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Whelen ML, Ezawa ID, Strunk DR. Clinical Judgments of Response Profiles: Do They Tell Us What Matters for Whom? Behav Ther 2024; 55:457-468. [PMID: 38670661 DOI: 10.1016/j.beth.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 08/05/2023] [Accepted: 08/13/2023] [Indexed: 04/28/2024]
Abstract
DeRubeis and colleagues (2014a) proposed that psychotherapy research has been limited by underappreciated variability in how patients respond to psychotherapy. They proposed that the relationship between the quality of therapy and outcome varies according to patient response profiles. In a study of cognitive-behavioral therapy (CBT) for depression, we tested clinician ratings of this construct as a moderator of the relationship between therapist adherence to cognitive or behavioral methods in predicting symptom change. Patients (N = 125) participated in CBT for depression. Assessors rated response profiles following the intake and therapists rated them after the first session. We collected data on adherence at the first five sessions and symptoms at the first six sessions. Therapist ratings following the first session, but not assessor ratings at intake, moderated the relationship between each form of adherence and symptom change. Patients given lower ratings (identifying them as spontaneous remitting or easy patients) had a stronger relationship between adherence and greater symptom change, with this relationship reversed such that adherence was related to less robust symptom change for those with the highest ratings (intractable or challenging patients). Our findings suggest promise for clinical evaluation of response profiles. We encourage future research evaluating refinements to such measures.
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Affiliation(s)
| | - Iony D Ezawa
- The Ohio State University, Vanderbilt University, and University of Southern California
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2
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Esposito G, Di Maro A, Passeggia R. The relationship between treatment integrity and outcome in group psychotherapy: A systematic review. Clin Psychol Psychother 2024. [PMID: 38217388 DOI: 10.1002/cpp.2952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 12/22/2023] [Accepted: 12/28/2023] [Indexed: 01/15/2024]
Abstract
Treatment integrity is defined as the extent to which the treatment has been implemented according to a specific theoretical model. It consists of two components: adherence, that is, the degree to which the therapist implements the techniques prescribed by the theoretical model, and competence, that is, the degree to which the therapist skilfully and appropriately implements the techniques prescribed by the model. Recently, the issue of integrity is gaining increasing importance in psychotherapy research, especially in an attempt to clarify its role in influencing the effectiveness of treatments. However, most studies focus on the individual setting. Therefore, this systematic review aims at investigating the relationship between integrity and outcome in group clinical treatments. Results highlighted a positive relationship between group treatment integrity and outcome. Moreover, this review provided insights for implications for research, clinical practice, and training of therapists, identifying questions that still need to be answered and tracing possible future research directions.
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Affiliation(s)
- Giovanna Esposito
- Department of Humanities, University of Naples Federico II, Naples, Italy
| | - Angela Di Maro
- Department of Humanities, University of Naples Federico II, Naples, Italy
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3
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Castonguay LG, Youn SJ, Boswell JF, Ryan Kilcullen J, Xiao H, McAleavey AA, Boutselis MA, Braver M, Chiswick NR, Hemmelstein NA, Jackson JS, Lytle RA, Morford ME, Scott HS, Spayd CS, O'Leary Wiley M. Therapeutic techniques and session impact: A practice-research network study in private practice. Psychother Res 2023:1-13. [PMID: 37946364 DOI: 10.1080/10503307.2023.2262099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 09/12/2023] [Indexed: 11/12/2023] Open
Abstract
Objective: This study investigated the relationship between therapeutic techniques and session impact, by examining the replicability of findings observed in a university-based training clinic (Boswell et al., 2010) in another practice-oriented setting: private practice. Method: N = 8 therapists completed session-level assessments of their technique use for N = 38 clients. The same client sample completed session-level assessments of session outcome. Technique-outcome associations were examined with multilevel models. Results: As in Boswell et al., common factors were associated with positive session impact. For clients who received higher average common factor techniques (relative to their own therapist's caseload), session impact was the poorest in sessions with higher behavioral change techniques use (relative to the client's own average). Moreover, clients with the lowest average common factor techniques (relative to their therapist's caseload) reported better session impact in sessions that involved a higher degree of session-level behavioral change techniques (relative to their own average). Conclusion: In line with Boswell et al., therapists should be mindful of the consistency of their routine technique use between- and within-clients, and this can be aided through collection of their own practice-oriented data.
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Affiliation(s)
| | - Soo Jeong Youn
- Reliant Medical Group, Optum Care, Harvard Medical School, Boston, MA, USA
| | - James F Boswell
- Department of Psychology, University at Albany, State University of New York, Albany, New York, USA
| | - J Ryan Kilcullen
- Department of Psychology, Penn State University, State College, PA, USA
| | - Henry Xiao
- Counseling and Psychological Services, Penn State University, State College, PA, USA
| | - Andrew A McAleavey
- District General Hospital of Førde, Førde, Norway
- Department of Health and Caring Sciences, Western Norway University of Applied Sciences, Førde, Norway
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4
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Salkovskis PM, Sighvatsson MB, Sigurdsson JF. How effective psychological treatments work: mechanisms of change in cognitive behavioural therapy and beyond. Behav Cogn Psychother 2023; 51:595-615. [PMID: 38180111 DOI: 10.1017/s1352465823000590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
BACKGROUND Cognitive behavioural therapy (CBT) has, in the space of 50 years, evolved into the dominant modality in psychological therapy. Mechanism/s of change remain unclear, however. AIMS In this paper, we will describe key features of CBT that account for the pace of past and future developments, with a view to identifying candidates for mechanism of change. We also highlight the distinction between 'common elements' and 'mechanisms of change' in psychological treatment. METHOD The history of how behaviour therapy and cognitive therapy developed are considered, culminating in the wide range of strategies which now fall under the heading of cognitive behavioural therapy (CBT). We consider how the empirical grounding of CBT has led to the massive proliferation of effective treatment strategies. We then consider the relationship between 'common factors' and 'mechanisms of change', and propose that a particular type of psychological flexibility is the mechanism of change not only in CBT but also effective psychological therapies in general. CONCLUSION Good psychological therapies should ultimately involve supporting people experiencing psychological difficulties to understand where and how they have become 'stuck' in terms of factors involved in maintaining distress and impairment. A shared understanding is then evaluated and tested with the intention of empowering and enabling them to respond more flexibly and thereby reclaim their life.
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Affiliation(s)
- Paul M Salkovskis
- University of Oxford Department of Experimental Psychology and Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
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5
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Lorenzo-Luaces L. Identifying active ingredients in cognitive-behavioral therapies: What if we didn't? Behav Res Ther 2023; 168:104365. [PMID: 37453179 PMCID: PMC10534234 DOI: 10.1016/j.brat.2023.104365] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 06/24/2023] [Accepted: 07/02/2023] [Indexed: 07/18/2023]
Abstract
Identifying active ingredients of psychological interventions is a major goal of psychotherapy researchers that is often justified by the promise that it will lead to improved patient outcomes. Much of this "active ingredients" research is conducted within randomized controlled trials (RCTs) with patient populations, putting it in Phase T2 of the clinical-translational spectrum. I argue that RCTs in patient populations are very "messy laboratories" in which to conduct active ingredient work and that T0 and T1 research provide more controlled contexts. However, I call attention to the long road from identifying active ingredients of CBTs, whether in T0, T1, or T2 research, to improving outcomes. Dissemination and implementation research (T3 and T4 approaches) may be conceptually closer to improving outcomes. Given how common and disabling mental health symptoms are, I argue that if researchers want to improve patient outcomes, these research programs must receive more attention including work on the uptake of psychological interventions as well as work on optimal ordering of existing interventions.
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Marsh LC, Patel SD, Smith AJ, So M, Armstrong H, Elliott R, Watkins E, Moulds M, Dalgleish T, Hitchcock C. From basic science to clinical practice: Can cognitive behavioural therapy tasks be augmented with enhanced episodic specificity? Behav Res Ther 2023; 167:104352. [PMID: 37331240 DOI: 10.1016/j.brat.2023.104352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 02/28/2023] [Accepted: 06/02/2023] [Indexed: 06/20/2023]
Abstract
Individuals with depression typically remember their past in a generalised manner, at the cost of retrieving specific event memories. This may impair engagement with cognitive behavioural therapy (CBT) tasks that use concrete episodic information to challenge maladaptive beliefs, potentially limiting their therapeutic benefit. Study 1 demonstrated that an episodic specificity induction increased detail and specificity of autobiographical memory in people with major depression, relative to control conditions (N = 88). We therefore examined whether the induction enhanced the efficacy of CBT tasks that depend on episodic memory - cognitive reappraisal (Study 2, N = 30), evidence gathering (Study 2, N = 30), and planning behavioural experiments (Study 3a, N = 30). Across all three tasks, there were no significant differences in emotion- or belief-change between the specificity and control conditions. Although the induction temporarily enhanced specificity in depressed individuals, it did not significantly augment the efficacy of CBT tasks theorised to benefit from the use of specific mnemonic information.
