The Intersession Process in Psychotherapy for Anorexia Nervosa: Characteristics and Relation to Outcome

Exploring alliance ruptures through the lenses of therapeutic distance

Objective: To observe ruptures through clients' and therapists' experiences of closeness and distance in therapy. Method: Sixty-six clients and their 29 therapists underwent RAP interviews that were rated with the Therapeutic-Distance-Scale- observer version (TDS-O) and completed the Post-Session-Questionnaire (PSQ) three times along therapy (early, mid and late therapy). Using a dyadic model, we associated client and therapist self-report of ruptures with TDS-O observer ratings. Results: Clients' report of ruptures positively associated with clients' observed scores that the therapist was too distant, while therapists' report of ruptures related to their observed scores that the client was too close. Clients report that the rupture addressed related to their higher observed autonomy, but therapists report that the rupture addressed related to less client's autonomy. Resolution related to lower observed distance and higher observed engagement of both partners. In dyads in which the therapist was rated as experiencing distance, there was a higher level of resolution than in dyads in which the client observed as experiencing distance and the therapist did not. Clinical examples demonstrate how ruptures were manifested and understood through the therapeutic-distance prism. Conclusions: Observing the therapeutic-distance potentially improves therapists' ability to identify, negotiate, and resolve ruptures.

Between-Session Homework in Clinical Training and Practice: A Transtheoretical Perspective

Background

This paper defines and illustrates the ways in which Between-Session Homework (BSH) may be integrated into clinical work with clients across various treatment approaches. In line with the focus of this special issue, we explore how clinical training and supervision can enhance therapist skills and competence in the use of BSH.

Method

After providing a brief historical overview and an integrative perspective on BSH, along with a review of empirical research supporting its efficacy, we delve into the discussion of BSH as a transtheoretical clinical method with heuristic value across different treatment approaches, such as cognitive-behavioral, psychodynamic, and humanistic-experiential therapies.

Results

There exists diversity in how BSH is incorporated into distinct treatment approaches. Furthermore, we emphasize the significance of therapist skills and competence in utilizing BSH to facilitate client engagement and achieve positive treatment outcomes. Finally, we address how clinical training and supervision contribute to the development of these essential skills and competence.

Conclusions

Our findings highlight three main points: (1) substantial empirical support for the integration of BSH within cognitive-behavioral therapies, (2) the potential of BSH as a promising transtheoretical clinical method, even though research beyond cognitive-behavioral therapies remains limited, and (3) the imperative need for further research into how clinical training and supervision can effectively enhance therapist skills and competence in implementing BSH.

Intersession experiences and internalized representations of psychotherapy: A scoping review

INTRODUCTION

Between-session processes outside the therapy room and beyond the direct interaction between a therapist and client can play an important role in the psychotherapeutic process and outcome. These processes are called intersession experiences and can be seen as internalized mental representations of therapy and/or therapists. Due to the COVID-19 pandemic, different digital forms of treatment have successfully been implemented and could be relevant even after the end of the COVID-19 pandemic. Therefore, patients' internalized mental representations may become highly relevant in the future.

RATIONALE

The aim of this study was to conceptually delineate the current state of research on internalized mental representations of therapy or therapists in the period between sessions and to provide an overview of the evidence. In addition, we aimed to identify research gaps to provide a baseline for further research.

METHODS

For this purpose, we conducted a scoping review to obtain a comprehensive overview of the evidence and to identify the relevant research gaps. We searched PsycArticles, Medline, PsycINFO, and PSYNDEX for publications on internalized mental representations.

RESULTS

The final sample comprised 30 publications published from 1989 to 2021. Based on the individual study results, it can be assumed that intersession experiences are of central importance for psychotherapeutic treatment. However, the scoping review showed that there was a large gap in knowledge in the research of intersession experiences. All previous research was barely comparable, and therefore, a generalized statement is not possible.

