insight by treatment condition (ST vs. SET) by time, was used to predict alliance strengthening.

RESULTS

The findings suggest that, for individuals receiving ST, those with higher levels of insight show greater alliance strengthening. For individuals receiving SET, those with lower levels of insight show greater alliance strengthening.

CONCLUSION

The current study suggests that one size may not fit all and, whereas some individuals may benefit more from ST to achieve alliance strengthening, others may benefit more from SET.

Integrating exploration and prediction in computational psychotherapy science: proof of concept

Introduction

Psychotherapy research has long preferred explanatory over predictive models. As a result, psychotherapy research is currently limited in the variability that can be accounted for in the process and outcome of treatment. The present study is a proof-of-concept approach to psychotherapy science that uses a datadriven approach to achieve robust predictions of the process and outcome of treatment.

Methods

A trial including 65 therapeutic dyads was designed to enable an adequate level of variability in therapist characteristics, overcoming the common problem of restricted range. A mixed-model, data-driven approach with cross-validation machine learning algorithms was used to predict treatment outcome and alliance (within- and between-clients; client- and therapist-rated alliance).

Results and discussion

Based on baseline predictors only, the models explained 52.8% of the variance for out-of-sample prediction in treatment outcome, and 24.1-52.8% in therapeutic alliance. The identified predictors were consistent with previous findings and point to directions for future investigation. Although limited by its sample size, this study serves as proof of the great potential of the presented approach to produce robust predictions regarding the process and outcome of treatment, offering a potential solution to problems such as p-hacking and lack of replicability. Findings should be replicated using larger samples and distinct populations and settings.

Therapeutic alliance in two forms of guided self-help for binge eating

The role of therapeutic alliance within psychological treatments for eating disorders (EDs), including those delivered remotely, is well established. However, few studies have investigated alliance in guided self-help, a widely recommended first-line treatment for EDs characterised by regular binge eating. Using data from a randomised controlled trial, the current study examined both facilitator and patient assessments of alliance within e-mail-assisted and face-to-face guided self-help and looked at associations between alliance, ED symptoms and ED-related impairment. One hundred thirteen patients and 11 facilitators completed measures of alliance during and following a course of guided self-help. Whilst ratings were reliable across patients and facilitators, alliance scores were higher both in the patient sample and in the face-to-face condition. Ratings of alliance showed no correlations with ED symptoms at post-treatment, and early alliance was not significantly associated with outcome, which could inform how early symptom change is encouraged in guided self-help.

Temporal sequencing of change in trauma-related beliefs and therapeutic alliance during prolonged exposure and sertraline for chronic PTSD

OBJECTIVE

Changes in trauma-related beliefs and therapeutic alliance have been found to temporally precede symptom reduction; however, it is likely these processes do not act in isolation but rather in interactive ways.

METHODS

The present study examined the temporal relationships between negative posttraumatic cognitions (PTCI) and therapeutic alliance (WAI) in 142 patients who were part of a randomized trial comparing prolonged exposure (PE) to sertraline for chronic PTSD.

RESULTS

Using time-lagged mixed regression models, improvements in the therapeutic alliance predicted subsequent improvements in trauma-related beliefs (d = 0.59), an effect accounted for by between-patient variability (d = 0.64) compared to within-patient variability (d = .04) giving weaker support to the causal role of alliance on outcome. Belief change did not predict improvements in alliance and neither model was moderated by treatment type.

CONCLUSION

Findings suggest alliance may not be an independent driver of cognition change and point to the need for additional study of the impact of patient characteristics on treatment processes.

Agreement in patient-therapist alliance ratings and its relation to dropout and outcome in a large sample of cognitive behavioral therapy for panic disorder

Objective: The therapeutic alliance is related to treatment outcome but less is known about the agreement on alliance between patients and therapists and its relationship to outcomes. We examined the association of patient-therapist congruence of alliance perceptions, early and late in cognitive behavioral therapy for panic disorder in relation to symptom reduction and dropout. Method: Patients (n = 181) and their therapists provided alliance ratings early and late during 11-session treatment. Independent evaluators rated patients' symptomatic levels post-treatment. Polynomial regression and response surface analysis were used to examine congruence as a predictor of outcome. Results: Early in therapy, stronger combined patient-therapist alliances, regardless of agreement, predicted lower symptom severity at the end of therapy and a lower likelihood of dropout. Late in treatment, the outcome was worse when therapist ratings of the alliance were higher than those of the patient. Conclusions: Therapist-patient agreement on the strength of the alliance is important for symptom improvement and dropout. The study highlights the importance of understanding the dyadic nature of the alliance and its impact on therapeutic change.

Session-to-session bidirectional associations of alliance with depressive symptoms and relationship satisfaction

The relationship between therapeutic alliance and treatment outcomes is one of the most widely studied topics in psychotherapy research. Research has primarily considered a unidirectional model whereby alliance predicts outcomes, which implies that building alliance early in therapy results in later symptom improvement and ignores the possibility that early symptom improvement could also subsequently lead to improved alliance. This study explored the bidirectional associations of alliance and outcomes session-to-session for 15 sessions among a sample of 24 couples randomized to emotionally focused therapy or treatment as usual for depression and relationship dissatisfaction. Multilevel models tested associations between the prior week's alliance and the following week's clinical outcomes (i.e., depressive symptoms and relationship satisfaction) and the prior week's clinical outcomes with the following week's alliance. Findings indicated that the prior week's alliance was associated with the following week's relationship satisfaction, but not depressive symptoms, when controlling for the prior week's depressive symptoms and relationship satisfaction in each respective model. In addition, the prior week's depressive symptoms and relationship satisfaction were both associated with the following week's alliance, when controlling for the prior week's alliance. Only one of these associations differed by sex: previous week's higher relationship satisfaction was associated with higher therapeutic alliance the following week for males than females. These bidirectional associations did not differ by treatment condition. This study contributes to the emerging empirical support suggesting bidirectionality among alliance and treatment outcomes.

Between- and within-person effects of affective experiences on coping in CBT: Direct effects and interplay with therapeutic alliance and resource activation

OBJECTIVE

The role of affective experiences (AE) in cognitive-behavioral therapy (CBT) has rarely been investigated. We examined between- and within-person effects of AE on coping in CBT for family caregivers and interactions with therapeutic alliance and resource activation.

METHODS

67 family caregivers rated AE, therapeutic alliance, resource activation, and coping after each of 12 sessions of telephone-based CBT. We examined direct session-to-session effects of AE on coping in structural equation modeling and interactions of AE with therapeutic alliance and resource activation in multilevel models.

RESULTS

AE did not directly predict coping. Instead, within-person effects of AE interacted with simultaneous within-person emotional bond. Given strong emotional bond, AE positively predicted coping, whereas given weak emotional bond, AE negatively predicted coping. Further, cross-level interactions of between-person AE and within-person agreement on collaboration and resource activation indicated that these positively predicted coping only in dyads with high between-person AE.