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Affiliation(s)
- Laura C Marsh
- MRC Cognition and Brain Sciences Unit, University of Cambridge, UK
| | - Shivam D Patel
- MRC Cognition and Brain Sciences Unit, University of Cambridge, UK
| | - Alicia J Smith
- MRC Cognition and Brain Sciences Unit, University of Cambridge, UK
| | - Melody So
- MRC Cognition and Brain Sciences Unit, University of Cambridge, UK
| | | | - Rachel Elliott
- MRC Cognition and Brain Sciences Unit, University of Cambridge, UK
| | | | | | - Tim Dalgleish
- MRC Cognition and Brain Sciences Unit, University of Cambridge, UK
| | - Caitlin Hitchcock
- MRC Cognition and Brain Sciences Unit, University of Cambridge, UK; Melbourne School of Psychological Science, University of Melbourne, Australia.
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7
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Swartz HA, Bylsma LM, Fournier JC, Girard JM, Spotts C, Cohn JF, Morency LP. Randomized trial of brief interpersonal psychotherapy and cognitive behavioral therapy for depression delivered both in-person and by telehealth. J Affect Disord 2023; 333:543-552. [PMID: 37121279 DOI: 10.1016/j.jad.2023.04.092] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/12/2023] [Accepted: 04/24/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Expert consensus guidelines recommend Cognitive Behavioral Therapy (CBT) and Interpersonal Psychotherapy (IPT), interventions that were historically delivered face-to-face, as first-line treatments for Major Depressive Disorder (MDD). Despite ubiquity of telehealth following the COVID-19 pandemic, little is known about differential outcomes with CBT versus IPT delivered in-person (IP) or via telehealth (TH) or whether working alliance is affected. METHODS Adults meeting DSM-5 criteria for MDD were randomly assigned to either 8 sessions of IPT or CBT (group). Mid-trial, COVID-19 forced a change of therapy delivery from IP to TH (study phase). We compared changes in Hamilton Rating Scale for Depression (HRSD-17) and Working Alliance Inventory (WAI) scores for individuals by group and phase: CBT-IP (n = 24), CBT-TH (n = 11), IPT-IP (n = 25) and IPT-TH (n = 17). RESULTS HRSD-17 scores declined significantly from pre to post treatment (pre: M = 17.7, SD = 4.4 vs. post: M = 11.7, SD = 5.9; p < .001; d = 1.45) without significant group or phase effects. WAI scores did not differ by group or phase. Number of completed therapy sessions was greater for TH (M = 7.8, SD = 1.2) relative to IP (M = 7.2, SD = 1.6) (Mann-Whitney U = 387.50, z = -2.24, p = .025). LIMITATIONS Participants were not randomly assigned to IP versus TH. Sample size is small. CONCLUSIONS This study provides preliminary evidence supporting the efficacy of both brief IPT and CBT, delivered by either TH or IP, for depression. It showed that working alliance is preserved in TH, and delivery via TH may improve therapy adherence. Prospective, randomized controlled trials are needed to definitively test efficacy of brief IPT and CBT delivered via TH versus IP.
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Affiliation(s)
- Holly A Swartz
- University of Pittsburgh, Pittsburgh, PA, United States of America; The Ohio State University, Columbus, OH, United States of America.
| | - Lauren M Bylsma
- University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Jay C Fournier
- University of Kansas, Lawrence, KA, United States of America
| | | | - Crystal Spotts
- University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Jeffrey F Cohn
- University of Pittsburgh, Pittsburgh, PA, United States of America
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8
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Dambi JM, Mavhu W, Beji-Chauke R, Kaiyo-Utete M, Mills R, Shumba R, Muchemwa S, Musesengwa R, Verhey R, Abas M, Hirsch CR, Chibanda D. The impact of working alliance in managing youth anxiety and depression: a scoping review. NPJ MENTAL HEALTH RESEARCH 2023; 2:1. [PMID: 37520938 PMCID: PMC9885927 DOI: 10.1038/s44184-023-00021-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 01/17/2023] [Indexed: 01/31/2023]
Abstract
A working alliance (WA) is a multidimensional construct signifying a collaborative relationship between a client and a therapist. Systematic reviews of therapies to treat depression and anxiety, almost exclusively in adults, show WA is essential across psychotherapies. However, there are critical gaps in our understanding of the importance of WA in low-intensity therapies for young people with depression and anxiety. Here, we describe an initiative to explore the effect of WA on anxiety and depression outcomes in youth aged 14-24 years through a scoping review and stakeholders' consultations (N = 32). We analysed 27 studies; most were done in high-income countries and evaluated one-on-one in-person therapies (18/27). The review shows that optimal WA is associated with improvements in: relationships, self-esteem, positive coping strategies, optimism, treatment adherence, and emotional regulation. Young people with lived experience expressed that: a favourable therapy environment, regular meetings, collaborative goal setting and confidentiality were vital in forming and maintaining a functional WA. For a clinician, setting boundaries, maintaining confidentiality, excellent communication skills, being non-judgmental, and empathy were considered essential for facilitating a functional WA. Overall, a functional WA was recognised as an active ingredient in psychotherapies targeting anxiety and depression in young people aged 14-24. Although more research is needed to understand WA's influence in managing anxiety and depression in young people, we recommend routine evaluation of WA. Furthermore, there is an urgent need to identify strategies that promote WA in psychotherapies to optimise the treatment of anxiety and depression in young people.
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Affiliation(s)
- Jermaine M. Dambi
- Rehabilitation Sciences Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, PO Box AV178, Avondale, Harare, Zimbabwe
- Friendship Bench, 4 Weale Road, Harare, Zimbabwe
| | - Webster Mavhu
- Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), 4 Bath Road, Harare, Zimbabwe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA UK
| | | | - Malinda Kaiyo-Utete
- Mental Health Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, PO Box A178, Avondale, Harare, Zimbabwe
| | - Rhiana Mills
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, SE5 8AF UK
| | | | - Sidney Muchemwa
- Rehabilitation Sciences Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, PO Box AV178, Avondale, Harare, Zimbabwe
- Friendship Bench, 4 Weale Road, Harare, Zimbabwe
| | | | - Ruth Verhey
- Friendship Bench, 4 Weale Road, Harare, Zimbabwe
| | - Melanie Abas
- Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, SE5 8AF UK
| | - Colette R. Hirsch
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, SE5 8AF UK
| | - Dixon Chibanda
- Friendship Bench, 4 Weale Road, Harare, Zimbabwe
- Mental Health Unit, Faculty of Medicine and Health Sciences, University of Zimbabwe, PO Box A178, Avondale, Harare, Zimbabwe
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
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9
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Alexandersson K, Wågberg M, Ekeblad A, Holmqvist R, Falkenström F. Session-to-session effects of therapist adherence and facilitative conditions on symptom change in CBT and IPT for depression. Psychother Res 2023; 33:57-69. [PMID: 35068364 DOI: 10.1080/10503307.2022.2025626] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
| | - Malin Wågberg
- Sundsvall Hospital, County Council of Västernorrland, Sundsvall, Sweden
| | - Annika Ekeblad
- Sundsvall Hospital, County Council of Västernorrland, Sundsvall, Sweden
- Department of Behavioural Sciences and Learning, Linköping University, Linkoping, Sweden
| | - Rolf Holmqvist
- Department of Behavioural Sciences and Learning, Linköping University, Linkoping, Sweden
| | - Fredrik Falkenström
- Department of Behavioural Sciences and Learning, Linköping University, Linkoping, Sweden
- Department of Psychology, Linnaeus University, Växjö, Sweden
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10
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Fuhr K, Werle D, Batra A. How does early symptom change predict subsequent course of depressive symptoms during psychotherapy? Psychol Psychother 2022; 95:137-154. [PMID: 34676660 DOI: 10.1111/papt.12370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 09/28/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Previous studies reported about the influence of early changes on treatment response. However, the question of whether early changes can predict the subsequent course of depressive symptoms during treatment with psychotherapy has not yet been clearly answered. We aimed to investigate whether symptom course in the first weeks at the level of individual session can predict the further symptom progression on a session to session level during psychotherapy treatment in patients with Major Depression (MD). DESIGN Monocentric randomized controlled trial with psychotherapeutic treatment either with cognitive-behavioural therapy (CBT) or hypnotherapy (HT). The longitudinal course of weekly depressive symptoms during the six months treatment period was examined. METHODS In this RCT with 152 randomized patients suffering from current mild-to-moderate MD, depressive symptoms were assessed on a weekly basis during the 20 sessions' treatment with individual psychotherapy. We only included patients for which sufficient data for our analysis were available. Three different linear and quadratic mixed model analyses with random effects for each patient were tested: Early change was defined as the individual percentage symptom change during the first two, three, four and five weeks. Symptoms from session four, five, six and seven onward were predicted using different models, with early change added to the model in a final step. Calculating all models separately for CBT and HT lead to comparable results. RESULT A slow symptom decrease after session four, five, six, seven onward to the end of the treatment was found. However, adding early change to the model, had no effect on the further symptom course in all models. CONCLUSION Symptom changes at early stages of psychotherapy should not be considered as being predictive for further symptom course. PRACTITIONER POINTS The individual early symptom change in a treatment with psychotherapy in the first two, three, four, or five weeks of treatment does not predict the subsequent symptom course from session four, five, six, or seven onward at a session to session level. Symptom changes at early stages of psychotherapy should not be considered as being predictive for further symptom course. We found a symptom reduction ranging from 3% to 16% in the first two, three, four, or five weeks. Treatment response between the first and last therapy session was found in 54.5%, the number of remitted patients (with PHQ-9 scores < 5) was 44.7%. A small symptom improvement of between 0.21 and 0.42 points in the PHQ-9 scores per week in later stages of psychotherapy is likely in all patients (with and without early symptom improvement).