CONCLUSION

Future research should provide sufficient information about relevant aspects, such as the setting, therapists, and patients, as these factors are likely to have a significant impact on the outcome. Furthermore, better measurements for the assessment of these processes should be developed.

The oracle of Delphi 2.0: considering artificial intelligence as a challenging tool for the treatment of eating disorders

In this editorial, we discuss how the diffusion of Artificial Intelligence (AI)-based tools-such as the recently available conversational AIs-could impact and transform eating disorders (EDs) care. We try to envision the possible use of AI by individuals affected by EDs and by clinicians, in terms of prevention, support to treatment, and development of new and actually personalized treatment strategies. We then focus on how the introduction of AI into psychotherapy could either represent an element of disruption for the therapeutical relationship or be positively and creatively integrated into session and inter-sessional dynamics. As technological advancements open scenarios where anyone could have access to a personal and all-knowing "oracle", the ability to formulate questions, individuals' experiences, and the scientific rigor with which clinicians study them must remain at the center of our work. Ethical and legal issues about the use of AI are also considered.

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.

Mind-wandering rates fluctuate across the day: evidence from an experience-sampling study

Previous research has demonstrated reliable fluctuations in attentional processes during the course of the day. Everyday life experience sampling, during which participants respond to "probes" delivered at random intervals throughout the day on their mobile devices, is an effective tool for capturing such diurnal fluctuations in a naturalistic way. The existence of diurnal fluctuations in the case of mind-wandering, however, has not been examined to date. We did so in two studies. In the first study, we employed everyday experience sampling to obtain self-reports from 146 university students who rated the degree of free movement in their thoughts multiple times per day over five days. These time course data were analyzed using multilevel modelling. Freely moving thought was found to fluctuate reliably over the course of the day, with lower ratings reported in the early morning and afternoon and higher ratings around midday and evening. In the second study, we replicated these effects with a reanalysis of data from a past everyday experience-sampling study. We also demonstrated differences in parameter values for the models representing freely moving thought and two common conceptualizations of mind-wandering: task-unrelated thought and stimulus-independent thought. Taken together, the present results establish and replicate a complex pattern of change over the course of the day in how freely thought moves, while also providing further evidence that freedom of movement is dissociable from other dimensions of thought such as its task-relatedness and stimulus-dependence. Future research should focus on probing possible mechanisms behind circadian fluctuations of thought dynamics.

Therapeutic agency, in-session behavior, and patient-therapist interaction

OBJECTIVE

The aim of this study was to investigate associations between patients' subjective agency, their observable in-session behavior, and the patient-therapist interaction during the early phase of psychotherapy.

METHODS

The sample included 52 depressed patients in psychodynamic psychotherapy. After Session 5, the patients' agency and the quality of the therapeutic alliance were assessed. Based on session recordings, two independent observers rated the patients' involvement, their interpersonal behavior, and the therapists' directiveness.

RESULTS

Higher agency was associated with stronger therapeutic alliances. Patients who indicated higher agency in their therapy participated more actively in the session and showed less hostile impact messages. Patients' agency was not related to therapists' directiveness.

CONCLUSIONS

Patients' sense of agency in psychotherapy was associated with more active involvement and affiliative interaction. The findings support the idea that patients need to feel capable of acting within and having an influence on their therapy to benefit from it.

An Overview of Conceptualizations of Eating Disorder Recovery, Recent Findings, and Future Directions

PURPOSE OF REVIEW

This review delineates issues in the conceptualization and operationalization of eating disorder recovery, highlights recent findings about recovery (since 2016), and proposes future directions.