CONCLUSION

AE may enhance coping when complemented with strong emotional bond. Further, within-person effects of agreement on collaboration and resource activation seem to rely on a certain degree of between-person AE. Results are discussed in relation to current findings on emotional processing in CBT.

Patient perspectives on working with preferences in psychotherapy: A consensual qualitative research study

OBJECTIVE

Assessing and accommodating patient preferences is integral to evidence-based practice. This qualitative study sought to explore patient perspectives and experiences of preference work in psychotherapy.

METHODS

Participants were 13 UK-based patients who had completed up to 24 sessions of a collaborative-integrative psychotherapy. Ten participants identified as female and three as male. Interviews were conducted at endpoint and analyzed using a team-based, consensual qualitative research approach.

RESULTS

Three superordinate domains were developed: Preferences Themselves, Process of Working with Preferences in Psychotherapy, and Effect of Preference Work (or its Absence). Patients typically wanted leadership, challenge, and input from their psychotherapist, and an affirming style. Patients attributed the origin of their preferences to personal history, characteristics, or circumstances; the present psychotherapy; or past episodes of psychotherapy. Some preferences changed over time. Preference work was described as having positive effects on the therapeutic relationship and patients' intrapersonal worlds; however, variantly, non-accommodation of preferences was also experienced as beneficial.

CONCLUSION

Our findings provide in-depth answers to a range of novel questions on preference work-potential mechanisms by which preference work impacts outcomes, factors that may facilitate preference work, and origins of preferences-as well as nuancing previously-established quantitative findings. Implications for clinical training and practice are discussed.

Psychotherapy process research: Identifying productive in-session processes to enhance treatment outcomes and therapist responsiveness

This paper provides an overview of my research programme for the past 37 years. The focus of my work has been on identifying productive in-session processes to enhance treatment outcomes and therapist responsiveness. Two foci will be reviewed, first, my research on client and therapist interpersonal process and second, productive processing in psychotherapy in three different therapeutic approaches including EFT, CBT and CCT. Given that many competing theoretical perspectives are effective, I was curious about change processes that are common and unique to each. In my work, I employed a variety of research methodologies drawing on frameworks with alternative epistemological and ontological assumptions to capture specific in-session change processes in an attempt to reveal the richness and complexity of the phenomena being studied and illuminate the process of change.

How therapists respond to "uneven" alliances in couple and family therapy: A conversation-analytic study

This article examines how family and couple therapists respond to uneven alliances with their clients at the micro-level of therapeutic exchanges in the context of Interpersonal Process Recall (IPR) interviews. We operationalize uneven alliance with the interactional concept of asymmetry of affiliation. To this end, first, using conversation analysis (CA), we identify episodes of asymmetry of affiliation in the moment-by-moment conversation between the therapist and the client in therapy consultation. Second, applying CA to the IPR interview data, we examine how therapists orient to the episodes of the session in which the asymmetry of affiliation was identified. The findings demonstrate therapists' two key practices of orienting to the episodes of asymmetry of affiliation: (1) therapists' exclusive identification with one participant by typically invoking gender roles and (2) therapists' investigation of their agency in the emergence of asymmetry.

Client-counselor behavioral and inter-brain synchronization among dismissing and secure clients and its association with alliance quality and outcome

Objective This study aimed to explore whether behavioral synchrony (BS) and inter-brain synchrony (IBS) could serve as potential biomarkers for alliance quality or outcomes among clients with different adult attachment styles. Method: We assessed the clients' self-report working alliance and clinical outcomes as well as simultaneously measured BS using motion energy analysis (MEA) and IBS with functional near-infrared spectroscopy (fNIRS) among 37 secure (N = 21) or dismissing (N = 16) clients with their counselors during the first psychological counseling meeting. Results: Dismissing dyads manifested significantly higher late-stage counselor-led and client-led IBS (p = .018) than secure dyads. Adult attachment style served as the moderators in the correlation of both whole-stage client-led BS with bond dimension of alliance (p = .015) as well as in the correlation of both whole-stage no-lag IBS with CORE-10 score changes (p = .022). Moreover, increases in the whole-stage client-led BS were significantly associated with decreases in early-stage, late-stage and whole-stage no-lag IBS (all ps ≤ 0.01). Conclusion: These findings revealed the potentially impeding role of interpersonal synchrony in alliance quality for dismissing clients, at least during the first psychological counseling meetings. They also might partially validate the relationship between different modalities of interpersonal synchrony.

Therapist's warmth and competence increased positive outcome expectations and alliance in an analogue experiment

Objective: The quality of the therapeutic alliance, treatment motivation, outcome expectations (OE), and specific health behaviour predicts psychotherapy success. Therapists should be able to improve these factors to optimize outcomes. This study investigated the therapist's interpersonal behaviour to optimize alliance, motivation, OE, and health behaviour. Method: A stressed study sample (N = 465) completed an online analogue experiment. We gave participants positive information about psychotherapy effectiveness and varied the therapist's interpersonal behaviour along the dimensions of warmth and competence.Results: High (vs. low) competence and high (vs. low) warmth increased alliance, OE, and help-seeking scores, while high (vs. low) competence increased motivation to do psychotherapy. We found no effects on health behaviour.Conclusion: In contrast to previous correlational analyses, our experimental study supports the causal role of the therapist's warmth and competence and its impact on alliance, motivation, and OE. We discuss approaches for future studies and clinical implications.

Examining Predictors of Depression and Anxiety Symptom Change in Cognitive Behavioral Immersion: Observational Study

BACKGROUND

Depressive and anxiety disorders are the most common mental disorders, and there is a critical need for effective, affordable, and accessible interventions. Cognitive Behavioral Immersion (CBI) is a novel group-based cognitive behavioral skills training program delivered by lay coaches in the metaverse that can be accessed through various modalities including virtual reality (VR) head-mounted displays or flat-screen devices. Combining its ability to offer empirically supported therapy skills in a digital setting that can still facilitate interpersonal variables (eg, working alliance and sense of social support) with the aid of lay coaches, CBI has the potential to help fill this critical need.

OBJECTIVE

This study had 2 primary aims. First, we aimed to examine changes in depression and anxiety symptoms in a sample of individuals who participated in CBI. Second, we aimed to examine 2 interpersonal process variables (working alliance and web-based social support) as predictors of symptom changes. We predicted CBI participants would experience depression and anxiety symptom improvements and that such improvements would be associated with an increase in both interpersonal process variables.

METHODS

The study sample consists of 127 participants who endorsed clinical levels of depression or anxiety symptoms during their first CBI session and attended at least 2 sessions. Participants were asked to complete self-report measures of depression symptoms, anxiety symptoms, alliance, and web-based social support throughout their participation in CBI.