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Affiliation(s)
- Kristina Fuhr
- Department of Psychiatry and Psychotherapy, University Hospital of Tuebingen, Germany
| | - Dustin Werle
- Clinical Psychology and Psychotherapy, Department of Psychology, University of Tuebingen, Germany
| | - Anil Batra
- Department of Psychiatry and Psychotherapy, University Hospital of Tuebingen, Germany
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12
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Garrote-Caparrós E, Bellosta-Batalla M, Moya-Albiol L, Cebolla A. Effectiveness of mindfulness-based interventions on psychotherapy processes: A systematic review. Clin Psychol Psychother 2021; 29:783-798. [PMID: 34687581 DOI: 10.1002/cpp.2676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/18/2021] [Accepted: 10/19/2021] [Indexed: 11/09/2022]
Abstract
In the field of psychotherapy, scientific research has highlighted the importance of empathy and therapeutic alliance in regard to the effectiveness and better results of psychological treatments. In recent years, mindfulness-based interventions (MBIs) have shown to be effective at increasing empathy and therapeutic alliance and how this could affect the patients' symptomatology. In this study, we conducted a systematic review of the effectiveness of MBIs applied to psychotherapists to improve their empathy, the therapeutic alliance and the patients' symptomatology. Sixteen studies evaluating the impact of an MBI on some of these variables were identified, of which six included measures evaluated by the patients whose ahe MBI. The risk of bias of the included studies was analysed following the methodological standards. We found very different designs and methodologies in the studies included in this review, with few of them including a control group. The results show a limited increase in empathy, measured by the psychotherapist, after an MBI. However, the results in therapeutic alliance are not conclusive, as well as the improvements in the perception of patients about their symptomatology. It is concluded that MBIs can have a beneficial effect on the psychotherapeutic practice, through the development of psychotherapists' empathy. Future research would require new studies with a higher methodological quality, and in which the effects of MBIs on empathy, therapeutic alliance and patients' symptomatology and the relationships between them are analyzed.
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Affiliation(s)
| | - Miguel Bellosta-Batalla
- El Arte de Escuchar, Psychotherapy and Mindfulness, Valencia, Spain.,Department of Personality, Evaluation and Psychological Treatment, University of Valencia, Valencia, Spain
| | - Luis Moya-Albiol
- Department of Psychobiology, University of Valencia, Valencia, Spain
| | - Ausiàs Cebolla
- Department of Personality, Evaluation and Psychological Treatment, University of Valencia, Valencia, Spain.,Ciber Physiopathology of Obesity and Nutrition (CIBEROBN), Institute of Health Carlos III, Madrid, Spain
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13
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Malins S, Moghaddam N, Morriss R, Schröder T, Brown P, Boycott N. The predictive value of patient, therapist, and in-session ratings of motivational factors early in remote cognitive behavioural therapy for severe health anxiety. BRITISH JOURNAL OF CLINICAL PSYCHOLOGY 2021; 61:364-384. [PMID: 34514604 DOI: 10.1111/bjc.12328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/24/2021] [Indexed: 01/23/2023]
Abstract
OBJECTIVES Remote psychotherapy and the prevalence of Severe Health Anxiety (SHA) are both growing as a result of the COVID-19 pandemic. Remotely delivered Cognitive Behavioural Therapy (rCBT) for SHA is evidenced as effective, but many who seek help do not benefit. Motivational processes can influence outcomes, but it is unclear what assessment methods offer the best clinical utility in rCBT for SHA. DESIGN This study compared the predictive validity of patient, therapist and in-session ratings of motivational factors taken at session two of rCBT for SHA among high healthcare users experiencing multimorbidity. METHODS Motivational factors were assessed for 56 participants who attended at least two sessions of CBT for SHA delivered via video-conferencing or telephone. Following session two, therapists and patients completed online assessments of patient motivation. Two trained observers also rated motivational factors and therapeutic alliance from in-session interactions using session two recordings and transcripts. Multilevel modelling was used to predict health anxiety and a range of secondary health outcomes from motivation assessments. RESULTS Where patients were more actively engaged in discussion of positive changes during session two, greater outcome improvements ensued in health anxiety and all secondary outcomes. Conversely, larger proportions of session two spent describing problems predicted poorer outcomes. Therapist and patient assessments of motivation did not predict health anxiety, but therapist assessments of client confidence and motivation predicted all secondary outcomes. CONCLUSIONS Motivation remains an important process in CBT when delivered remotely, and motivational factors may predict outcomes more consistently from in-session interactions, compared to self-reports.
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Affiliation(s)
- Sam Malins
- Division of Psychiatry and Applied Psychology, University of Nottingham, UK.,Nottinghamshire Healthcare NHS Foundation Trust, UK
| | | | - Richard Morriss
- Division of Psychiatry and Applied Psychology, University of Nottingham, UK.,Nottinghamshire Healthcare NHS Foundation Trust, UK
| | - Thomas Schröder
- Division of Psychiatry and Applied Psychology, University of Nottingham, UK
| | - Paula Brown
- Division of Psychiatry and Applied Psychology, University of Nottingham, UK
| | - Naomi Boycott
- Division of Psychiatry and Applied Psychology, University of Nottingham, UK
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14
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Merzhvynska M, Simmonds-Buckley M, Delgadillo J, Kellett S. Trajectories of change in the therapeutic alliance during Cognitive Analytic Therapy for depression. Psychol Psychother 2021; 94:464-480. [PMID: 33448617 DOI: 10.1111/papt.12322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 10/21/2020] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
| | | | - Jaime Delgadillo
- Clinical Psychology Unit, Department of Psychology, University of Sheffield, UK
| | - Stephen Kellett
- Clinical Psychology Unit, Department of Psychology, University of Sheffield, UK
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15
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Hollon SD, Andrews PW, Thomson JA. Cognitive Behavior Therapy for Depression From an Evolutionary Perspective. Front Psychiatry 2021; 12:667592. [PMID: 34290628 PMCID: PMC8287180 DOI: 10.3389/fpsyt.2021.667592] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 05/26/2021] [Indexed: 11/16/2022] Open
Abstract
Evolutionary medicine attempts to solve a problem with which traditional medicine has struggled historically; how do we distinguish between diseased states and "healthy" responses to disease states? Fever and diarrhea represent classic examples of evolved adaptations that increase the likelihood of survival in response to the presence of pathogens in the body. Whereas, the severe mental disorders like psychotic mania or the schizophrenias may involve true "disease" states best treated pharmacologically, most non-psychotic "disorders" that revolve around negative affects like depression or anxiety are likely adaptations that evolved to serve a function that increased inclusive fitness in our ancestral past. What this likely means is that the proximal mechanisms underlying the non-psychotic "disorders" are "species typical" and neither diseases nor disorders. Rather, they are coordinated "whole body" responses that prepare the individual to respond in a maximally functional fashion to the variety of different challenges that our ancestors faced. A case can be made that depression evolved to facilitate a deliberate cognitive style (rumination) in response to complex (often social) problems. What this further suggests is that those interventions that best facilitate the functions that those adaptations evolved to serve (such as rumination) are likely to be preferred over those like medications that simply anesthetize the distress. We consider the mechanisms that evolved to generate depression and the processes utilized in cognitive behavior therapy to facilitate those functions from an adaptationist evolutionary perspective.
