Defining the therapeutic relationship in the context of alcohol use, other drug use, and behavior change: Principles and practices

OVERVIEW

This article contributes to knowledge and practice of core processes that are shared by evidence-based alcohol or other drug (AOD) therapies. It is the fourth in a series with this aim, and here we discuss perhaps the most universally acknowledged ingredient of effective therapy - the therapeutic relationship. We consider various related terms and definitions in the literature, but in the present review, we offer a definition that underscores the context of behavior change.

METHOD

This study conducted a literature review and qualitative content analysis to derive a set of principles and practices for facilitating and maintaining the therapeutic relationship. The sources for this review included government-issued practice guidelines, therapy manuals or books, demonstration videos, and peer-reviewed articles (61 sources). The content analysis was performed in NVIVO, and reliability analysis showed moderate agreement between raters (kappa = 0.60).

RESULTS

Six principles and 16 practices were identified. The distribution of principles and practices could be broken into three categories: 1) the facilitation of client behavior change mechanisms (i.e., self-determination, motivation, self-efficacy), 2) partnership considerations (e.g., goal and task alignment), and 3) therapist interpersonal skills (e.g., empathy).

CONCLUSIONS

The therapeutic relationship is foundational to the behavior change process. We frame it as a combination of broader interpersonal considerations and attention to key mechanisms of client behavior change. The present work provides a novel resource for trainees, clinicians, and clinical supervisors interested in fostering therapy relationships with clients in AOD or other behavior change settings.

Self-compassion and fear of compassion in the treatment of chronic depression: Mechanisms of change?

OBJECTIVE

The aim of this naturalistic process study was to investigate the relationship between self-compassion, fear of compassion from others, and depressive symptoms over the course of psychotherapy in patients with chronic depression.

METHOD

A sample of 226 patients with chronic depression who received inpatient short-term psychodynamic psychotherapy (STPP) provided weekly self-report measures of self-compassion, fear of compassion, and depressive symptoms (Patient Health Questionnaire-9). Trivariate latent curve modeling with structured residuals was applied to investigate the between- and within-patient relationships among the variables.

RESULTS

At the between-patient level, a significant positive correlation was found between slope of depression and the slope of fear of compassion. At the within-patient level, a lower than expected level of fear of compassion predicted a subsequent lower than expected level of depression (mean weekly effect size = 0.12), with a smaller reciprocal relationship (mean weekly effect size = 0.08). There was no significant within-patient effect of self-compassion predicting subsequent depression, but a significant effect of a lower than expected level of depression predicting a subsequent higher than expected level of self-compassion (mean weekly effect size = -0.13). No within-patient effect between self-compassion and fear of compassion was found.

CONCLUSIONS

In the context of this study, it appears that fear of compassion may be a putative mechanism of change involved in alleviating depressive symptoms in patients with chronic depression treated with STPP. On the other hand, self-compassion appears to be an outcome of psychotherapy. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Measurement-based care professional practice guideline: Fine, but guidelines do not make good therapy

Boswell et al. (2022) persuasively make the case for and propose professional practice guidelines (PPG) for measurement-based care (MBC). Although the evidence for MBC is robust, implementing MBC effectively in practice requires skills and processes not discussed in the PPG. We discuss five problems with the PPG for MBC: The "what's in a name?" problem, lack of actionable actions problem, the stopwatch problem, the stock market problem, and looking for the keys under the light problem. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Effectiveness of telemental health during the COVID-19 pandemic: A propensity score noninferiority analysis of outcomes

The COVID-19 pandemic forced governments to implement a range of public health measures that disrupted the personal and professional lives of many, including an abrupt adoption of telemental health services. Using data from a nonprofit counseling practice, we tested whether telemental health services delivered during the pandemic were inferior to face-to-face services delivered prior to the pandemic. We first characterized patients seeking therapy services before and during the pandemic to ascertain whether the demographics and presenting concerns of patients pre- and during COVID-19 differed and found that pandemic patients reported greater anxiety, greater overall distress, were more likely female and not partnered, and earned less than before the pandemic. We used a propensity score matching analysis to account for these differences and investigated whether or not telemental health therapy was inferior to face-to-face therapy. Based on the propensity-matched samples (2,180 patients in each condition), telemental health services were found not to be inferior to in-person services, allaying concerns about the effectiveness of telemental health services delivered during the COVID-19 pandemic. The present study also illustrates the usefulness of propensity matching for examining treatment effects in naturalistic settings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The alliance in mental health care: conceptualization, evidence and clinical applications

The concept of alliance reflects the collaborative relationship between a clinician and a patient, defined as consisting of three elements: a) the agreement on the goals of treatment; b) the agreement on a task or series of tasks; c) the development of a bond. Although much of the theory and research on the alliance comes from the domain of psychotherapy, the concept is applicable to any practice involving a person seeking help and a socially sanctioned healer. An extensive research evidence suggests that the alliance (typically measured at the third or fourth session) is a robust predictor of the outcomes of various forms of psychotherapy, even when prior symptom improvement and other factors are considered. Both the clinician and the patient bring to the therapy situation different capacities to form an alliance. Factors concerning the patient include, among others, the diagnosis, attachment history and style, motivation, and needs for affiliation. However, the benefits of the alliance have been found to be mostly due to the therapist's contribution, in particular his/her facilitative interpersonal skills, including verbal fluency, communication of hope and positive expectations, persuasiveness, emotional expression; warmth, acceptance and understanding; empathy, and alliance rupture-repair responsiveness. Placebo studies have allowed to experimentally manipulate aspects of the relationship between a therapist and a patient in non-psychotherapy contexts. In these settings, two components of the relationship have emerged: an emotional one (involving being cared for and understood by the clinician) and a cognitive one (including the belief in the competence of the therapist to select and administer an effective treatment). Here we propose a model that describes three pathways through which the alliance creates benefits, named CARE (caring, attentive, real and empathic), EXPECTANCY, and SPECIFIC. Although research and clinical attention have mostly focused on the alliance between a clinician and a patient in face-to-face interactions, there is preliminary evidence concerning the alliance between patients and other clinic staff, systems of care, or the program in Internet-mediated services. These new research areas clearly require further development.