RESULTS

Repeated measures ANOVAs determined that depression and anxiety symptom scores differed significantly across sessions (Ps<.01). We also found participants' web-based social support predicted improvement in depression symptoms (P=.01), but neither the alliance nor web-based social support predicted change in anxiety symptoms (Ps>.05). We also observed a significant difference in anxiety symptoms between participants who used a VR head-mounted display to access CBI and those who did not, such that participants who used VR head-mounted displays endorsed lower anxiety symptoms than those who did not at nearly every session (P=.04).

CONCLUSIONS

Participation in CBI is associated with both depression and anxiety symptom improvement. Web-based social support may play an important role in fostering changes in depression symptoms. Future studies are encouraged to continue examining the process of change in CBI with special attention paid to methods that can elucidate causal mechanisms of change.

The real relationship: the Portuguese version of the <em>Real Relationship Inventory-Client</em> form

The Real Relationship is a relational construct that has influenced other constructs, like the working alliance, although empirically neglected. The development of the Real Relationship Inventory provides a reliable and valid way of measuring the Real Relationship in research and clinical applications. This study aimed to validate and explore the psychometric properties of the Real Relationship Inventory Client Form with a Portuguese adult sample in the context of psychotherapy. The sample includes 373 clients currently in psychotherapy or concluded recently. All clients completed the Real Relationship Inventory (RRI-C) and the Working Alliance Inventory. The confirmatory analysis revealed the same two factors in the RRI-C for the Portuguese adult population, Genuineness and Realism. The observation of the same factor structure suggests the cross-cultural value of the Real Relationship. The measure demonstrated good internal consistency and acceptable adjustment. A significant correlation was found between the RRI-C and the Working Alliance Inventory and significant correlations between the Bond and Genuineness and Realism subscales. The present study reflects on the RRI-C while also contributing to the importance of the Real Relationship in different cultures and clinical contexts.

Study Based on the Alliance Between Serum Magnesium Levels and Preterm Labor: An Inclusive Review

Preterm labor, regarded as the onset of labor before 37 weeks of gestation, is a highly prevalent issue in obstetrics with repercussions for neonatal health. This review article presents an in-depth analysis of the alliance between serum magnesium levels and preterm labor. The review explores the physiological roles of magnesium right through pregnancy, including its significance for energy metabolism, smooth muscle contraction, deoxyribonucleic acid (DNA), and protein synthesis. It addresses cellular transport and the homeostasis of magnesium. The pathophysiological processes encompassing inflammation, oxidative stress, calcium regulation, smooth muscle contractility, and neuroendocrine pathways are investigated. The review evaluates epidemiological studies investigating the alliance between serum magnesium levels and preterm labor. The review incorporates an assortment of study varieties, such as observational studies, case-control studies, prospective cohort studies, and meta-analyses. In the course of reviewing the prognostic relevance of serum magnesium levels in premature labor, therapeutic implications involving diagnostic precision, prognostic significance, and therapeutic response assessment have additionally been addressed. Therapeutic interventions targeting magnesium levels, such as magnesium supplementation, tocolytic therapy, and the role of magnesium in antenatal corticosteroid administration, are explored. This review provides an in-depth evaluation of the correlation between serum magnesium levels and preterm labor, stressing its therapeutic significance and repercussions for future research and treatment strategies.

The Pharmacist Prescriber: A Psychological Perspective on Complex Conversations about Medicines: Introducing Relational Prescribing and Open Dialogue in Physical Health

Pharmacists have traditionally supported the prescribing process, arguably in reactive or corrective roles. The advent of pharmacist prescribing in 2004 represented a major shift in practice, leading to greater responsibility for making clinical decisions with and for patients. Prescribing rights require pharmacists to take a more prescriptive role that will allow them to contribute to long-standing prescribing challenges such as poor medication adherence, overprescribing, and the need for shared decision-making and person-centered care. Central to these endeavors are the development and possession of effective consultation skills. University schools of pharmacists in the UK now routinely include consultation skills training, which is also provided by national education bodies. These challenges remain difficult to overcome, even though it is understood, for example, that increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments. More recently, a concerted effort has been made to tackle overprescribing and the harm that may occur through the inappropriate use of medication. In routine pharmacy work, these priorities may linger at the bottom of the list due to the busy and complex nature of the work. Solutions to these problems of adherence, optimizing benefits of medication, and overprescribing have typically been pragmatic and structured. However, an arguably reductionist approach to implementation fails to address the complex patient interactions around prescribing and taking medication, and the heterogeneity of the patient's experience, leaving the answers elusive. We suggest that it is essential to explore how person-centered care is perceived and to emphasize the relational aspects of clinical consultations. The development of routine pharmacist prescribing demands building on the core values of person-centered care and shared decision making by introducing the concepts of "relational prescribing" and "open dialogue" to cultivate an essential pharmacotherapeutic alliance to deliver concrete positive patient outcomes. We provide a vignette of how a clinical case can be approached using principles of relational prescribing and open dialogue. We believe these are solutions that are not additional tasks but must be embedded into pharmacy practice. This will improve professional satisfaction and resilience, and encourage curiosity and creativity, particularly with the advent of all pharmacists in Great Britain becoming prescribers at graduation from 2026.

Forging gender and racial solidarities at trans-inclusive women's festivals

This article explores the interweaving of successes and failures at trans-inclusive women's festivals. I analyze conflicts that occurred at the Mystical Womxn's Magic Festival and the Ohio Lesbian Festival. In the process, I demonstrate that working across racial and gender divides in these spaces is possible but only if we understand that solidarity is processual and relational but also, quite simply, hard work. This labor requires acknowledging that failures are an integral part of the praxis of forging alliances. By failures, I am primarily referring to moments of insensitivity, casual macroaggressions, lack of deep listening, and other common occurrences of harm. Ultimately, I argue that solidarity is a journey not an end point and that a crucial aspect of the journey is grappling with collective and personal failures along the way.

V-episodes in the alliance: A single-case application of multiple methods to identify rupture repair

The therapeutic alliance has been consistently found to be a robust predictor of therapeutic outcome across various modalities of psychotherapy. Alliance ruptures are thought to occur commonly within each therapeutic dyad and, if left unresolved, are associated with premature termination and worsened psychotherapy outcome. Research efforts have identified V-shaped shifts in the alliance, characterized by a high-low-high pattern of postsession alliance scores, as a meaningful method of operationalizing rupture-repair episodes, but these efforts rarely evaluate the within-session process of the identified sessions. As a result, it is often unclear whether these sessions identified by methods based on postsession alliance measures are reflective of clinically meaningful within-session rupture process. This article aims to further explore the V-episode operationalization of rupture-repair episodes by assessing for convergence between rupture process identified by between-session measures and the within-session observer-based Rupture Resolution Rating Scale (3RS) in a single patient-therapist dyad in a 30-session brief relational therapy. V-episodes were operationalized using various previously utilized methods to identify ruptures based on postsession measures of alliance. Results of this case study demonstrate that postsession patient-rated V-episodes in the therapeutic alliance can be indicative of within-session rupture process, demonstrating convergence between within- and between-session measures of alliance process. Implications of these results for methodological approaches for identifying alliance ruptures are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Patient- and therapist-rated alliance predict improvements in posttraumatic stress disorder symptoms and substance use in integrated treatment

OBJECTIVE

Concurrent Treatment of Posttraumatic Stress Disorder (PTSD) and Substance Use Disorders Using Prolonged Exposure (i.e., COPE) is an efficacious, integrated, psychotherapy that attends to PTSD and substance use disorders simultaneously. No study has examined how therapeutic alliance functions during the provision of COPE and how this compares to non-integrated treatments, such as relapse prevention (RP) for substance use disorders. Understanding the role of alliance in COPE versus RP could inform treatment refinement and ways to enhance treatment outcomes.