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Affiliation(s)
- Steven D. Hollon
- Department of Psychology, Vanderbilt University, Nashville, TN, United States
| | - Paul W. Andrews
- Department of Psychology, Neuroscience and Behaviour, McMaster University, Hamilton, ON, Canada
| | - J. Anderson Thomson
- Counseling and Psychological Services, Student Health, and Institute of Law, Psychiatry, and Public Policy, University of Virginia, Charlottesville, VA, United States
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16
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Stirman SW, Gutner CA, Gamarra J, Suvak MK, Vogt D, Johnson C, Wachen JS, Dondanville KA, Yarvis JS, Mintz J, Peterson AL, Young-McCaughan S, Resick PA. A Novel Approach to the Assessment of Fidelity to a Cognitive Behavioral Therapy for PTSD Using Clinical Worksheets: A Proof of Concept With Cognitive Processing Therapy. Behav Ther 2021; 52:656-672. [PMID: 33990240 DOI: 10.1016/j.beth.2020.08.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 08/24/2020] [Accepted: 08/28/2020] [Indexed: 11/28/2022]
Abstract
Fidelity monitoring is a critical indicator of psychotherapy quality and is central to successful implementation. A major barrier to fidelity in routine care is the lack of feasible, scalable, and valid measurement strategies. A reliable, low-burden fidelity assessment would promote sustained implementation of cognitive behavioral therapies (CBTs). The current study examined fidelity measurement for cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) using clinical worksheets. External raters evaluated patient worksheets done as a part of treatment, both guided by the therapist and completed independently as homework. Results demonstrated that fidelity ratings from CPT session worksheets were feasible and efficient. Notably, they were strongly correlated with observer ratings of the fidelity of CPT strategies that were present on the worksheets. Agreement among ratings conducted by individuals with a range of experience with CPT was acceptable to high. There was not a main effect of therapist-guided, in-session worksheet ratings on PTSD symptom change. However, patient competence in completing worksheets independently was associated with greater PTSD symptom decline and in-session, therapist-guided worksheet completion was associated with larger symptom decreases among patients with high levels of competence. With further research and refinement, rating of worksheets may be an efficient way to examine therapist and patient skill in key CPT elements, and their interactions, compared to the gold standard of observer ratings of therapy video-recordings. Additional research is needed to determine if worksheets are an accurate and scalable alternative to gold standard observer ratings in settings in which time and resources are limited.
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Affiliation(s)
- Shannon Wiltsey Stirman
- Dissemination and Training Division, National Center for PTSD, VA Palo Alto Healthcare System & Stanford University.
| | - Cassidy A Gutner
- Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System &; Boston University School of Medicine
| | | | | | - Dawne Vogt
- Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System &; Boston University School of Medicine
| | - Clara Johnson
- Dissemination and Training Division, National Center for PTSD
| | - Jennifer Schuster Wachen
- Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System &; Boston University School of Medicine
| | | | | | - Jim Mintz
- University of Texas Health Science Center at San Antonio
| | - Alan L Peterson
- University of Texas Health Science Center at San Antonio; South Texas Veterans Health Care System; University of Texas at San Antonio
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17
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Whelen ML, Murphy ST, Strunk DR. Reevaluating the Alliance-Outcome Relationship in the Early Sessions of Cognitive Behavioral Therapy of Depression. Clin Psychol Sci 2021; 9:515-523. [PMID: 38463239 PMCID: PMC10922009 DOI: 10.1177/2167702620959352] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
The therapeutic alliance has been reliably associated with outcome across psychotherapies. We investigated the alliance-outcome relationship in the early sessions of cognitive behavioral therapy of depression using a model that disaggregates within- and between-person variance while estimating the reciprocal relation between variables. We utilized this model in a combined dataset from two studies totaling 191 patients. In our primary model, we found evidence for a predictive within-patient relationship between alliance and symptoms such that symptoms predicted regressed change in alliance and alliance predicted regressed change in symptoms. In a more conservative detrended model, these relationships were not significant. Given that a) most of the variability in alliance scores is between-patient; b) the size of the alliance-outcome relationship is modest; and c) the alliance-outcome relationship is not robust to detrending, our findings suggest the alliance plays at most a small role in improving patient outcomes in cognitive behavioral therapy of depression.
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18
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Don FJ, Driessen E, Peen J, Spijker J, DeRubeis RJ, Blankers M, Dekker JJM. The Temporal Associations of Therapeutic Alliance and Manual Adherence With Depressive Symptom Change in Cognitive Behavioral Therapy for Adult Outpatient Major Depression. Front Psychiatry 2021; 11:602294. [PMID: 33519551 PMCID: PMC7838346 DOI: 10.3389/fpsyt.2020.602294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 12/11/2020] [Indexed: 11/13/2022] Open
Abstract
Background: The therapeutic alliance is considered an important causal agent of psychotherapy efficacy. However, studies in cognitive behavioral therapy (CBT) for depression have suggested that alliance might be more of a consequence rather than a cause of depressive symptom change, while adherence to CBT specific techniques was found to be associated with subsequent depression change. We aimed to add to this body of literature by assessing the temporal associations of both therapeutic alliance and manual adherence with depressive symptom change in a relatively large sample of depressed adult outpatients over the full course of CBT. Methods: Adults with a major depressive episode (n = 98) participating in a randomized clinical trial were offered 22 weeks of CBT and rated the Penn Helping Alliance Questionnaire (HAq-I) at weeks 5 and 22. Therapists rated their adherence to the CBT manual after each session and observers assessed the Hamilton Depression Rating Scale scores at weeks 0, 5, 10, and 22. Linear mixed model analyses were used to assess the associations of alliance and adherence with prior and subsequent depression change. Results: HAq-I Relationship and manual adherence ratings were not significantly associated with prior nor with subsequent depression change (p > 0.14). Prior depression change was associated with the HAq-I subscale Perceived helpfulness at the end of treatment (r = 0.30, CI = 0.03-0.56, p = 0.03). Conclusion: We were not able to replicate prior depression change in CBT for depression to be associated with improved quality of the therapeutic alliance when using a more "pure" measure of the therapeutic relationship. Limitations of this study include the subjective alliance and adherence assessments. Our findings indicate the need to appropriately distinguish between the perceived helpfulness and the relationship factors when examining therapeutic alliance.
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Affiliation(s)
- Frank J. Don
- Expert Center for Depression, Pro Persona Mental Health Care, Nijmegen, Netherlands
- Department of Research, Arkin Mental Health Care, Amsterdam, Netherlands
| | - Ellen Driessen
- Department of Research, Arkin Mental Health Care, Amsterdam, Netherlands
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Jaap Peen
- Department of Research, Arkin Mental Health Care, Amsterdam, Netherlands
| | - Jan Spijker
- Expert Center for Depression, Pro Persona Mental Health Care, Nijmegen, Netherlands
- Department of Clinical Psychology, Behavioral Science Institute, Radboud University, Nijmegen, Netherlands
| | - Robert J. DeRubeis
- School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, United States
| | - Matthijs Blankers
- Department of Research, Arkin Mental Health Care, Amsterdam, Netherlands
| | - Jack J. M. Dekker
- Department of Research, Arkin Mental Health Care, Amsterdam, Netherlands
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
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19
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Beierl ET, Murray H, Wiedemann M, Warnock-Parkes E, Wild J, Stott R, Grey N, Clark DM, Ehlers A. The Relationship Between Working Alliance and Symptom Improvement in Cognitive Therapy for Posttraumatic Stress Disorder. Front Psychiatry 2021; 12:602648. [PMID: 33935823 PMCID: PMC8085346 DOI: 10.3389/fpsyt.2021.602648] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 03/18/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Working alliance has been shown to predict outcome of psychological treatments in multiple studies. Conversely, changes in outcome scores have also been found to predict working alliance ratings. Objective: To assess the temporal relationships between working alliance and outcome in 230 patients receiving trauma-focused cognitive behavioral treatment for posttraumatic stress disorder (PTSD). Methods: Ratings of working alliance were made by both the patient and therapist after sessions 1, 3, and 5 of a course of Cognitive Therapy for PTSD (CT-PTSD). Autoregressive, cross-lagged panel models were used to examine whether working alliance predicted PTSD symptom severity at the next assessment point and vice versa. Linear regressions tested the relationship between alliance and treatment outcome. Results: Both patients' and therapists' working alliance ratings after session 1 predicted PTSD symptom scores at the end of treatment, controlling for baseline scores. At each assessment point, higher therapist working alliance was associated with lower PTSD symptoms. Crossed-lagged associations were found for therapist-rated alliance, but not for patient-rated alliance: higher therapists' alliance ratings predicted lower PTSD symptom scores at the next assessment point. Similarly, lower PTSD symptoms predicted higher therapist working alliance ratings at the next assessment point. Ruminative thinking was negatively related to therapists' alliance ratings. Conclusions: Working alliance at the start of treatment predicted treatment outcome in patients receiving CT-PTSD and may be an important factor in setting the necessary conditions for effective treatment. For therapists, there was a reciprocal relationship between working alliance and PTSD symptom change in their patients during treatment, suggesting that their alliance ratings predicted symptom change, but were also influenced by patients' symptom change.