RECENT FINDINGS

A longstanding problem in the field is that there are almost as many different definitions of recovery in eating disorders as there are studies on the topic. Yet, there has been a general shift to accepting that psychological/cognitive symptoms are important to recovery in addition to physical and behavioral indices. Further, several operationalizations of recovery have been proposed over the past two decades, and some efforts to validate operationalizations exist. However, this work has had limited impact and uptake, such that the field is suffering from "broken record syndrome," where calls are made for universal definitions time and time again. It is critical that proposed operationalizations be compared empirically to help arrive at a consensus definition and that institutional/organizational support help facilitate this. Themes in recent recovery research include identifying predictors, examining biological/neuropsychological factors, and considering severe and enduring anorexia nervosa. From qualitative research, those who have experienced eating disorders highlight recovery as a journey, as well as factors such as hope, self-acceptance, and benefiting from support from others as integral to the process of recovery. The field urgently needs to implement a universal definition of recovery that is backed by evidence, that can parsimoniously be implemented in clinical practice, and that will lead to greater harmonization of scientific findings.

Daily dynamic assessment and modelling of intersession processes in ambulatory psychotherapy: A proof of concept study

Background: the typical mode of assessment in studies on intersession processes (ISP) in psychotherapy is using cross-sectional or weekly measurements. Daily dynamics of intersession processes have not yet been studied. Method: intersession process data from 22 ambulatory psychotherapy cases were collected in a naturalistic study with high temporal resolution, resulting in a total of 1026 daily measurements. Multilevel vector autoregressive (VAR) modelling was applied to discover the temporal course and causal influences among intersession processes. Centrality analysis was applied to discover unique functions of various intersession process variables. Results: a group-level network structure was discovered, offering first insights on the role of different intersession processes during psychotherapy. Centrality analysis revealed unique roles for various aspects of the intersession process. Temporal distance from the last session had only weak influence on the ISP. Conclusions: using short, daily measures, the unique role of various aspects of the ISP were uncovered. Some aspects of the ISP, like recalling session contents or reflection on future session contents, are facilitators of overall ISP intensity. Other aspects like thoughts on payment or appointments or negative treatment-related emotions are likely to suppress ISP.

Advances in the treatment of anorexia nervosa: a review of established and emerging interventions

BACKGROUND

Anorexia nervosa (AN) is a disabling, deadly and costly mental disorder. Until recently, treatment recommendations were based on expert opinion and limited evidence. The aim of this systematic review is to synthesise recent evidence on established and emerging AN treatments and to forecast trends for future developments.

METHODS

We systematically review trials of established treatments and associated process outcome studies from the last 5 years, published since a previous review in this journal. 'Established' treatments were those that are widely used in AN, recommended by guidelines and/or have been tested in at least one large randomised controlled trial. Secondly, we summarise emerging treatments for AN, i.e. those that have only been (or are currently being) tested in proof-of concept, feasibility or pilot trials.

RESULTS

We identified 19 published trials of established treatments (15 of high or moderate quality), mostly assessing psychological therapies (n = 17). We also found 11 published trials of emerging treatments, and a total of 34 registered, as yet unpublished trials. Promising emerging treatments include cognitive remediation therapy, exposure therapy and non-invasive neuromodulation.

CONCLUSIONS

Evidence generation on the treatment of AN has dramatically accelerated, with our understanding of the role of family-based approaches for adolescents more nuanced and a range of psychological approaches available for the treatment of adults. Evidence on emerging treatments and from forthcoming trials suggests that there is a shift towards more targeted brain-based interventions. Future studies need to focus on elucidating mechanisms of action of treatments and what works best for whom.

Sudden gains in the outpatient treatment of anorexia nervosa: A process-outcome study

OBJECTIVE

Sudden gains (SGs), broadly defined as sudden symptom reductions occurring between two consecutive treatment sessions, have been associated with improved treatment outcomes in anxiety and depression. The present study is the first to formally define SGs in anorexia nervosa and explore the characteristics, demographic and baseline clinical predictors, and clinical impact of SGs in anorexia nervosa.

METHOD

This is a secondary analysis of data from 89 outpatients with broadly defined anorexia nervosa who received one of two psychotherapeutic interventions as part of the MOSAIC trial (Schmidt et al., 2015). SGs were defined using session-by-session body mass index (BMI) measures. This study investigated whether SGs were associated with changes in BMI, eating disorder symptomology, general psychopathology, and psychosocial impairment between baseline and 6, 12, and 24 months follow-up.