METHODS

Participants (N = 55 veterans) were randomized to 12, individual, weekly sessions of COPE or RP in a randomized clinical trial. Piecewise linear mixed effect models examined how mid-treatment (1) patient-rated alliance, (2) therapist-rated alliance, and (3) the convergence between patient- and therapist-rated alliance as measured by a difference score predicted reductions in PTSD symptoms and substance use across treatment and follow-up periods.

RESULTS

Both patient- and therapist-rated alliance predicted reductions in PTSD symptoms in COPE. Higher patient-rated alliance predicted lower percent days using substances in RP. Difference score models showed higher patient-rated alliance relative to therapist-rated alliance scores predicted symptom reductions in COPE whereas higher therapist-rated alliance scores relative to patient-rated alliance scores predicted symptom reductions in RP.

DISCUSSION

Preliminary findings show a unique relationship between the rater of the alliance and treatment modalities. Patient-rated alliance may be important in trauma-focused, integrated treatments whereas therapist-rated alliance may be more important in skills-focused, substance use interventions.

A qualitative process evaluation of social recovery therapy for enhancement of social recovery in first-episode psychosis (SUPEREDEN3)

BACKGROUND

Many individuals with first-episode psychosis experience severe and persistent social disability despite receiving specialist early intervention. The SUPEREDEN3 trial assessed whether augmenting early intervention in psychosis services with Social Recovery Therapy (SRT) would lead to better social recovery.

AIMS

A qualitative process evaluation was conducted to explore implementation and mechanisms of SRT impact from the perspective of SUPEREDEN3 participants.

METHOD

A subsample of SUPEREDEN3 trial participants (n = 19) took part in semi-structured interviews, which were transcribed verbatim and analysed thematically. Trial participants were early intervention service users aged 16-35 years with severe and persistent social disability. Both SRT plus early intervention and early intervention alone arm participants were interviewed to facilitate better understanding of the context in which SRT was delivered and to aid identification of mechanisms specific to SRT.

RESULTS

The six themes identified were used to generate an explanatory model of SRT's enhancement of social recovery. Participant experiences highlight the importance of the therapist cultivating increased self-understanding and assertively encouraging clients to face feared situations in a way that is perceived as supportive, while managing ongoing symptoms. The sense of achievement generated by reaching targets linked to personally meaningful goals promotes increased self-agency, and generates hope and optimism.

CONCLUSIONS

The findings suggest potentially important processes through which social recovery was enhanced in this trial, which will be valuable in ensuring the benefits observed can be replicated. Participant accounts provide hope that, with the right support, even clients who have persistent symptoms and the most severe disability can make a good social recovery.

Scales for participant Alliance with Recovery Coach (SPARC): initial development and pilot test

Recovery coaches are individuals with lived experience with recovery from substance use disorder who typically engender a greater sense of trust than found with other types of healthcare providers. However, there currently are no validated tools that measure the connection between recovery coaches and their participants. The purpose of this study was to describe the initial development of the Scales for Participant Alliance with Recovery Coach (SPARC) to measure recovery coach connection or alliance, including initial psychometric analyses. Measurement development began with five scales of the Client Evaluation of Self Treatment (treatment participation, treatment satisfaction, rapport, peer support, and social support). Adapted items were pre-tested with focus groups (n = 8) to ensure they were meaningful and accurately reflected the domains (Study 1). After modifications, the SPARC has six scales (engagement, satisfaction, rapport, motivation and encouragement, role model and community linkage). The survey was piloted with 100 individuals (Study 2) age 18 or over who had met with a recovery coach within the last six months. Most study participants were male (60%) and white (87%) with less than two years in recovery. After removing two low performing items, the items for five of the domains had acceptable internal consistency. The items for the engagement domain had a slightly lower reliability. Findings suggest that items cover relevant recovery coach roles, are internally consistent within domains, and can be easily administered to individuals engaging in recovery coaching services. Additional research is needed with a larger, more heterogenous sample to further refine items.

The Therapy Process Observational Coding System: Group cohesion scale in youth anxiety treatment: Psychometric properties

BACKGROUND

There are no well-established measures of group cohesion, defined as the collaborative bond between group members, in group cognitive behavioral therapy (GCBT) with youth. We therefore examined the Therapy Process Observational Coding System for Child Psychotherapy-Group Cohesion Scale (TPOCS-GC), which has previously only been used with adult samples, in a youth sample.

METHODS

Observers coded 32 sessions from 16 groups with 83 youth aged 8 to 15 years (90.7% European White). Youth had anxiety disorders and received manualized GCBT in community clinics. We examined psychometric properties of the TPOCS-GC and its' construct validity in terms of relations with pretreatment variables, alliance and fidelity during treatment, and post-treatment variables. Group cohesion was measured twice during treatment (early and late).

RESULTS

The TPOCS-GC was internally consistent (α = 0.72) and was reliably coded (M ICC = 0.61). Higher clinical severity at pretreatment predicted lower early group cohesion. Higher youth age, higher clinical severity at pretreatment, and higher youth-rated early alliance predicted lower late group cohesion. Higher therapist-rated early alliance predicted higher early group cohesion. Higher therapist-rated late alliance predicted higher late group cohesion. Higher late group cohesion predicted lower clinical severity and higher client treatment satisfaction at post-treatment. Early group cohesion did not predict any post-treatment variables.

CONCLUSIONS

A four-item version of the TPOCS-GC can be reliably used in youth GCBT. The TPOCS-GC is distinct from, but associated with, multiple clinical variables.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Renegotiating tasks or goals as rupture repair: A task analysis in a cognitive-behavioral therapy for personality disorder

OBJECTIVE

The purpose of this study was to provide some definition of rupture repair in a cognitive-behavioral therapy (CBT) for personality disorders, specifically how treatment tasks or goals are renegotiated.

METHOD

Following a task analysis, a rational model was developed with the support of an expert panel. An empirical analysis was conducted on six CBT cases sampled from a clinical trial that included personality disordered patients and treatment adherent therapists. Two sessions from each case indicating rupture repair were selected, based on patient and therapist ratings of the Working Alliance Inventory-12 item version (WAI-12) and rupture presence. A qualitative analysis of the sessions was conducted with the support of the observer-based Rupture Resolution Rating System (3RS-2022).