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Affiliation(s)
- Esther T Beierl
- Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom
| | - Hannah Murray
- Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom.,Oxford Health NHS Foundation Trust, Oxford, United Kingdom
| | - Milan Wiedemann
- Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom.,Oxford Health NHS Foundation Trust, Oxford, United Kingdom
| | - Emma Warnock-Parkes
- Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom.,Department of Psychology, King's College London, London, United Kingdom
| | - Jennifer Wild
- Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom.,Oxford Health NHS Foundation Trust, Oxford, United Kingdom
| | - Richard Stott
- Department of Psychology, King's College London, London, United Kingdom.,South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Nick Grey
- Department of Psychology, King's College London, London, United Kingdom.,South London and Maudsley NHS Foundation Trust, London, United Kingdom.,Psychology and Psychological Therapies, Sussex Partnership NHS Foundation Trust, Worthing, United Kingdom
| | - David M Clark
- Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom.,Oxford Health NHS Foundation Trust, Oxford, United Kingdom.,Department of Psychology, King's College London, London, United Kingdom
| | - Anke Ehlers
- Department of Experimental Psychology, University of Oxford, Oxford, United Kingdom.,Oxford Health NHS Foundation Trust, Oxford, United Kingdom.,Department of Psychology, King's College London, London, United Kingdom
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20
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Crits-Christoph P, King C, Goldstein E, Connolly Gibbons MB. Use of cognitive techniques is associated with change in positive compensatory skills in the treatment of major depressive disorder in a community mental health setting. Psychother Res 2020; 31:909-920. [PMID: 33377425 DOI: 10.1080/10503307.2020.1866785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
To examine the association between adherence and competence in cognitive therapy (CT) techniques and change in positive compensatory skills and depressive symptoms within a community mental health setting. Adherence ratings were available for 97 individuals receiving CT for major depressive disorder. Assessments of adherence and competence were rated on one early session of CT. Compensatory skills were measured using the Ways of Responding Community Version at baseline and months 1, 2, and 5. Symptom severity was evaluated using the Hamilton Rating Scale for Depression at baseline and months 1, 2, 4, and 5. In mixed effects models, adherence was significantly associated with linear change in positive compensatory skills from baseline to month 5 (F [1, 76] = 8.05, p=.006, r=.31). Competence was also significantly associated with change in positive compensatory skills from baseline to month 5 (F [1, 78] = 5.1, p=.027, r=.25). High adherence was associated with improvements in HAM-D scores from baseline to month 5 (F [1, 78] = 5.1, p=.027, r=.25). Results support the hypothesis that use of CT techniques is associated with change in compensatory skills in a community mental health setting.
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Affiliation(s)
| | - Catherine King
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Elena Goldstein
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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21
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Baier AL, Kline AC, Feeny NC. Therapeutic alliance as a mediator of change: A systematic review and evaluation of research. Clin Psychol Rev 2020; 82:101921. [DOI: 10.1016/j.cpr.2020.101921] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 08/06/2020] [Accepted: 09/14/2020] [Indexed: 02/07/2023]
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22
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Factors Associated With Response to Adapted Cognitive Behavioral Therapy for Anxiety and Depression Following Traumatic Brain Injury. J Head Trauma Rehabil 2020; 35:117-126. [DOI: 10.1097/htr.0000000000000510] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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23
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Stone SJ, Strunk DR. Fostering Cognitive Change in Cognitive Therapy of Depression: An Investigation of Therapeutic Strategies. COGNITIVE THERAPY AND RESEARCH 2019. [DOI: 10.1007/s10608-019-10055-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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24
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Schleider JL, Abel MR, Weisz JR. Do Immediate Gains Predict Long-Term Symptom Change? Findings from a Randomized Trial of a Single-Session Intervention for Youth Anxiety and Depression. Child Psychiatry Hum Dev 2019; 50:868-881. [PMID: 30993499 DOI: 10.1007/s10578-019-00889-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Single-session interventions (SSIs) can help reduce youth psychopathology, but SSIs may benefit some youths more than others. Identifying predictors of SSIs' effectiveness may clarify youths' likelihoods of benefitting from an SSI alone, versus requiring further treatment. We tested whether pre-to-post-SSI shifts in hypothesized symptom change mechanisms predicted subsequent reductions in youth internalizing symptoms. Data were from a trial evaluating whether an SSI teaching growth mindset (the belief that personality is malleable) reduced youth anxiety and depression. Youths (N = 96, ages 12-15) self-reported growth mindsets, perceived primary control, and perceived secondary control pre- and immediately post-intervention. They self-reported depression and anxiety symptoms at pre-intervention and 3, 6, and 9-month follow-ups. Larger immediate increases in primary control predicted steeper depressive symptoms declines across the follow-up; larger immediate increases in secondary control predicted steeper anxiety symptoms declines. Immediate shifts in proximal intervention "targets" may predict longer-term response to an SSI for youth internalizing distress. CLINICAL TRIALS: Clinicaltrials.gov registration: NCT03132298.
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Affiliation(s)
| | | | - John R Weisz
- Psychology Department, Harvard University, Cambridge, USA
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25
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Webb CA, Stanton CH, Bondy E, Singleton P, Pizzagalli DA, Auerbach RP. Cognitive versus behavioral skills in CBT for depressed adolescents: Disaggregating within-patient versus between-patient effects on symptom change. J Consult Clin Psychol 2019; 87:484-490. [PMID: 30998049 DOI: 10.1037/ccp0000393] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Despite a growing body of research supporting the efficacy of cognitive-behavioral therapy (CBT) for depressed adolescents, few studies have investigated the role of the acquisition and use of CBT skills in accounting for symptom improvement. The present study examined the role of cognitive versus behavioral skills in predicting symptom improvement in depressed youth. Analyses considered different raters of patient skills (patient vs. therapist) as well as disaggregated between-patient versus within-patient effects. METHOD Data were derived from a 12-week clinical trial of CBT for depressed adolescent females (N = 33; ages 13-18 years; 69.7% White). Both therapist-report and patient-report measures of CBT skills (skills of cognitive therapy) were acquired at 5 time points throughout therapy: Sessions 1, 3, 6, 9, and 12. Depressive symptoms (Beck Depression Inventory-II) were assessed at every session. RESULTS Therapist and patient ratings of CBT skills showed small to moderate associations (rs = .20-.38). Intraclass correlation coefficients indicated that the majority of the variance in skills scores (61-90%) was attributable to within-patient variance from session to session, rather than due to between-patient differences. When disaggregating within-patient and between-patient effects, and consistent with a causal relationship, within-patient variability in both patient-rated (b = -2.55; p = .025) and therapist-rated (b = -2.41; p = .033) behavioral skills predicted subsequent symptom change. CONCLUSIONS Analyses highlight the importance of the acquisition and use of behavioral skills in CBT for depressed adolescents. Findings also underscore the importance of disentangling within-patient from between-patient effects in future studies, an approach infrequently used in process-outcome research. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Affiliation(s)
- Christian A Webb
- Center for Depression, Anxiety, and Stress Research and Department of Psychiatry, Harvard Medical School-McLean Hospital
| | - Colin H Stanton
- Center for Depression, Anxiety, and Stress Research and Department of Psychiatry, Harvard Medical School-McLean Hospital
| | - Erin Bondy
- Center for Depression, Anxiety, and Stress Research and Department of Psychiatry, Harvard Medical School-McLean Hospital
| | - Paris Singleton
- Center for Depression, Anxiety, and Stress Research and Department of Psychiatry, Harvard Medical School-McLean Hospital
| | - Diego A Pizzagalli
- Center for Depression, Anxiety, and Stress Research and Department of Psychiatry, Harvard Medical School-McLean Hospital
| | - Randy P Auerbach
- Division of Child and Adolescent Psychiatry, Columbia University
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26