Threat alert: The effect of outliers on the alliance-outcome correlation

Meta-analyses have established the alliance as the most robust predictor of outcome in psychotherapy. A growing number of studies have evaluated potential threats to the conclusion that alliance is a causal factor in psychotherapy. One potential threat that has not been systematically examined is the possibility that the alliance-outcome association is driven by low alliance outliers. We examined the influence of removing low alliance outliers on the alliance-outcome association using data drawn from two large-scale, naturalistic psychotherapy data sets (Ns = 1,052; 11,029). These data sets differed in setting (university counseling center, community mental health center), country (United States and Canada), alliance measure (four-item Working Alliance Inventory Short Form Revised, 10-item Session Rating Scale), and outcome measure (Counseling Center Assessment of Psychological Symptoms-34, Outcome Questionnaire-45). We examined the impact of treating outliers in five different ways: retaining them, removing values three or two standard deviations from the mean, and winsorizing values three or two standard deviations from the mean. We also examined the effect of outliers after disaggregating alliance ratings into within-therapist and between-therapist components. The alliance-outcome correlation and the proportion of variance in posttest outcomes explained by alliance when controlling for pretest outcomes were similar regardless of how low alliance outliers were treated (change in r ≤ .04, change in R² ≤ 1%). Results from the disaggregation were similar. Thus, it appears that the alliance-outcome association is not an artifact of the influence of low alliance outliers. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The Effectiveness of an Intensive Inpatient Psychotherapy Program for Chronic Depression: A naturalistic comparison with wait list

BACKGROUND

Patients with chronic depression (CD) typically have an early symptom onset, more psychiatric comorbidities, more treatment attempts, and more frequent and longer inpatient hospitalizations than patients with major depressive disorders. The main purpose of this study was to investigate the effectiveness of an intensive inpatient psychotherapy program for patients with chronic depression (CD). The primary research question was whether two intensive psychodynamic inpatient treatments, affect phobia therapy (APT) and VITA, were superior to an outpatient wait list condition, receiving treatment as usual (TAU), at completion of treatment. To investigate if a potential difference between the intensive treatment and the wait list control group was dependent on a specific psychotherapeutic model, the study contrasted two therapies with similar intensity, but different theoretical rationales.

METHODS

Two hundred eighty patients with CD were included in a naturalistic study. Patients were assessed at four time points; assessment, start of therapy, end of therapy and 1-year follow-up. Three comparisons were performed with patients matched across groups; Intensive inpatient treatment program (APT + VITA) vs wait list during treatment, APT vs VITA during treatment and APT vs VITA during follow-up. The outcome measure was the BDI-II.

RESULTS

Intensive inpatient treatment program vs. wait list showed a significant difference in favor of the intensive treatment. No significant differences were found between APT and VITA during therapy or follow-up; but both groups had large effect sizes during treatment, which were maintained during follow-up.

CONCLUSIONS

The intensive inpatient psychotherapy program showed superior effect on chronic depression over an outpatient wait list condition receiving treatment as usual (TAU), but no significant differences were found between the two intensive inpatient psychodynamic treatments. The results provide support for the effectiveness of an intensive inpatient psychotherapy program in treatment of chronic and severe disorders, such as CD, which could be of benefit for policymakers and the health care sector as they are allocating recourses efficiently.

TRIAL REGISTRATION

This study has been retrospectively registered on ClinicalTrials.gov (NCT05221567) on February 3rd, 2022.

Emotional clarity and tolerance of emotional distress as mechanisms of change in short-term psychodynamic psychotherapy for chronic depression

OBJECTIVE

The aim of this naturalistic process study was to investigate the relationship between emotional clarity and tolerance of emotional distress and depressive symptoms over the course of short-term psychodynamic psychotherapy for chronically depressed patients.

METHOD

Weekly self-reports of emotional clarity, tolerance of emotional distress, and depressive symptoms (PHQ-9) were provided by 252 patients with chronic depression who were admitted to a 13-week inpatient treatment program. Latent curve modeling with structured residuals (LCM-SR) was applied to investigate the between- and within-person effects of week-to-week change in emotional clarity and tolerance of emotional distress as predictors of subsequent depression. The relationship between emotional clarity and tolerance of emotional distress was also investigated.

RESULTS

At the within-person level, higher level of emotional clarity and tolerance of emotional distress predicted subsequent lower level of depression. A reciprocal relationship was found for tolerance of emotional distress (lower level of depression predicted subsequent level of tolerance emotional distress) but not for emotional clarity. No within-person effect between emotional clarity and tolerance of emotional distress was found.

DISCUSSION

The results indicate that emotional clarity and tolerance of emotional distress may be mechanisms of change in short-term psychodynamic psychotherapy for chronic depression. The results are consistent with previous findings of the importance of emotional clarity and tolerance of emotional distress in psychotherapy. This study demonstrated the utility of LCM-SR as a method to identity mechanisms of change in psychotherapy. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The relative efficacy of bona fide cognitive behavioral therapy and applied relaxation for generalized anxiety disorder at follow-up: A longitudinal multilevel meta-analysis

OBJECTIVE

This meta-analysis examined the relative efficacy of bona fide psychotherapy conditions in generalized anxiety disorder (GAD) from posttreatment to follow-up in adults.