RESULTS

The empirical analysis provided some support for many of the stages defined in the rational model, but less support for the hypothesized sequences of stages. A rational-empirical synthesis yielded a revised model that suggested therapists combine various strategies in rupture repair in a variety of ways, not necessarily in consistent sequences.

CONCLUSIONS

The renegotiation of tasks and goals in this CBT sample was variable. The importance of responsiveness and the need to validate the rational-empirical model were highlighted.

Session-to-session effects of therapist adherence and facilitative conditions on symptom change in CBT and IPT for depression

OBJECTIVE

The objective of this study was to analyze the effect of adherence to both specific technique factors and facilitative condition variables (e.g., therapists' involvement, understanding and support) in Cognitive Behavior Therapy (CBT) and Interpersonal Psychotherapy (IPT). In addition, we were interested in whether the effect of therapist adherence would depend on the level of the working alliance.

METHOD

Three sessions each from 74 patients diagnosed with Major Depressive Disorder who were randomized to 14 sessions of IPT or CBT were rated for adherence using a modified version of The Collaborative Study Psychotherapy Rating Scale-6 (CSPRS-6). Data was analyzed using Multilevel Modeling.

RESULTS

No effects of adherence to specific factors on outcome were found in neither CBT nor IPT. Facilitative conditions were associated with better outcome in CBT but not in IPT, even after adjustment for the quality of the working alliance. No interaction effects were found.

CONCLUSIONS

Our findings highlight the importance of relational factors in CBT, but do not support the need for specific adherence to any of the two treatments. Possible explanations of the findings and directions for future research are discussed.Trial registration: ClinicalTrials.gov identifier: NCT01851915.

The Relationship Between Patients' Personality Traits, the Alliance, and Change in Interpersonal Distress in Intensive Group Treatment for Personality Dysfunction

This study examined patients' personality traits as operationalized by the five-factor model in relation to early alliance and reduction of interpersonal distress through an intensive group treatment program for personality dysfunction. A sample of 79 consecutively admitted psychiatric outpatients with personality dysfunction who attended an 18-week intensive group treatment program completed the NEO Five-Factor Inventory at pretreatment, the Inventory of Interpersonal Problems at pre- and posttreatment, and the Edmonton Therapeutic Alliance Scale, a measure of the therapeutic alliance with the program therapist, at Session 5. Results indicated that patients who were relatively extraverted tended to rate the alliance with their program therapist higher and subsequently reported more improvement of interpersonal distress. The presence of a personality disorder did not moderate this mediation. Patients' extraversion likely promotes a bonding with the therapist and facilitates the interpersonal group work necessary for improvement. Assessing patients' level of extraversion before starting intensive group treatment might indicate which intervention strategies could be useful with that patient within the program frame.

Treatment alliance and needs of care concerning religiousness and spirituality: A follow-up study among psychiatric inpatients

BACKGROUND

Patient satisfaction with religious/spiritual (R/S) care during mental health treatment has been associated with a better treatment alliance.

AIMS

To investigate the longitudinal relations between (un)met R/S care needs and treatment alliance/compliance over a 6-month period.

METHOD

201 patients in a Christian (CC) and a secular mental health clinic completed a questionnaire (T0) containing an R/S care needs questionnaire, the Working Alliance Inventory (WAI) and the Service Engagement Scale (SES). After 6 months 136 of them took part in a follow-up (T1). Associations were analysed using hybrid linear mixed models and structural equation modelling.

RESULTS

R/S care needs decreased over time, but a similar percentage remained unanswered (e.g. 67% of the needs on R/S conversations in a secular setting). Over a 6-month period, met R/S care needs were associated with a higher WAI score (β = .25; p < .001), and unmet R/S care needs with lower WAI score (β = -.36; p < .001), which were mainly between subjects effects. Patients reporting a high score of unmet R/S care at baseline, reported a decrease in SES over time (β = -.13; p < .05).

CONCLUSIONS

Satisfaction with R/S care among mental health patients is related to a better treatment alliance. When unmet R/S care needs persist, they precede a decrease in treatment compliance. Mental health professionals are recommended to assess the presence of R/S care needs and consider possibilities of R/S care especially in the first weeks of treatment.

Therapists' confidence in their theory of change and outcomes

Previous research has sought to understand what therapist characteristics contribute to positive outcomes for clients. It is widely accepted knowledge that the alliance between the therapist and client is a significant contributing factor to client outcomes. With that said, few studies have examined specific characteristics within the therapist themselves that may contribute to client success, regardless of the therapeutic model being used. Using data from a sample of therapist-trainees at a large, midwestern institution, this study sought to explore therapist confidence in their theory of choice and its potential impact on client outcomes. Findings suggest that those clients who have therapists with greater confidence in their theory are less likely to terminate treatment prematurely or without agreement. These findings have the potential to inform the curriculum for training programs to focus more on developing confidence in the chosen theory.

The relationship between youth involvement, alliance and outcome in trauma-focused cognitive behavioral therapy

OBJECTIVE

Research suggests that combining the trauma-specific elements with a strong alliance helps optimize treatment outcomes in Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) for youth. Building on this, we investigate whether more positive and less negative involvement behaviors during trauma narration are associated with a stronger alliance and predict fewer posttraumatic stress symptoms (PTSS).

METHOD

Participants were 65 youth (M age = 15.5, SD = 2.2; 77% girls) receiving TF-CBT. Both youth self-report (Child PTSD Symptom Scale and Therapeutic Alliance Scale for Children) and observer ratings (Client Involvement Rating Scale) were used, and relationships were investigated with correlations and regression analyses.

RESULTS

The positive involvement behaviors demonstration of treatment understanding and self-disclosure predicted fewer PTSS but were not associated with the alliance - while initiation of discussions and showing enthusiasm predicted more PTSS but were associated with a stronger alliance. The negative involvement behaviors passivity and avoidance did not predict PTSS but were negatively associated with the alliance.

CONCLUSION

The relationships between traumatized youths' positive and negative involvement behaviors, alliance and PTSS outcomes appear mixed. The combination of a clear understanding of why processing the trauma can be helpful, more trauma-related self-disclosure and a stronger alliance seem favorable for alleviating PTSS.Trial registration: ClinicalTrials.gov identifier: NCT00635752..