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Marques L, Valentine SE, Kaysen D, Mackintosh MA, Dixon De Silva LE, Ahles EM, Youn SJ, Shtasel DL, Simon NM, Wiltsey-Stirman S. Provider fidelity and modifications to cognitive processing therapy in a diverse community health clinic: Associations with clinical change. J Consult Clin Psychol 2019; 87:357-369. [PMID: 30883163 DOI: 10.1037/ccp0000384] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The purpose of this study is to examine associations between therapist adherence, competence, and modifications of an evidence-based protocol (EBP) delivered in routine clinical care and client outcomes. METHOD Data were derived from a NIMH-funded implementation-effectiveness hybrid study of Cognitive Processing Therapy (CPT) for PTSD in a diverse community health center. Providers (n = 19) treated clients (n = 58) as part of their routine clinical care. Clients completed the PCL-S and PHQ-9 at baseline, after each CPT session, and posttreatment. CPT sessions were rated for treatment fidelity and therapist modifications. RESULTS Overall, therapist adherence was high, although it decreased across sessions suggesting potential drift. Therapist competence ratings varied widely. Therapists made on average 1.6 fidelity-consistent and 0.4 fidelity-inconsistent modifications per session. Results show that higher numbers of fidelity-consistent modifications were associated with larger reductions in posttraumatic stress and depressive symptoms. High adherence ratings were associated with greater reductions in depressive symptoms, whereas higher competence ratings were associated with greater reduction in posttraumatic stress symptoms. CONCLUSIONS The results highlight the importance of differentially assessing therapist adherence, competence, and modifications to EBP in usual care settings. The findings also suggest that effective EBP delivery in routine care may require minor adaptations to meet client needs, consistent with previous studies. Greater attention to fidelity and adaptation can enhance training so providers can tailor while retaining core components of the intervention. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Affiliation(s)
- Luana Marques
- Department of Psychiatry, Massachusetts General Hospital
| | | | - Debra Kaysen
- Department of Global Health, University of Washington
| | | | | | - Emily M Ahles
- Department of Psychiatry, Massachusetts General Hospital
| | - Soo Jeong Youn
- Department of Psychiatry, Massachusetts General Hospital
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27
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Guan K, Lau AS, Zhang A, Chlebowski C, Haine-Schlagel R, Brookman-Frazee L. In-Session Caregiver Behaviors during Evidence-Based Intervention Delivery for Children with ASD in Community Mental Health Services. EVIDENCE-BASED PRACTICE IN CHILD AND ADOLESCENT MENTAL HEALTH 2019; 4:55-71. [PMID: 31263772 PMCID: PMC6602542 DOI: 10.1080/23794925.2019.1565500] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
An Individualized Mental Health Intervention for ASD, ("AIM HI"), is a collaborative, caregiver-mediated and child-directed intervention for reducing challenging behaviors in children with autism spectrum disorder developed for delivery in community mental health programs. Using observational data from AIM HI sessions, the present study characterized the occurrence of two types of in-session caregiver behaviors: expressed concerns (i.e., expressing concerns about treatment strategies; expressing difficulty using skills; expressing difficulty completing homework) and participation engagement (i.e., asking questions; participating in session activities; showing commitment to therapy). Further analyses examined cultural differences in caregiver behaviors and associations between caregiver behaviors and clinician adherence. Participants included 39 caregiver-clinician dyads enrolled in a community effectiveness trial of AIM HI. Video recordings from 107 sessions during the first two months of treatment were coded for in-session caregiver behaviors and clinician adherence. Results indicated that expressed concerns were observed in 47% of sessions. When controlling for household income, Latinx caregivers were rated lower for expressing concerns about treatment strategies and demonstrated lower participation engagement behaviors in session compared with non-Latinx White caregivers, suggesting that cultural factors may impact verbal engagement in sessions. Finally, expressing concerns about treatment strategies, expressing difficulty using skills, and participation engagement were positively associated with clinician adherence. Findings suggest that some expressed concerns and participation engagement behaviors may be indicators of positive caregiver engagement in the context of a collaborative intervention, and lower levels of such caregiver engagement may actually impede clinicians' delivery of intensive evidence-based intervention in routine care.
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Affiliation(s)
- Karen Guan
- Department of Psychology, University of California, Los Angeles, 1285 Franz Hall, Los Angeles, CA 90095 U.S.A
| | - Anna S. Lau
- Department of Psychology, University of California, Los Angeles, 1285 Franz Hall, Los Angeles, CA 90095 U.S.A
| | - Aimee Zhang
- Department of Psychology, University of California, Los Angeles, 1285 Franz Hall, Los Angeles, CA 90095 U.S.A
| | - Colby Chlebowski
- Department of Psychiatry, University of California, San Diego
- Child and Adolescent Services Research Center, 3020 Children’s Way, San Diego, CA 92123 U.S.A
| | - Rachel Haine-Schlagel
- Department of Child and Family Development, San Diego State University
- Child and Adolescent Services Research Center, 3020 Children’s Way, San Diego, CA 92123 U.S.A
| | - Lauren Brookman-Frazee
- Department of Psychiatry, University of California, San Diego
- Child and Adolescent Services Research Center, 3020 Children’s Way, San Diego, CA 92123 U.S.A
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28
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Crits-Christoph P, Gallop R, Gaines A, Rieger A, Connolly Gibbons MB. Instrumental variable analyses for causal inference: Application to multilevel analyses of the alliance-outcome relation. Psychother Res 2018; 30:53-67. [PMID: 30451094 DOI: 10.1080/10503307.2018.1544724] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Objective: To introduce readers to instrumental variable analyses for causal inferences using as an example a test of the hypothesis that the quality of the therapeutic alliance has a causal role in relation to the outcome of psychotherapy. Method: We used data from a recent non-inferiority trial of cognitive and dynamic therapies for major depressive disorder in a community mental health setting. The data (N = 161) were analyzed using standard approaches as well as a multilevel 2-stage instrumental variables approach that allows for causal interpretations by removing the influence of unmeasured confounds. Results: Instrumental variables were created at the patient and therapist level using baseline patient and therapist variables. These baseline variables predicted the alliance but were otherwise unrelated to treatment outcome other than through their effects on the alliance. Standard multilevel mixed effects analyses revealed statistically significant associations of the alliance with outcome at the therapist level of analysis. The therapist level effect remained statistically significant when using the instrumental variables approach. Conclusion: Our results support the hypothesis that, at least at the therapist level, the alliance plays a causal role in producing better outcomes. Instrumental variable analyses can be a useful tool to supplement standard analyses.
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Affiliation(s)
| | - Robert Gallop
- Department of Mathematics, West Chester University, West Chester, PA, USA
| | - Averi Gaines
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | - Agnes Rieger
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
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29
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Snippe E, Schroevers MJ, Tovote KA, Sanderman R, Emmelkamp PMG, Fleer J. Explaining variability in therapist adherence and patient depressive symptom improvement: The role of therapist interpersonal skills and patient engagement. Clin Psychol Psychother 2018; 26:84-93. [PMID: 30199135 PMCID: PMC6585745 DOI: 10.1002/cpp.2332] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 08/05/2018] [Accepted: 09/05/2018] [Indexed: 11/16/2022]
Abstract
Understanding why therapists deviate from a treatment manual is crucial to interpret the mixed findings on the adherence–outcome association. The current study aims to examine whether therapists' interpersonal behaviours and patients' active engagement predict treatment outcome and therapist adherence in cognitive behaviour therapy (CBT) and mindfulness‐based cognitive therapy (MBCT) for depressive symptoms. In addition, the study explores rater's explanations for therapist nonadherence at sessions in which therapist adherence was low. Study participants were 61 patients with diabetes and depressive symptoms who were randomized to either CBT or MBCT. Depressive symptoms were assessed by the Beck Depression Inventory‐II. Therapist adherence, therapist interpersonal skills (i.e., empathy, warmth, and involvement), patients' active engagement, and reasons for nonadherence were assessed by two independent raters (based on digital video recordings). Therapist adherence, therapists' interpersonal skills, and patients' active engagement did not predict posttreatment depressive symptom reduction. Patients' active engagement was positively associated with therapist adherence in CBT and in MBCT. This indicates that adherence may be hampered when patients are not actively engaged in treatment. Observed reasons for nonadherence mostly covered responses to patient's in‐session behaviour. The variety of reasons for therapist nonadherence might explain why therapist adherence was not associated with outcomes of CBT and MBCT.