METHODS

Omnibus tests of relative efficacy across bona fide psychotherapies for primary and secondary outcomes were conducted. Longitudinal multilevel subgroup analyses investigated, (a) applied relaxation versus cognitive behavioral therapy (CBT) without applied relaxation and (b) well-established CBT versus augmented integrative CBT.

RESULTS

In total, 54 repeated effect sizes nested in 23 studies were included in this meta-analysis. Omnibus test of relative efficacy indicated no significant differences among the bona fide psychotherapy contrasts in primary and some differences in secondary outcomes. When contrasting applied relaxation with CBT without applied relaxation, negligible relative efficacy differences were found at each assessment time. There were small efficacy differences in favor of augmented integrative CBT in comparison to well-established CBT.

CONCLUSION

Small relative efficacy differences were found between bona fide psychotherapies in GAD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The efficacy and optimal matching of an Internet-based acceptance and commitment therapy intervention for depressive symptoms among university students: A randomized controlled trial in China

OBJECTIVE

The present study tested the efficacy of an unguided internet-based Acceptance and Commitment Therapy (iACT) program for depression, and identified the psychological characteristics of participants who benefitted the most from the program.

METHOD

Undergraduate students with mild to severe symptoms of depression were randomized to the iACT group (n = 95) or the waiting-list group (WLC group; n = 87). Depressive symptoms and positive mental health were assessed at baseline (T₀ ), at the end of the 6-week program (T₁ ), and at a 3-month follow-up (T₂ ).

RESULTS

Compared with the WLC group, the iACT group showed significantly more improvement in depressive symptoms (d = 1.27) and positive mental health (d = 0.59), both at T₁ and T₂ . Latent Profile Analysis identified three classes of participants: Sensitive-to-Relationship, Low-Reactive-Depression, and Endogenous-Depression group. In general, the treatment was particularly suitable for the Sensitive-to-Relationship class.

CONCLUSION

The iACT was effective in treating the depressive symptoms of undergraduates, especially suitable for the clients with high baseline depression, high externality, high resistance, and high sensitivity to relationships.

A latent trajectory analysis of inpatient depression treatment

Patients seeking psychotherapy may progress through treatment in varying ways. Modeling multiple treatment trajectories through growth mixture modeling provides a comprehensive way of understanding a patient population. Multiple trajectories may additionally help researchers describe complexities within a patient population, such as those with severe and persistent disorders and comorbid symptoms, to understand characteristics of patients that may be struggling during treatment. We analyzed the depression symptom outcome measures (PHQ-9) for 246 patients receiving inpatient depression treatment. We constructed a growth mixture model of depression symptom changes, allowing the number of treatment trajectories to emerge through the data, and utilized goodness-of-fit indices to select the superior model. Results indicated three classes was the best fitting model, with patients either (a) patients started above the clinical cutoff score for depression and had significant linear change over time, ending therapy just above the clinical cutoff-"Improvement-leveling off-improvement"; (b) patients started therapy well above the clinical cutoff, showed symptom alleviation at the beginning of therapy before the trajectory started to level off-"High symptom pressure"; or (c) patients started therapy just below the clinical cutoff, had steady change throughout therapy, ending well below the clinical cutoff-"continuous improvement." Implications of the study may include altering the length of treatment based on patient presenting symptoms in order to best serve patients and utilize hospital resources. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Trajectories of change in chronic depression: Differences in self-criticism and somatic symptoms between users of antidepressants and nonmedicated patients

OBJECTIVE

Depression is typically seen as composed of several factors (i.e., cognitive, affective, somatic) which may be targeted by different interventions (i.e., pharmacotherapy, psychotherapy, or combination treatment). Successfully targeting these factors may contribute to improved treatment response in depression. A previous study identified two subfactors on Beck Depression Inventory-II (BDI-II) in a sample of chronically depressed patients: (a) self-criticism and (b) somatic symptoms (sleep disturbance, fatigue, changes in appetite). Prior research indicates that these symptoms may respond differently to psychotherapy and pharmacotherapy. In this study, we examined whether patients who were on antidepressant medication (ADM) had different outcomes on these factors than patients not using medication while undergoing intensive inpatient psychotherapeutic treatment.

METHOD

After adjusting for baseline difference with propensity score matching, a total of 238 patients with chronic depression were included in the analysis of which 119 patients were using ADM during treatment while 119 were not. We analyzed whether the two groups had different trajectories of change on the factors "self-criticism" and "somatic symptoms" using multilevel growth curve modeling.

RESULTS

Patients not using medication during treatment had significantly larger symptom reduction than ADM users on the self-criticism factor, while there was no difference between groups on the somatic factor.

CONCLUSION

There seems to be a difference in outcomes on self-criticism depending on the use of ADM for this patient group. This may suggest that the simultaneous use of ADM while in psychotherapy could make patients less accessible to the effects of psychotherapeutic interventions on this factor. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Healing in a Social Context: The Importance of Clinician and Patient Relationship

When a patient presents to a health provider, the course of the disorder is composed of three effects: natural effects, specific effects, and contextual effects. Part of the contextual effect is due to the relationship between the healer and the patient. Social healing appears to be present in eusocial species and particularly well-developed in humans. Evidence for the importance of the relationship in healing is found in placebo studies, including placebo analgesics, medicine, and psychotherapy. Although the theory for how the relationship is therapeutic is not well-developed, four possible mechanisms are discussed. The implications for health care and the treatment of pain are discussed.