Competence in Delivering Cognitive Processing Therapy and the Therapeutic Alliance Both Predict PTSD Symptom Outcomes

Cognitive Processing Therapy (CPT) is efficacious in treating PTSD, but there remains a need to improve outcomes for individuals who do not fully respond to treatment. Differences between patient-therapist dyads in the fidelity (i.e., adherence and competence) of CPT delivery and the quality of the therapeutic relationship may partly explain differential levels of symptom improvement. Sessions were sampled from a randomized trial comparing different consultation conditions in training therapists new to CPT. Among 69 patients, one session from Sessions 1-3 and one session from Sessions 4-7 were reliably rated for adherence and competence using the CPT Therapist Adherence and Competence Scale, and for therapeutic alliance using the Working Alliance Inventory-Observer scale. Mixed models, including detrending using a fixed effect of session, predicted self-reported Posttraumatic Stress Disorder Checklist (PCL-IV) scores in one session using process scores from the previous session. The statistical interaction between fidelity and alliance scores to predict outcome was also examined. Alliance had significant, positive correlations (rs = 0.18-0.21) with same-session adherence and competence. Higher competence scores and higher therapeutic alliance scores in one session were independently associated with lower PCL-IV scores in the subsequent session. Adherence scores, which tended to be very high with relatively less variability, did not significantly relate to subsequent-session PCL-IV scores. Competence significantly interacted with alliance, such that sessions high in both competence and alliance predicted especially lower subsequent-session PCL-IV scores. A strong therapeutic alliance may have a synergistic, salutary effect with the competent delivery of CPT.

Why Does Psychotherapy Work and for Whom? Hormonal Answers

The questions of for whom and why psychotherapy is effective have been the focus of five decades of research. Most of this knowledge is based on self-report measures. Following the biopsychosocial model of mental disorders, this article explores the potential of hormones in answering these questions. The literature on cortisol, oxytocin, and oestradiol in psychotherapy was systematically searched, focusing on (a) baseline hormonal predictors of who may benefit from psychotherapy and (b) hormonal changes as indicators of therapeutic change. The search was limited to depression and anxiety disorders. In sum, the findings show that, of all three hormones, the role of cortisol is most established and that both cortisol and oxytocin are implicated in psychotherapy, although a causal role is still waiting to be demonstrated. Moreover, there is a differential role of hormones in the psychotherapy of depression versus anxiety. The directions of research mapped in this article may elucidate how psychotherapy can be selected to match patients’ endocrine states and how hormonal levels can be manipulated to improve outcomes.

Alliance ruptures and resolutions in short-term psychoanalytic psychotherapy for adolescent depression: An empirical case study

ABSTRACTMost research on alliance rupture-repair processes in psychotherapy has been carried out with adults and little is known about the alliance dynamics with adolescents, especially in psychodynamic treatments.Objective: This study aimed to better understand the process of alliance rupture-resolution and its role in a good-outcome case of a depressed adolescent treated with short-term psychoanalytic-psychotherapy (STPP).Method: A longitudinal, mixed-methods empirical single-case approach was employed. Multiple sources of information (questionnaires, interviews, sessions recordings) from various perspectives (adolescent, therapist, observer) were assembled and analysed.Results: The different sources of evidence converged and showed that, despite the presence of frequent alliance ruptures, patient and therapist managed to resolve these and develop a good and collaborative relationship. Both patient and therapist regarded the evolution in their relationship as the treatment factor mainly responsible for the positive changes experienced by the adolescent. Based on both theoretical and empirical data, a preliminary model of how to explore and repair alliance ruptures in STPP is presented.Conclusion: This study illustrates one way of applying an empirical, mixed-method approach to a single case. Its finding supports the idea that the process of repairing ruptures is an important mechanism of change. Strengths, limitations, and possible implications are discussed.

Addressing interpersonal patterns in patients with personality disorders partially explains psychotherapy outcome via changes in interaction patterns: A mediation analysis

OBJECTIVE

Many patients with personality disorders (PDs) present with problematic interaction patterns. These may also manifest in the therapeutic relationship. For successful treatment, therapists must therefore find effective ways to address such problematic interaction patterns.

METHODS

A total of 382 patients with PDs were recruited within a naturalistic setting and received integrative cognitive-behavioral therapy (CBT). Two subscales of the observer-rated Process-Content-Relationship Scale were applied to sessions 15, 20, and 25 of treatment: one on patient interaction patterns and the other on therapist addressing these. Symptom severity was assessed at intake and discharge. Mediation analysis was applied.

RESULTS

We found significant main effects of (1) therapists' addressing problematic interaction patterns in session 15 on patients' changes in such patterns from session 15 to 25 and (2) patients' changes in problematic interaction patterns on symptom severity at treatment termination. Further, the effect of therapists' addressing problematic interaction patterns on outcome was mediated by changes in patients' interaction patterns.

CONCLUSION

The results indicate that therapists' addressing of PD patients' problematic interaction patterns may be particularly important to improve such patterns and thereby treatment outcome. Future research should identify in which patients the mechanism of addressing interaction patterns works best.

The beginning of the end: A comparison of treatment completers and early dropouts in trainee-provided time-limited Cognitive Behavioral Therapy

About one in five clients drops out of treatment prematurely. Premature termination has been found to correlate with patient, therapist, and treatment factors, as well as complex interpersonal processes, including ruptures in the therapeutic alliance. This study examines the therapeutic alliance using a qualitative approach to patient-, therapist-, and observer-based data. The sample includes five trainee therapists, each of whom worked with one patient who terminated after the first or second session, and one who completed a cognitive-behavioral therapy protocol. The session(s) preceding premature termination in the drop case and the corresponding session(s) in the completer case were examined. Rupture resolution process was prevalent in both groups, though confrontation ruptures seemed more prevalent with completers and withdrawal ruptures were more clinically impactful with dropouts. Therapist awareness of process and responsiveness or contribution to rupture were identified as potential factors contributing to patient retention.

Four perspectives on traumatized youths' therapeutic alliance: Correspondence and outcome predictions

OBJECTIVE

Does the rater-perspective of youths' therapeutic alliance matter? To answer this, we evaluated the relationships between four perspectives of youths' alliance, then, we examined whether each perspective and potential discordance between the perspectives predicted outcomes.

METHOD

Participants were 65 youth (M age = 15.11, SD = 2.14; 76.9% girls) undergoing trauma-focused cognitive behavioral therapy (TF-CBT) and their therapists (n = 24). Youths' alliance was rated by youth, therapists and parents using the Therapeutic Alliance Scale for Children-revised and by observers using the Therapy Process Observational Coding System-Alliance scale. Posttraumatic stress symptoms (PTSS) were assessed with the Child PTSD Symptom Scale (CPSS) and the Clinician Administered PTSD Scale for Children and Adolescents (CAPS-CA).

RESULTS

The alliance ratings by youth-parent, parent-therapist, and therapist-observer significantly correlated. Only a higher youth-rated alliance significantly predicted fewer PTSS. Furthermore, a higher therapist-rated than youth-rated alliance significantly predicted higher scores on CPSS and CAPS-CA, and a higher parent-rated than youth-rated alliance predicted significantly higher CPSS score.

CONCLUSION

Therapists should explicitly check in with youth clients about the alliance; because only youths' evaluation of their alliance predicted the outcome and an overestimation of their alliance by therapists and parents predicted more PTSS.Trial registration: ClinicalTrials.gov identifier: NCT00635752..