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Affiliation(s)
- Evelien Snippe
- Interdisciplinary Center Psychopathology and Emotion regulation (ICPE), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maya J Schroevers
- Department of Health Psychology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - K Annika Tovote
- Department of Health Psychology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robbert Sanderman
- Department of Health Psychology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Psychology, Health and Technology, University of Twente, Enschede, The Netherlands
| | - Paul M G Emmelkamp
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands.,HSK Group, Woerden, The Netherlands
| | - Joke Fleer
- Department of Health Psychology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Boyer B, MacKay KJ, McLeod BD, van der Oord S. Comparing Alliance in Two Cognitive-Behavioural Therapies for Adolescents With ADHD Using a Randomized Controlled Trial. Behav Ther 2018; 49:781-795. [PMID: 30146144 DOI: 10.1016/j.beth.2018.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 01/08/2018] [Accepted: 01/09/2018] [Indexed: 11/30/2022]
Abstract
Alliance is defined as the client-therapist bond and their ability to collaborate on therapeutic activities. Treatment for adolescents with ADHD is rarely studied in terms of alliance. In this study, two cognitive-behavioral treatments (CBT; one structured treatment aimed at planning skills and one less-structured solution-focused treatment, both delivered in the style of Motivational Interviewing) were compared with regard to alliance and alliance-outcome association. The influence of therapist competence on this alliance-outcome association was also evaluated. The alliance between 69 adolescents diagnosed with ADHD and their therapists was measured early in treatment, using the Therapy Process Observational Coding System for Child Psychotherapy-Alliance scale. Observer-rated therapist competence was measured using the Motivational Interviewing Treatment Integrity scale (version 3.1.1.). Outcome variables were the adolescents' reduction in planning problems and ADHD symptoms. The alliance, and, more specifically, collaboration on therapeutic activities, was significantly higher for the more structured CBT (p = .04; moderate effect size). Alliance was not related to outcome in the more structured CBT, while the alliance was positively related to the reduction in planning problems in the less structured CBT. Finally, alliance was a significant mediator between therapist competence and treatment outcome for the less-structured CBT. The clarity and structure of CBT may help facilitate alliance formation for adolescents with ADHD who often have difficulty implementing structure themselves. Therapists may need to invest more in alliance formation in less structured CBT as the alliance affects outcome. Moreover, enhancing therapist competence in less structured CBT may help improve outcomes in less structured CBT, as therapist competence may impact outcome through alliance.
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Affiliation(s)
- Bianca Boyer
- Developmental Psychology, University of Amsterdam
| | | | | | - Saskia van der Oord
- Health Behavior and Psychopathology, KU Leuven; Developmental Psychology, University of Amsterdam.
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31
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Guthrie E, Hughes R, Brown RJ. PI-E: An Empathy Skills Training Package to Enhance Therapeutic Skills of IAPT and Other Therapists. BRITISH JOURNAL OF PSYCHOTHERAPY 2018. [DOI: 10.1111/bjp.12378] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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32
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Predictive Value of Parent-Professional Alliance for Outcomes of Home-Based Parenting Support. CHILD & YOUTH CARE FORUM 2018. [DOI: 10.1007/s10566-018-9467-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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33
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Richardson D, Adamson S, Deering D. Therapeutic alliance predicts mood but not alcohol outcome in a comorbid treatment setting. J Subst Abuse Treat 2018; 91:28-36. [DOI: 10.1016/j.jsat.2018.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 04/13/2018] [Accepted: 04/16/2018] [Indexed: 11/29/2022]
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34
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Glickman K, Katherine Shear M, Wall MM. Therapeutic Alliance and Outcome in Complicated Grief Treatment. Int J Cogn Ther 2018. [DOI: 10.1007/s41811-018-0018-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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35
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Rapley HA, Loades ME. A systematic review exploring therapist competence, adherence, and therapy outcomes in individual CBT for children and young people. Psychother Res 2018; 29:1010-1019. [PMID: 29683046 DOI: 10.1080/10503307.2018.1464681] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
Objective: Whilst the evidence base for cognitive behavioural therapy (CBT) with children and young people is growing, the mechanisms through which these beneficial effects occur are still unclear. This systematic review seeks to appraise the relationship between therapeutic outcomes in CBT and therapist adherence and competence, within the child and adolescent literature. Method: A systematic review was carried out, with five studies identified as meeting the inclusion criteria. Results: The literature is currently small and inconclusive. Amongst the studies reviewed, there were inconsistent findings, with minimal-to-no effect sizes found between adherence, competence, and outcomes. Conclusions: The current paucity of research in this area means that conclusions are currently limited. The role and impact of adherence and competence on therapeutic outcomes remains unclear within individual CBT in a child population. This is comparable with the current adult literature, where findings also remain inconclusive. Further research avenues are discussed.
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Affiliation(s)
- Hannah A Rapley
- Department of Psychology, University of Bath , Bath , UK.,Oxford Health NHS Foundation Trust , Oxford , UK
| | - Maria E Loades
- Department of Psychology, University of Bath , Bath , UK.,Bristol Medical School, University of Bristol , Bristol , UK
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36
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Flückiger C. Bedeutung der Arbeitsallianz für die Psychotherapie. ZEITSCHRIFT FUR KLINISCHE PSYCHOLOGIE UND PSYCHOTHERAPIE 2018. [DOI: 10.1026/1616-3443/a000480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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37
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Marchese MH, Robbins SJ, Morrow MT. Nonconscious priming enhances the therapy relationship: An experimental analog study. Psychother Res 2018; 28:183-191. [DOI: 10.1080/10503307.2016.1158434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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38
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Pihlaja S, Stenberg JH, Joutsenniemi K, Mehik H, Ritola V, Joffe G. Therapeutic alliance in guided internet therapy programs for depression and anxiety disorders - A systematic review. Internet Interv 2018; 11:1-10. [PMID: 30135754 PMCID: PMC6084872 DOI: 10.1016/j.invent.2017.11.005] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/11/2017] [Accepted: 11/15/2017] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE The role of internet therapy programs for mental disorders is growing. Those programs employing human support yield better outcomes than do those with no such support. Therapeutic alliance may be a critical element in this support. Currently, the significance of therapeutic alliance in guided, internet-delivered cognitive behavioral therapy programs (iCBT) remains unknown. This review aims to determine whether the therapeutic alliance influences outcome of iCBTs and if it does, what plausible factors underlie this association. METHOD Towards that goal searches were made in PubMed, PsycINFO, SCOPUS, The Cochrane Library and CINAHL in May 2016 and January 2017. RESULTS From the 1658 relevant studies, only six studied the relationship of therapeutic alliance and outcome. All six studies showed a high level of client-therapist alliance; in the three most recent studies, the alliance was directly associated with outcome. No studies reported alliance-adherence associations. CONCLUSIONS Alliance research in iCBT for mental disorders is scarce. Therapeutic alliance seems to associate with outcomes. More studies are necessary to define the optimal support to strengthen alliance. iCBT is a feasible environment for alliance research both practically and theoretically. The impact of alliance on adherence to iCBT requires study.
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Affiliation(s)
| | | | | | | | | | - Grigori Joffe
- Hospital District of Helsinki and Uusimaa, Department of Psychiatry, University of Helsinki and Helsinki University Hospital, P.O. Box 590, 00029 HUS, Finland
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39
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Zilcha-Mano S. Major developments in methods addressing for whom psychotherapy may work and why. Psychother Res 2018; 29:693-708. [DOI: 10.1080/10503307.2018.1429691] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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40
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Katz M, Hilsenroth MJ. Psychodynamic technique early in treatment related to outcome for depressed patients. Clin Psychol Psychother 2017; 25:348-358. [PMID: 29277973 DOI: 10.1002/cpp.2167] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 11/01/2017] [Accepted: 11/22/2017] [Indexed: 01/18/2023]
Abstract
We examined the relationship between psychodynamic techniques early in treatment with reliable change in depressive symptomatology. Forty-six patients admitted for individual psychodynamic psychotherapy who received a diagnosis representative of a depressive spectrum disorder were assessed pretreatment and posttreatment through self-report of depressive symptoms. Videotapes from two early treatment sessions (3rd and 9th) were independently rated on the Comparative Psychotherapy Process Scale for use of psychodynamic-interpersonal and cognitive-behavioural techniques, with excellent interrater reliability (intraclass correlation coefficient > .75). We found a significant relationship between overall use of psychodynamic technique across early treatment (r = .31, p = .036), as well as specific psychodynamic techniques delivered across early treatment, with change in patient-reported depressive symptoms. Our findings suggest that focusing on affective experiencing and expression, as well as providing interpretations are particularly helpful early in psychodynamic treatment for depression. Clinical implications and future directions are discussed.