It's the therapist and the treatment: The structure of common therapeutic relationship factors

Objective: Prior research has established that common therapeutic relationship factors are potent predictors of change in psychotherapy, but such factors are typically studied one at a time and their underlying structure when studied simultaneously is not clear. We assembled empirically validated relationship factors (e.g., therapist empathy; patient expectations; agreement about goals) into a single instrument and subjected it to factor analysis. Method: The instrument was applied to patients (N = 332) undergoing intensive psychotherapy of different types for depressive disorders, anxiety disorders, eating disorders, and childhood trauma in an inpatient specialized mental health setting. In order to examine the psychometric properties of the scale, we used half the sample (N=164) to conduct exploratory factor analysis (EFA) and parallel analysis before we tested the solution using exploratory structural equation modeling (ESEM) on the second half of the sample (N=168). Measurement invariance analysis was conducted to examine the stability of the factor structure. Results: The analysis yielded two factors, which were termed 1. "Confidence in the therapist" and 2. "Confidence in the treatment." Discussion: When assessed simultaneously, patients differentiate between their evaluation of the therapist and of the treatment. The results indicate that there is substantial overlap among previously established relationship factors.Trial registration: ClinicalTrials.gov identifier: NCT03503981.

Do self-criticism and somatic symptoms play a key role in chronic depression? Exploring the factor structure of Beck depression inventory-II in a sample of chronically depressed inpatients

BACKGROUND

The factor structure of depression differs for different sub-samples. The purpose of this study was to explore the factor structure of Beck Depression Inventory-II in patients with chronic depression presenting for inpatient treatment.

METHODS

Using exploratory structural equation modeling (ESEM), we explored whether a two-factor solution or a bifactor solution provided best model fit for a sample of 377 patients. For the best fitting model stability was assessed with tests for invariance across primary diagnosis (persistent depressive disorder v. recurrent major depressive disorder), and presence of comorbidity.

RESULTS

A bifactor solution with one general factor and two specific factors provided best model fit. Invariance analyses provided support for measurement invariance and stability of the factor solution.

LIMITATIONS

The naturalistic study design implies some uncertainty regarding possible systematic differences between the patients on demographic and clinical characteristics.

CONCLUSION

The factor structure in our sample was best explained by a general depression factor, one specific factor pertaining to self-criticism, and one consisting of the somatic items fatigue, disturbance of sleep, and appetite. Clinicians could benefit from paying special attention to the subfactors identified, as these findings may have implications for treatment choice for patients with chronic depression.

Predicting change through individual symptoms and relationship distress: A study of within- and between-person processes in couple therapy

OBJECTIVE

In couple therapy clients often suffer from a blend of individual psychiatric symptoms as well as severe relational distress. However, research is inconclusive on whether relational change predicts symptom change or vice versa. Because answers to this question could have important clinical implications on what to focus on in couple therapy at which time in treatment, more research is recommended.

METHOD

In this study, data collected before every therapy session were used to test whether changes in relational functioning predicted symptom functioning or vice versa. The study used a multilevel modelling approach, and the variables of interest were disaggregated into within- and between-person effects.

RESULTS

The results indicated that if an individual improved more than expected on relational functioning, this predicted more improvement than expected on individual symptoms. No significant reciprocal relationship was found between these variables.

CONCLUSIONS

The clinical implication is discussed, suggesting that an emphasis on relational improvement seems to be an important mechanism during couple therapy that may facilitate the change on individual symptoms in the long run.

Comparing outcomes in chronic depression following inpatient psychotherapy for patients continuing versus discontinuing antidepressant medication

Research indicates that combination of psychotherapy and antidepressant medication (ADM) provides cumulative effects and thus outperforms monotherapy in treating chronic depression. In this quasi-experimental study, we explored symptom change for patients with chronic depression treated with ADM when presenting for a 12-week psychotherapeutic inpatient treatment programme. We compared outcomes through treatment and follow-up of patients who continued medication with those who discontinued. We also tested possible moderator effects of initial depression severity on change between the groups. Based on prior research, we hypothesized that combination treatment would yield better results (i.e., more reduction in depression). Patients (N = 112) were referred from general practitioners or local secondary health care. Outcome was measured by Beck Depression Inventory-II (BDI-II), and comparisons were carried out using multilevel modelling. Although 35 patients discontinued ADM during treatment, 77 continued. Both continuers and discontinuers had a significant treatment effect that was maintained at 1-year follow-up. There was no difference in outcome between continuers and discontinuers of ADM. Patients with severe depression had significantly more symptom improvement than patients with moderate depression, but depression severity did not affect outcomes across continuers and discontinuers of ADM differently. The results could indicate that patients had developed resistance and/or tolerance to the prophylactic effects of medication and that ADM did not contribute to the reduction of depressive symptoms. The findings may also indicate that psychotherapy alone in some instances can be a viable alternative to continued combined treatment. Clinicians should carefully assess benefits of patients' ongoing use of antidepressant medication when entering psychotherapy.