Alliance rupture profiles by personality disorder pathology in psychotherapy for depression: Tendencies, development, and timing

OBJECTIVE

Clinical and theoretical considerations presume that patients with different personality disorder (PD) clusters will be associated with distinct alliance rupture profiles; however, there is scarce empirical literature examining this. The present study adopted a systematic framework for investigating profiles of alliance ruptures for individuals belonging to each of the three PD clusters.

METHOD

The sample consisted of 94 patients from a randomized controlled trial for treatment of depression. PD cluster features were assessed at intake and ruptures were assessed across treatment. Three sets of multilevel analyses were conducted to test differences between the PD clusters in the general tendency to show a rupture profile, rupture development throughout the treatment, and timing of predicting ruptures by PD within sessions.

RESULTS

The three clusters were associated with distinct profiles of alliance ruptures. Clusters A and B were characterized by a general tendency to show more withdrawal and confrontation ruptures. Cluster A had a greater decrease in confrontation ruptures over the course of treatment, while cluster B had a greater decrease in withdrawal ruptures. Cluster C was characterized by a general tendency to show fewer withdrawal and confrontation ruptures, with a greater increase in both ruptures over the course of treatment. For withdrawal ruptures, the differences between clusters were evident from the beginning of sessions, whereas for confrontation ruptures, there was less of a difference between beginning and end of sessions.

CONCLUSION

The distinct profiles of alliance ruptures for each PD cluster may contribute to progress towards tailoring treatment to individuals with PDs.

Shared leadership, value and risks in large scale transport projects: Re-calibrating procurement policy for post COVID-19

Before the 2019 Coronavirus Disease (COVID-19) outbreak, the Australian Commonwealth and State Governments invested significantly in the upgrade and construction of large-scale transport infrastructure projects (>AU$500 million). However, two trends prevail in Australia. Concessionaires/contractors face a requirement for fixed-price contracts, high levels of risk, and low margins. Concomitantly, an increasing number of projects have experienced significant cost blowouts, with adverse impacts on both the public and private sectors. Calls for the public sector to engage with collaborative procurement approaches to deliver large-scale transport projects, however, have gone unheeded. In this paper, we critically review existing policies and practices used to procure large-scale transport projects and examine the challenges they pose in a post-COVID-19 world. We suggest that the public and private sectors need to work in unison to overcome the significant economic hurdles that COVID-19 presents to the nation's infrastructure demands. We then proffer that governments need to re-calibrate their procurement policies to future-proof their large-scale transport infrastructure projects. To facilitate the process of re-calibration, we develop a theoretical procurement framework for consideration based on the concepts of shared leadership, value creation, and risks. It is envisaged that our procurement framework will provide a platform for engendering economic value and accounting for all-important societal costs and benefits in a world post pandemic.

Therapeutic Alliance: A Comparison Study between Adolescent Patients and Their Therapists

The aim of this study was to examine the congruence of adolescent- and therapist-rated therapeutic alliance, and to explore which rating or combination of ratings would predict treatment outcome or premature termination. We also studied whether the alliance changes over the course of treatment and if the change is related to the outcome or dropout. This study comprised 58 adolescents clinically referred for psychotherapeutic interventions. The alliance (Working Alliance Inventory, patient/therapist ratings) and treatment outcomes (Beck Depression Inventory, Clinical Outcomes in Routine Evaluation—Outcome Measure) were measured at baseline and at 3-, 6-, and 12-month follow-ups. The alliance did not change significantly over the course of therapy, but adolescent and therapist ratings did not correlate. Low values in the early assessment of adolescent-rated alliance and discrepancy between the ratings were significant predictors of undesirable treatment outcome. Weak adolescent- or therapist-rated alliance later in treatment and change for the worse in adolescent-rated alliance was associated with treatment dropout. As adolescent-rated alliance predicts treatment outcome better than therapist-rated alliance, therapists should frequently use assessments of therapeutic relationship within the therapy and pay attention if the adolescent feels the alliance is weakening or his/her evaluation is contrary to the therapist’s.

The Significance of Alliance Networks in Research and Development of Digital Health Products for Diabetes: Observational Study

Background

Digital health has been advancing owing to technological progress by means of smart devices and artificial intelligence, among other developments. In the field of diabetes especially, there are many active use cases of digital technology supporting the treatment of diabetes and improving lifestyle. In the innovation ecosystem, new alliance networks are formed not only by medical device companies and pharmaceutical companies, but also by information and communications technology companies and start-ups. While understanding and utilizing the network structure is important to increase the competitive advantage of companies, there is a lack of previous research describing the structure of alliance networks and the factors that lead to their formation in digital health.

Objective

The aim of this study was to explore the significance of alliance networks, focusing on digital health for diabetes, in effectively implementing processes, from the research and development of products or services to their launch and market penetration.

Methods

First, we listed the companies and contracts related to digital health for diabetes, visualized the change in the number of companies and the connections between companies in each industry, and analyzed the overview of the network. Second, we calculated the degree, betweenness centrality, and eigenvector centrality of each company in each year. Next, we analyzed the relationship between network centrality and market competitiveness by using annual sales as a parameter of company competitiveness. We also compared the network centrality of each company by industry or headquarters location (or both) and analyzed the characteristics of companies with higher centrality. Finally, we analyzed the relationship between network centrality and the number of products certified or approved by the US Food and Drug Administration.

Results

We found the degree centrality of companies was correlated with an increase in their sales. The betweenness and eigenvector centralities of medical devices companies located in the United States were significantly higher than those outside the United States (P=.04 and .005, respectively). Finally, the degree, betweenness, and eigenvector centralities were correlated with an increase in the number of Class III, but not of Class I nor II, medical device products.

Conclusions

These findings give rise to new insights into industry ecosystem for digital health and its requirement and expect a contribution to research and development practices in the field of digital health.

Strength of the genetic counselor: patient relationship is associated with extent of increased empowerment in patients with arrhythmogenic cardiomyopathy

Genetic testing and genetic counseling (GC) are increasingly recommended in the cardiovascular setting, with multiple guidelines recommending GC for patients with or at risk for inherited cardiovascular conditions. There are scant data, however, describing patient outcomes to guide evidence-based care. No studies have quantified the influence of the strength of the genetic counselor:patient relationship on outcomes. Individuals referred for first time GC at the Johns Hopkins Arrhythmogenic Cardiomyopathy (ACM) center were surveyed prior to their visit and immediately after, before any genetic test results ordered at the session had been returned. Outcomes and measures were selected based on the Reciprocal Engagement Model of GC and include empowerment assessed by the Genetic Counseling Outcome Scale (GCOS), anxiety assessed by the Cardiac Anxiety Questionnaire (CAQ), and genetic counselor:patient therapeutic alliance assessed by the Working Alliance Inventory (WAI-SR). Response rate was 59% (120/203). 54 (45%) of patients had genetic testing ordered prior to their GC visit. There was a significant increase in GCOS score (mean 15.7 points) within 4 weeks post-GC session (p<.0001) with no significant difference in GCOS change between patients who had genetic testing ordered previously and those attending pre-test counseling (17.4 ± 18.2 versus. 14.1 ± 16 [p=.35]). Average CAQ score was high at baseline (1.67 ± 0.68), and there was a significant inverse relationship between pre-GC CAQ score and extent of increase in GCOS score (p=.008) post-GC. Controlling for baseline anxiety, there was a strong positive relationship between the WAI-SR score and GCOS change (B = 0.80, 95% CI: 0.43, 1.17, p<.001). These results demonstrate a significant increase in empowerment after GC in ACM patients and that this outcome is not reliant on the ordering of a genetic test but instead sensitive to the quality of the genetic counselor:patient relationship. Genetic counselors can strive to further improve empowerment by focusing on reducing pre-visit anxiety and alliance building with the patient.