RESULTS

SGs, experienced by 61.8% of patients, mostly occurred during the early and middle phases of treatment. A larger proportion of SGs predicted larger increases in BMI between baseline and 6, 12, and 24 months follow-up. Amongst those experiencing at least one SG, fewer days between baseline and a patient's first SG predicted a larger increase in BMI between baseline and both 6 and 12 months follow-up. The proportion and timing of SGs did not predict changes in other outcome measures.

DISCUSSION

SGs in BMI during the outpatient treatment of anorexia nervosa are clinically useful predictors of longer-term weight outcomes.

DynAMo: A Modular Platform for Monitoring Process, Outcome, and Algorithm-Based Treatment Planning in Psychotherapy

BACKGROUND

In recent years, the assessment of mental disorders has become more and more personalized. Modern advancements such as Internet-enabled mobile phones and increased computing capacity make it possible to tap sources of information that have long been unavailable to mental health practitioners.

OBJECTIVE

Software packages that combine algorithm-based treatment planning, process monitoring, and outcome monitoring are scarce. The objective of this study was to assess whether the DynAMo Web application can fill this gap by providing a software solution that can be used by both researchers to conduct state-of-the-art psychotherapy process research and clinicians to plan treatments and monitor psychotherapeutic processes.

METHODS

In this paper, we report on the current state of a Web application that can be used for assessing the temporal structure of mental disorders using information on their temporal and synchronous associations. A treatment planning algorithm automatically interprets the data and delivers priority scores of symptoms to practitioners. The application is also capable of monitoring psychotherapeutic processes during therapy and of monitoring treatment outcomes. This application was developed using the R programming language (R Core Team, Vienna) and the Shiny Web application framework (RStudio, Inc, Boston). It is made entirely from open-source software packages and thus is easily extensible.

RESULTS

The capabilities of the proposed application are demonstrated. Case illustrations are provided to exemplify its usefulness in clinical practice.

CONCLUSIONS

With the broad availability of Internet-enabled mobile phones and similar devices, collecting data on psychopathology and psychotherapeutic processes has become easier than ever. The proposed application is a valuable tool for capturing, processing, and visualizing these data. The combination of dynamic assessment and process- and outcome monitoring has the potential to improve the efficacy and effectiveness of psychotherapy.

How do patients with anorexia nervosa "process" psychotherapy between sessions? A comparison of cognitive-behavioral and psychodynamic interventions

OBJECTIVE

Patients' processing of psychotherapy between sessions ("inter-session process" (ISP)) has been repeatedly shown to be related to outcome. The aim of this study was to compare ISP characteristics of cognitive-behavioral vs. psychodynamic psychotherapy in the treatment of anorexia nervosa (AN) and their relation to outcome.

METHODS

Data of 106 patients participating in a randomized-controlled trial who received either 40 sessions of enhanced cognitive-behavioral therapy (CBT-E) or focal psychodynamic therapy (FPT) were analyzed. The ISP was measured with the Inter-session Experience Questionnaire (IEQ). Three outcome classes were distinguished: full recovery, partial recovery, and still fulfilling all AN criteria.

RESULTS

Patients receiving CBT-E reported more on "applying therapy" in the initial and the final treatment phase compared to FPT patients. In terms of process-outcome relations, higher levels of "recreating the therapeutic dialogue between sessions," "recreating the therapeutic dialogue with negative emotions" as well as "applying therapy with negative emotions" in the final phase of treatment predicted negative outcome in FPT, whereas overall higher levels of negative emotions predicted negative outcome in CBT-E.

CONCLUSIONS

In outpatient treatment in AN, the processing of therapy as measured by the IEQ showed surprisingly few differences between CBT-E and FPT. However, different ISP patterns were predictive of outcome, pointing to different mechanisms of change.