Alliance predicting progress in couple therapy

The therapeutic alliance has gained status as a common factor in psychotherapy due to its robust predictive relationship with outcome. The current challenge in our field is to gain a more nuanced understanding of alliance's impact on the progress of treatment over the course of therapy. In the current study, alliance was measured on 3 dimensions: (a) the individual's as well as the couple's joint perception of alliance with the therapist ("self/group-therapist"), (b) each partner's perception of the alliance between the spouse and the therapist ("other-therapist"), and (c) the couple's assessment of alliance with each other ("within-system"). Based on self-reported data from 165 adult clients, we analyzed whether scores on these alliance dimensions at the beginning of therapy predicted the frequently measured outcomes on individual symptoms and relationship distress during treatment. We found that 2 of the alliance dimensions, the "self/group-therapist" and the "other-therapist," at the start of treatment predicted the slopes of the outcome measures. These findings add to established research suggesting that early establishment of alliance is an important predictor for progress during treatment. Variations in the results among the 3 alliance dimensions suggest the usefulness of the clinician assessing different aspects of alliance in couple therapy. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The influence of extra-therapeutic social support on the association between therapeutic bond and treatment outcome

Objective: Both good therapeutic bond as well as extra-therapeutic social support seem to enhance treatment outcomes. Some features of the therapeutic bond are similar to experiences in extra-therapeutic relationships (e.g., feelings of trust or belongingness). Patients with a lack of social support might benefit particularly from a good therapeutic bond, because a well-formed bond can partly substitute relationship needs. This study replicates former research (main effects of bond and social support) and investigates the hypothesized interaction between both constructs. Method: Data from 1206 adult patients receiving cognitive-behavioral outpatient therapy were analyzed. Patients rated early therapeutic bond, their impairment, as well as their social support. Multilevel regression analyses were applied to test for main effects and interactions between bond and social support predicting therapy outcome post treatment. Results: Consistent with prior research, both therapeutic bond and social support predicted therapy outcome. Among patients with high social support, the impact of the therapeutic bond was minimal, while patients with low social support benefited most from a good therapeutic bond. Conclusions: Results suggest that both the therapeutic bond and social support play a role in therapy outcomes and that good therapeutic bond quality might be especially important if a patient lacks social support.

Does it make a difference to be more "on the same page"? Investigating the role of alliance convergence for outcomes in two different samples

Objective: To better understand the complexity of dyadic processes, such as the mechanisms of the working alliance, researchers recommend taking advantage of innovations in data analytic procedures when studying the interactions between therapists and patients that are associated with favorable therapeutic outcomes. Inspired by a recent line of alliance research using dyadic multilevel modeling, the present study investigated the hypothesis that convergence in the patient-therapist working alliance (i.e., increased similarity in ratings of the alliance across treatment) would be associated with better outcomes. Method: Data were retrieved from two samples: 1. A randomized controlled trial for treatment resistant depression (N = 96 dyads), and 2. An archival dataset of naturalistic psychotherapies from public health care (N = 139 dyads). Multilevel growth curve analysis was employed to investigate the degree of change in session-to-session agreement of global WAI ratings between therapists and patients (i.e., alliance convergence) as a predictor of symptom reduction in the BDI-II and the SCL-90R. Results: Contrary to our expectations, alliance convergence did not predict outcome in either sample, but was negatively associated with symptom severity in Study 2. Implications for understanding the complexity of dyadic processes and alliance work in psychotherapy are discussed.

The process of skills training: A content analysis of evidence-based addiction therapies

OVERVIEW

This work builds on previous efforts to delineate cross-cutting factors of evidence-based therapies. In this report, we target a single therapeutic factor-skills training for addictive behavior change-and we operationalize this factor in a manner that will aid clinical training and quality control. Specifically, we identify principles, which we defined as broader understandings on the part of the therapist that must be kept in mind when implementing a specific therapeutic practice. We define a practice as discrete action step or specific type of intervention that the therapist uses when addressing skills training content with clients.

METHOD

We conducted a literature review and qualitative content analysis of 30 source documents (i.e., therapy manuals, literature reviews, and government issued practice guidelines) and videos (i.e., therapy demonstration videos). We performed analysis of source materials in NVIVO.

RESULTS

We identified 10 principles and 30 therapeutic practices. Together, the principles suggest that skills training in evidence-based addiction therapies can be characterized as a client-centered approach to teaching and behavioral practice. The identified practices fell into four function themes: 1) client-centered goal-setting, 2) building client self-efficacy, 3) engaging in teaching, and 4) engaging in practice.

CONCLUSIONS

When the identified principles and practices are combined, they can inform a fidelity-based approach to behavioral skills training that is applicable to a wide range of alcohol or other drug (AOD) content topics, therapeutic modalities, and implementation settings. We discuss future implications regarding standardized training and fidelity assessment.

Assessing the alliance-outcome association adjusted for patient characteristics and treatment processes: A meta-analytic summary of direct comparisons

The alliance is widely recognized as a robust predictor of posttreatment outcomes. However, there is a debate regarding whether the alliance is an epiphenomenon of intake characteristics and/or treatment processes occurring over the course of treatment. This meta-analysis aimed to synthesize the evidence on this issue. We identified 125 effect sizes in 60 independent samples (6,061 participants) of studies that reported alliance-outcome correlations as well as parallel intake or process characteristics. We examined the impact of these potential confounds on the alliance-outcome correlations. We meta-analyzed the studies estimates by computing omnibus effects models as well as multivariate models. We identified 3 variable types that were used to adjust the alliance-outcome correlations: (a) intake characteristics (k = 35); (b) simultaneous processes, such as adherence or competence (k = 13); and (c) both intake and simultaneous processes (k = 24). We found moderate alliance-outcome correlations with or without adjustments for intake and simultaneous processes (range from r = .23 to r = .31). Our results provide robust empirical evidence for the assertion that the alliance-outcome association is an independent process-based factor. Findings suggest that alliance is positively related to outcome above and beyond the studied patient intake characteristics and treatment processes. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Feedback in Couple and Family Therapy: A Randomized Clinical Trial

Routine Outcome Monitoring (ROM) is recommended as a psychotherapy procedure to serve as clinical feedback in order to improve client treatment outcomes. ROM can work as a warning signal to the therapist if the client shows signs of no change or deterioration. This study has investigated whether any difference in outcome could be detected between those clients in couple and family therapy who used the Systemic Therapy Inventory of Change (STIC) feedback system (ROM condition) versus those who were offered treatment without the use of STIC ("treatment as usual" or TAU condition). A sample of 328 adults seeking couple and family therapy in Norway was randomly assigned to ROM versus TAU conditions. Outcome measures were The Outcome Questionnaire-45 and The Revised Dyadic Adjustment Scale. The results demonstrated no significant differences in outcomes between the ROM and TAU. Possible explanations of this result related to design and implementation issues are discussed.