Clients' and therapists' experiences of five general change mechanisms during an Internet-based cognitive behavioral intervention for family caregivers

OBJECTIVES

Despite its efficacy, little is known about what makes Internet-based cognitive behavioral therapy (iCBT) effective. We, therefore, analyze participants' and therapists' experiences of Grawe's five general change mechanisms (alliance, resource activation, clarification, problem actuation, mastery) during an iCBT intervention for family dementia caregivers, and how their experiences were related to treatment outcomes.

METHOD

Participants (N = 30) exchanged eight weekly messages with a therapist via an Internet platform. We used the Bern Post Session Report to assess participants' and therapists' experiences of the general change mechanisms after each session.

RESULTS

Treatment outcomes were associated with therapists' overall experiences of alliance, clarification, and mastery. Participants experienced more problem actuation than therapists. Only participants' and therapists' experiences of clarification over time differed.

CONCLUSIONS

Grawe's general change mechanisms are also relevant for iCBT. We recommend considering Grawe's framework when designing Internet-based therapeutic interventions and when training therapists to deliver such interventions.

COVID-19 Related Traumatic Distress in Psychotherapy Patients during the Pandemic: The Role of Attachment, Working Alliance, and Therapeutic Agency

The early months of the COVID-19 pandemic have been a challenging time for many psychotherapy patients. To understand why certain patients were more resilient, we examined the role of patients' attachment anxiety and attachment avoidance, as well as collaborative therapy experiences (perceived working alliance and therapeutic agency) in their online sessions on their COVID-related traumatic distress over a three-month period. A total of 466 patients in online psychotherapy completed a survey during the first weeks of the pandemic, and 121 of those completed a follow-up survey three months later. Lower distress at follow-up was predicted by patients' lower attachment anxiety and higher therapeutic agency in their online sessions after controlling for baseline distress and time of survey completion. Higher working alliance predicted less distress at follow-up only for patients with high attachment anxiety. For patients with low attachment avoidance (i.e., more securely attached), higher therapeutic agency predicted less distress. These findings suggest that patients' attachment anxiety and therapeutic agency may play significant roles also in online therapy during COVID-19 in patient's experienced traumatic distress, and that working alliance and therapeutic agency may be differentially important for patients with different levels of attachment anxiety and avoidance.

Trajectories of change in the therapeutic alliance during Cognitive Analytic Therapy for depression

BACKGROUND

Managing the alliance is considered to be a core competency and central therapeutic change process during cognitive analytic therapy (CAT). This study examined latent trajectories of change in the alliance and their relationship to depression treatment outcomes.

DESIGN

Secondary analysis of a randomized controlled trial.

METHODS

A sample of N = 79 depressed participants completed standardized alliance (WAI-SF) and depression symptom measures (PHQ-9) every session during an 8-session CAT intervention. Growth mixture modelling was applied to model alliance trajectories and to classify cases into different latent classes. Associations between alliance class and post-treatment PHQ-9 scores were examined using hierarchical linear regression, controlling for confounders.

RESULTS

There were two classes of alliance trajectories. The majority class (91%) displayed stable alliance trajectories, whilst a minority class (9%) had initially poor alliance ratings that significantly improved during treatment. Baseline severity and early change in depression symptoms significantly predicted treatment outcomes, but early alliance and longitudinal alliance change did not.

CONCLUSIONS

Alliance trajectories did not significantly predict depression treatment outcomes after controlling for initial symptom severity and early change. An important limitation concerns the small sample size, so future replication in larger samples is necessary.

Systematic review and meta-analysis of therapeutic alliance, engagement, and outcome in psychological therapies for psychosis

AIM

The moderate association between therapeutic alliance (TA) and psychological therapy outcome is well established. Historically, the field has not focused on people with a severe mental illness. This is the first review to conduct a meta-analysis of associations between TA and therapeutic engagement as well as outcome in psychological therapy for psychosis.

ELIGIBILITY CRITERIA

Eligible studies conducted a quantitative investigation of the relationship between TA during a psychological therapy and outcome at a subsequent time-point.

METHOD

A systematic review examined the relationship between TA and engagement as well as outcome measures within psychological therapy for psychosis. Correlational meta-analyses using an aggregate random effects model were conducted.

RESULTS

Twenty-four studies were eligible for inclusion (n = 1,656) of which 13 were included in the meta-analyses. Client- and therapist-rated TA were associated with engagement in therapy (r_{client (c)}  = 0.36, p = .003; r_{therapist (t)}  = 0.40, p = .0053). TA was also associated with reduction in global (r_c  = 0.29, p = .0005; r_t  = 0.24, p = .0015) and psychotic symptoms (r_c  = 0.17, p = .0115; r_t  = 0.30, p = .0003). The systematic review identified no evidence or limited evidence for a relationship between TA during therapy and depression, substance use, physical health behaviours, global as well as social functioning, overall mental health recovery, and self-esteem at follow-up. Although number of studies was small, TA was related to a reduced risk of subsequent hospitalization in 40% of analyses (across two studies) and improved cognitive outcome in 50% of analyses (across three studies).

CONCLUSIONS

The observed TA-therapy engagement and TA-outcome associations were broadly consistent with those identified across non-psychotic diagnostic groups. Well-powered studies are needed to investigate the relationship between TA and process as well as outcome in psychological therapy for psychosis specifically.

PRACTITIONER POINTS

This is the first review to conduct a meta-analytic synthesis of the association between therapeutic alliance (TA) and both engagement and change in outcome in psychological therapies for psychosis. TA (as rated by therapist and client) was associated with the extent of therapeutic engagement as well as reduction in global mental health symptoms and psychotic symptoms. The significant associations between TA and engagement as well as change in outcome identified in the current review are broadly consistent with those observed across non-psychotic diagnostic groups. We consider factors that could impact upon the dynamic and potentially interdependent relationships between TA and therapeutic techniques, including attachment security and severity of paranoid ideation.