Individual distress and dyadic adjustment over the course of couple therapy and three-year follow-up: A replication study

This replication study examined the change over time and the relationship between depressive symptoms and dyadic adjustment during residential couple therapy and at one- and three-year follow-up. Mixed models were used in the analyses, and a disaggregation procedure was applied to examine the results on a between-person as well as on a within-person level. Overall, the results of the previous study were replicated. Significant improvement (p < .001) occurred on measures assessing relationship satisfaction and depressive symptoms from admission to discharge (effect sizes .47 to.72) and from admission to three-year follow-up (effect sizes .59 to .66). The within-person finding implies that when a person experiences more depressive symptoms than usual for him/her, subsequent dyadic adjustment is poorer than usual. Thus, our previous clinical implication suggestion is reinforced in this study: When treating couples suffering from co-existing relational and symptomatic distress, couple therapy should include the aim of lowering individual depressive symptoms.

Relationships and responsiveness in the psychological treatment of trauma: The tragedy of the APA Clinical Practice Guideline

The therapeutic relationship and responsiveness/treatment adaptations rightfully occupy a prominent, evidence-based place in any guidelines for the psychological treatment of trauma. In this light, we critique the misguided efforts of the American Psychological Association's (APA, 2017) Clinical Practice Guideline on Posttraumatic Stress Disorder in Adults to advance a biomedical model for psychotherapy and thus focus almost exclusively on treatment methods for particular disorders. Instead, the research evidence, clinical expertise, and patient preferences and culture (the necessary triumvirate of evidence-based practice) should converge on distinctive psychological guidelines that emphasize the therapy relationship, treatment adaptations, and individual therapist effects, all of which independently account for patient improvement more than the particular treatment method. Meta-analytic findings and several trauma-specific studies illustrate the thesis. Efforts to promulgate guidelines without including the relationship and responsiveness are seriously incomplete and potentially misleading. The net result is an APA Guideline that proves empirically dubious, clinically suspect, and marginally useful; moreover, it squanders a vital opportunity to identify what actually heals the scourge of trauma. We conclude with recommendations for moving forward with future APA practice guidelines. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A new therapy for each patient: Evidence-based relationships and responsiveness

In this study, we introduce the journal issue devoted to evidence-based responsiveness and frame it within the work of the third interdivisional APA Task Force on Evidence-Based Relationships and Responsiveness. We summarize the meta-analytic results and clinical practices on the adaptations of psychotherapy to multiple transdiagnostic characteristics of the patient, including attachment style, culture (race/ethnicity), gender identity, coping style, therapy preferences, reactance level, religion and spirituality, sexual orientation, and stages of change. We then discuss the clinical and research process of determining what works, and what does not work, for whom. The limitations of the Task Force's work are outlined and frequently asked questions are addressed. The article closes with the Task Force's formal conclusions and 28 recommendations and with some reflections on fitting psychotherapy to the individual client.

The Therapeutic Value of the Relationship for Placebo Effects and Other Healing Practices

Response to placebos has been documented experimentally for many medical disorders and had been verified in laboratory studies. However, the mechanisms that produce the response to placebos are not well identified, although it appears that the relationship between the medical practitioner and the patient plays an important role. Humans and other eusocial animals evolved to heal in a social context, so it is not surprising that the healing relationship is an important factor in the delivery of health services. Several well-designed studies have examined aspects of the relationship and response to placebo and the evidence is strong that various aspects of the relationship augment response to placebo. There is also meta-analytic evidence that the relationship improves physical and mental health services. Finally, there are three possible ways the relationship augments the response to placebo: combats loneliness, increases expectancies for relief, and coregulates emotions and decreases arousal.

In pursuit of truth: A critical examination of meta-analyses of cognitive behavior therapy

OBJECTIVE

Three recent meta-analyses have made the claim, albeit with some caveats, that cognitive-behavioral treatments (CBT) are superior to other psychotherapies, in general or for specific disorders (e.g., social phobia).

METHOD

The purpose of the present article was to examine four issues in meta-analysis that mitigate claims of CBT superiority: (a) effect size, power, and statistical significance, (b) focusing on disorder-specific symptom measures and ignoring other important indicators of psychological functioning, (c) problems inherent in classifying treatments provided in primary studies into classes of treatments, and (d) the inclusion of problematic trials, which biases the results, and the exclusion of trials that fail to find differences among treatments.

RESULTS

When these issues are examined, the effects demonstrating the superiority of CBT are small, nonsignificant for the most part, limited to targeted symptoms, or are due to flawed primary studies.

CONCLUSION

Meta-analytic evidence for the superiority of CBT in the three meta-analysis are nonexistent or weak.

Implications of Placebo and Nocebo Effects for Clinical Practice: Expert Consensus

BACKGROUND

Placebo and nocebo effects occur in clinical or laboratory medical contexts after administration of an inert treatment or as part of active treatments and are due to psychobiological mechanisms such as expectancies of the patient. Placebo and nocebo studies have evolved from predominantly methodological research into a far-reaching interdisciplinary field that is unravelling the neurobiological, behavioural and clinical underpinnings of these phenomena in a broad variety of medical conditions. As a consequence, there is an increasing demand from health professionals to develop expert recommendations about evidence-based and ethical use of placebo and nocebo effects for clinical practice.

METHODS

A survey and interdisciplinary expert meeting by invitation was organized as part of the 1st Society for Interdisciplinary Placebo Studies (SIPS) conference in 2017. Twenty-nine internationally recognized placebo researchers participated.

RESULTS

There was consensus that maximizing placebo effects and minimizing nocebo effects should lead to better treatment outcomes with fewer side effects. Experts particularly agreed on the importance of informing patients about placebo and nocebo effects and training health professionals in patient-clinician communication to maximize placebo and minimize nocebo effects.

CONCLUSIONS

The current paper forms a first step towards developing evidence-based and ethical recommendations about the implications of placebo and nocebo research for medical practice, based on the current state of evidence and the consensus of experts. Future research might focus on how to implement these recommendations, including how to optimize conditions for educating patients about placebo and nocebo effects and providing training for the implementation in clinical practice.

The alliance in adult psychotherapy: A meta-analytic synthesis

The alliance continues to be one of the most investigated variables related to success in psychotherapy irrespective of theoretical orientation. We define and illustrate the alliance (also conceptualized as therapeutic alliance, helping alliance, or working alliance) and then present a meta-analysis of 295 independent studies that covered more than 30,000 patients (published between 1978 and 2017) for face-to-face and Internet-based psychotherapy. The relation of the alliance and treatment outcome was investigated using a three-level meta-analysis with random-effects restricted maximum-likelihood estimators. The overall alliance-outcome association for face-to-face psychotherapy was r = .278 (95% confidence intervals [.256, .299], p < .0001; equivalent of d = .579). There was heterogeneity among the effect sizes, and 2% of the 295 effect sizes indicated negative correlations. The correlation for Internet-based psychotherapy was approximately the same (viz., r = .275, k = 23). These results confirm the robustness of the positive relation between the alliance and outcome. This relation remains consistent across assessor perspectives, alliance and outcome measures, treatment approaches, patient characteristics, and countries. The article concludes with causality considerations, research limitations, diversity considerations, and therapeutic practices. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

The effect of trauma and alcohol on the relationship between level of cytokines and depression among patients entering psychiatric treatment

BACKGROUND

Depression is associated with immunological responses as reflected by altered levels of circulating cytokines. Alcohol use and trauma may modulate immune activity, and few studies have investigated these factors in depressed patients. We aimed to explore the association between circulating peripheral cytokine levels and degree of depressive symptoms, taking trauma and alcohol into account.

METHODS

The study was a cross-sectional assessment of patients at admission to a specialized psychiatric center in Norway. A total of 128 patients were included. Information was gathered using the self-administered questionnaires Beck Depression Inventory-II (BDI-II) and the Alcohol Use Disorders Identification Test (AUDIT), in addition to clinical interviews recording childhood or adult life trauma. Serum levels of the cytokines Interleukin-1β (IL-1β), Interleukin-1 Receptor Antagonist (IL-1RA), Tumor Necrosis Factor-α (TNF-α) and the chemokine Monocyte Chemoattractant Protein-1 (MCP-1) were assessed. A Luminex bead-based multiplex assay was used for cytokine measurements. Patient cytokine levels were compared to those of healthy volunteers by the Mann-Whitney U test.

RESULTS

Levels of cytokines did not differ across patients with mild, moderate and severe depression. AUDIT score was not related to cytokine levels, but to level of depression. A history of trauma was related to higher levels of IL-1RA and TNF-α (p = 0.048 and p = 0.033, respectively), especially among the severely depressed. Serum levels of MCP-1 and TNF-α were significantly higher among psychiatric patients than in healthy volunteers.

CONCLUSIONS

Findings indicate that depression was not related to levels of circulating cytokines among patients in treatment, but that traumatized patients had higher levels of IL-1RA and TNF-α than patients without trauma experience. The lack of relationship between cytokine level and depression was evident both in those without and with trauma.

PTSD patients show increasing cytokine levels during treatment despite reduced psychological distress

BACKGROUND

A reciprocal relationship between activated innate immune system and changes in mood and behavior has been established. There is still a paucity of knowledge on how the immune system responds during psychiatric treatment. We aimed to explore circulating cytokines and assess psychiatric symptom severity scores during 12 weeks of inpatient psychiatric treatment.

METHODS

The study was a longitudinal assessment of 124 patients (88 women and 36 men) in treatment at Modum Psychiatric Center, Norway. The patient sample comprised a mixed psychiatric population of whom 39 were diagnosed with posttraumatic stress disorder (PTSD). Serum blood samples for cytokine analysis and measures of mental distress using Global Severity Index were collected at admission (T₀), halfway (T₁), and before discharge (T₂). Other factors assessed were age, gender, and the use of antidepressants and anti-inflammatory drugs. Multilevel modeling was used for longitudinal analyses to assess the repeated cytokine samples within each patient.

RESULTS

Overall level of IL-1RA was higher in PTSD patients when compared to those without PTSD (P=0.021). The level of IL-1β, MCP-1, and TNF-α increased over time in PTSD compared to non-PTSD patients (P=0.025, P=0.011 and P=0.008, respectively). All patients experienced reduced mental distress as measured by self-reported Global Severity Index scores. Stratified analysis showed that PTSD patients who used anti-inflammatory drugs had higher levels of IL-1β (P=0.007) and TNF-α (P=0.049) than PTSD patients who did not use such drugs.

CONCLUSION

The study indicates that traumatized patients may have a distinct neuroimmune development during recovery. Their activated immune system shows even further activation during their rehabilitation despite symptom reduction.

Inclusion and exclusion strategies for conducting meta-analyses

Some of the most important decisions that a researcher will make when conducting a meta-analysis are decisions about the search strategies and inclusion/exclusion criteria. Decisions regarding inclusion/exclusion criteria serve to define the scope of a meta-analysis and search strategy decisions can have a large impact on how well the results of a meta-analysis actually represent the existing body of literature. In this article, we provide descriptions and recommendations for performing searches and making inclusion/exclusion decisions. We also provide a review of 65 meta-analyses of psychotherapy versus pharmacotherapy in order to offer frequency data on the use of various search strategies and inclusion/exclusion decisions in the field.

Mindfulness-based interventions for psychiatric disorders: A systematic review and meta-analysis

Despite widespread scientific and popular interest in mindfulness-based interventions, questions regarding the empirical status of these treatments remain. We sought to examine the efficacy of mindfulness-based interventions for clinical populations on disorder-specific symptoms. To address the question of relative efficacy, we coded the strength of the comparison group into five categories: no treatment, minimal treatment, non-specific active control, specific active control, and evidence-based treatment. A total of 142 non-overlapping samples and 12,005 participants were included. At post-treatment, mindfulness-based interventions were superior to no treatment (d=0.55), minimal treatment (d=0.37), non-specific active controls (d=0.35), and specific active controls (d=0.23). Mindfulness conditions did not differ from evidence-based treatments (d=-0.004). At follow-up, mindfulness-based interventions were superior to no treatment conditions (d=0.50), non-specific active controls (d=0.52), and specific active controls (d=0.29). Mindfulness conditions did not differ from minimal treatment conditions (d=0.38) and evidence-based treatments (d=0.09). Effects on specific disorder subgroups showed the most consistent evidence in support of mindfulness for depression, pain conditions, smoking, and addictive disorders. Results support the notion that mindfulness-based interventions hold promise as evidence-based treatments.

Metacognitive therapy versus disorder-specific CBT for comorbid anxiety disorders: A randomized controlled trial

Few studies have compared the effects of Metacognitive therapy (MCT) and Cognitive behavioral therapy (CBT) for comorbid anxiety disorders. In the current study we compared CBT and MCT for heterogeneous anxiety disorders in a residential setting. Ninety patients with a primary diagnosis of Post Traumatic Stress Disorder, Social Phobia or Panic disorder, with and without Agoraphobia, were randomized to either CBT or MCT. Patients were assessed at pre-treatment, post-treatment and one-year follow-up. Primary outcome measures were Beck Anxiety Inventory and ADIS IV and secondary outcome measures were SCID II, Beck Depression Inventory, Penn State Worry Questionnaire, The Symptom Checklist-90 and the Inventory of Interpersonal Problems-64. Treatment fidelity was satisfactory and therapist credibility was equal in both treatments. There was a significant difference in the level of anxiety favouring MCT at post-treatment (d=0.7), but there were no differences at one-year follow-up, mainly due to a further improvement in the CBT group during the follow-up period. Both treatments were efficacious. No differences in effect on comorbid diagnoses and symptoms were found, but MCT produced larger change in personality problems. MCT seems to have a more rapid effect on anxiety symptoms, but there were no significant differences in the long term for patients with comorbid anxiety disorders.

Creating a climate for therapist improvement: A case study of an agency focused on outcomes and deliberate practice

Recent evidence suggests that psychotherapists may not increase in effectiveness over accrued experience in naturalistic settings, even settings that provide access to patients' outcomes. The current study examined changes in psychotherapists' effectiveness within an agency making a concerted effort to improve outcomes through the use of routine outcome monitoring coupled with ongoing consultation and the planful application of feedback including the use of deliberate practice. Data were available for 7 years of implementation from 5,128 patients seen by 153 psychotherapists. Results indicate that outcomes indeed improved across time within the agency, with increases of d = 0.035 (p = .003) per year. In contrast with previous reports, psychotherapists in the current sample showed improvements within their own caseloads across time (d = 0.034, p = .042). It did not appear that the observed agency-level improvement was due to the agency simply hiring higher-performing psychotherapists or losing lower-performing psychotherapists. Implications of these findings are discussed in relation to routine outcome monitoring, expertise in psychotherapy, and quality improvement within mental health care. (PsycINFO Database Record

Psychotherapy Expertise Should Mean Superior Outcomes and Demonstrable Improvement Over Time

How the field understands psychotherapy expertise is important. It affects how we practice and how we prepare others for practice. As in our other work, we argue that the most meaningful definition of expertise must involve steady improvement over time to achieve superior performance on some meaningful measure, which typically is client outcome. We also argue that the best means by which a therapist can achieve this is through ongoing deliberate practice. We contrast our position with not only Hill, Spiegel, Hoffman, Kivlighan, and Gelso’s preferred definition, in which they anchor expertise in therapist performance, but also with the various other possible definitions of expertise (e.g., therapist experience, therapist self-assessment of expertise) that they proffer as options.

Routine outcome monitoring: Coming of age--With the usual developmental challenges

The articles in this series present a variety of systems that involve routine outcome monitoring and the provision of feedback to therapists and/or patients with the goal of improving the quality of mental health care. Sufficient evidence exists for the adopting 1 of these systems (or 1 that was not discussed in this series); nevertheless, a number of challenges exist. Issues related to identifying the efficacious components, implementation, utilization, scientific inquiry, and the next generation are discussed.