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Affiliation(s)
- Michael Katz
- Derner School of Psychology, Adelphi University, Garden City, NY, USA
| | - Mark J Hilsenroth
- Derner School of Psychology, Adelphi University, Garden City, NY, USA
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41
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Eubanks CF, Burckell LA, Goldfried MR. Clinical Consensus Strategies to Repair Ruptures in the Therapeutic Alliance. JOURNAL OF PSYCHOTHERAPY INTEGRATION 2017; 28:60-76. [PMID: 29805243 DOI: 10.1037/int0000097] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Objective The alliance been recognized as an essential common factor and robust predictor of outcome. The present study sought to further our knowledge of the alliance and to promote the integration of research and practice by assessing consensus among peer-nominated expert therapists of varying theoretical orientations on the effectiveness of clinical strategies to repair alliance ruptures. Method This study drew on the behavioral-analytic model (Goldfried & D'Zurilla, 1969) and the methodology of the Expert Consensus Guideline Series (Frances, Docherty, & Kahn 1997). In Phase I, 69 therapists submitted clinical situations describing alliance ruptures. In Phase II, 177 therapists generated responses to the situations, and clinical strategies underlying the responses were identified. In Phase III, 134 peer-nominated experts (a mean of 22.3 therapists per situation) rated the effectiveness of these clinical strategies. Results The experts reached consensus on the use of strategies that validated the client's experience and explored the rupture during the rupture session. Change-oriented interventions (e.g., changing interpersonal interactions; highlighting patterns of behavior, thought, or emotions) were generally rated as less effective to use during the rupture, but effective for use in future sessions. Conclusions The findings are consistent with the growing literature on the value of using certain alliance-focused interventions during a rupture. The findings point to the importance of therapists' awareness of the state of the alliance so that they can identify when ruptures are occurring.
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Stirman SW, Gamarra J, Bartlett B, Calloway A, Gutner C. Empirical Examinations of Modifications and Adaptations to Evidence-Based Psychotherapies: Methodologies, Impact, and Future Directions. CLINICAL PSYCHOLOGY-SCIENCE AND PRACTICE 2017; 24:396-420. [PMID: 29593372 DOI: 10.1111/cpsp.12218] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This review describes methods used to examine the modifications and adaptations to evidence-based psychological treatments (EBPTs), assesses what is known about the impact of modifications and adaptations to EBPTs, and makes recommendations for future research and clinical care. One hundred eight primary studies and three meta-analyses were identified. All studies examined planned adaptations, and many simultaneously investigated multiple types of adaptations. With the exception of studies on adding or removing specific EBPT elements, few studies compared adapted EBPTs to the original protocols. There was little evidence that adaptations in the studies were detrimental, but there was also limited consistent evidence that adapted protocols outperformed the original protocols, with the exception of adding components to EBPTs. Implications for EBPT delivery and future research are discussed.
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Affiliation(s)
| | | | | | | | - Cassidy Gutner
- National Center for PTSD, VA Boston Healthcare System, and Boston University
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43
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Identifying the determinants of perceived quality in outpatient child and adolescent mental health services from the perspectives of parents and patients. Eur Child Adolesc Psychiatry 2017; 26:1269-1277. [PMID: 28382545 DOI: 10.1007/s00787-017-0985-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 03/27/2017] [Indexed: 11/27/2022]
Abstract
This cross-sectional survey adopting a multiple-informant perspective explores the factors that influence perceived quality (i.e., therapeutic alliance and satisfaction) in an outpatient setting within child and adolescent mental health services (CAMHS). A total of 1433 participants (parents, n = 770, and patients, n = 663) attending or having attended (drop-out) outpatient units participated in the study. The outcome measures were satisfaction (Client Satisfaction Questionnaire) and the therapeutic alliance (Helping Alliance Questionnaire). The determinants of these quality indicators were socio-demographic variables (e.g., age, gender, and mother's socio-economic status), factors related to the extent of difficulties (number of reasons for the consultation, number of people who referred the child to the CAMHS), the approach to treatment at outset (agreeing to the consultation, feeling reassured at the first appointment), the organizational friendliness (secretary, waiting room, waiting time for the first appointment) and the organization of the therapy (frequency of sessions, time for questions, change of therapist). The approach to treatment at outset, accessibility by phone, satisfaction with the frequency of the sessions and having enough time for questions were the factors that consistently explain the quality indicators from both perspectives (patients and parents). In contrast, the socio-demographic variables as well as the extent of difficulties and factors related to the organizational friendliness and the organization of the therapy (frequency of sessions, change of therapist) were not related to the quality indicators. This study identifies key determinants of the quality indicators from the perspective of patients and parents that should be considered to improve CAMHS care quality. First appointments should be carefully prepared, and clinicians should centre care on the needs and expectations of patients and parents.
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44
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Sutherland KS, Conroy MA, McLeod BD, Algina J, Wu E. Teacher Competence of Delivery of BEST in CLASS as a Mediator of Treatment Effects. SCHOOL MENTAL HEALTH 2017. [DOI: 10.1007/s12310-017-9224-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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45
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The implementation of prolonged exposure: Design of a multisite study evaluating the usefulness of workshop with and without consultation. Contemp Clin Trials 2017; 61:48-54. [PMID: 28739538 DOI: 10.1016/j.cct.2017.07.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 07/10/2017] [Accepted: 07/20/2017] [Indexed: 11/23/2022]
Abstract
This randomized trial examines the dissemination and implementation of prolonged exposure (PE) therapy for posttraumatic stress symptoms in U.S. Army medical treatment facilities. The study compares two PE training models: Standard PE training, comprised of a 4-day workshop only, and Extended PE training, comprised of a 4-day workshop plus expert case consultation. Behavioral health providers (N=180) across three medium-to-large Army installations will be randomly assigned to either Standard PE training or Extended PE training. Changes in provider attitudes will be examined across groups. After completing PE training, the use of PE components with patients reporting posttraumatic stress symptoms and clinical outcomes of these participating patients (N=500) will be examined. This article describes the rationale and methods of the study. In addition, a number of methodological issues in conducting a multisite naturalistic study in the U.S. Army are discussed.
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46
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Lemmens LH, Galindo-Garre F, Arntz A, Peeters F, Hollon SD, DeRubeis RJ, Huibers MJ. Exploring mechanisms of change in cognitive therapy and interpersonal psychotherapy for adult depression. Behav Res Ther 2017; 94:81-92. [DOI: 10.1016/j.brat.2017.05.005] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 05/03/2017] [Accepted: 05/06/2017] [Indexed: 11/27/2022]
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47
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O'Mahen HA, Wilkinson E, Bagnall K, Richards DA, Swales A. Shape of change in internet based behavioral activation treatment for depression. Behav Res Ther 2017; 95:107-116. [PMID: 28618298 DOI: 10.1016/j.brat.2017.05.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 04/14/2017] [Accepted: 05/15/2017] [Indexed: 11/29/2022]
Abstract
Shape of change, sudden gains and depression spikes were examined in an online 12-session Behavioral Activation (BA) treatment for depression. Client and therapist factors related to sudden gains were examined to investigate processes associated with outcome. METHODS Participants were postpartum Women with Major Depressive Disorder (n=42) who received online BA supported in 30-minute telephone sessions by a mental health worker. Depression symptoms were assessed at each session and number of sessions completed were recorded by the online program. Therapist records were rated for client stressful life event and therapist concrete focus. A quadratic pattern provided the best fit with the data; a cubic pattern was a poor fit. Sudden gains, but not depression spikes, predicted lower depression scores at 17-week outcome. Women who had higher baseline social functioning, did not experience a stressful life event during therapy, and completed more online modules, but not more telephone sessions, were more likely to have a sudden gain. A concrete therapist focus was associated with sudden gains. These results extend research on trajectories of change and sudden gains to an online BA treatment and to postpartum depression, and suggest important client and therapist factors associated with sudden gains.
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Affiliation(s)
- Heather A O'Mahen
- Mood Disorders Centre, University of Exeter, Washington Singer Building, Exeter EX4 4QG, UK.
| | | | - Kara Bagnall
- Mood Disorders Centre, University of Exeter, Washington Singer Building, Exeter EX4 4QG, UK.
| | - David A Richards
- University of Exeter Medical School, St. Lukes Campus, South Cloisters, Exeter EX1 2LU, UK.
| | - Amanda Swales
- Mood Disorders Centre, University of Exeter, Washington Singer Building, Exeter EX4 4QG, UK.
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48
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Falkenström F, Larsson MH. The Working Alliance: From Global Outcome Prediction to Micro-Analyses of Within-Session Fluctuations. PSYCHOANALYTIC INQUIRY 2017. [DOI: 10.1080/07351690.2017.1285186] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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49
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Gamarra JM, Luciano MT, Gradus JL, Wiltsey Stirman S. Assessing Variability and Implementation Fidelity of Suicide Prevention Safety Planning in a Regional VA Healthcare System. CRISIS 2016; 36:433-9. [PMID: 26648231 DOI: 10.1027/0227-5910/a000345] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND In 2008, the Veterans Health Administration (VHA) implemented the use of safety planning for suicide prevention. A safety plan is a list of strategies, developed collaboratively with a provider, for a patient to use when suicide risk is elevated. Despite the use of safety plans in VHA, little is known about implementation fidelity, the extent to which safety plans are delivered as intended, or patient-level outcomes of safety planning. AIMS This study aimed to explore the implementation fidelity of safety planning in a regional VHA hospital and examine the associations between safety plan quality and completeness with patient outcomes. METHOD A comprehensive chart review was conducted for patients who were flagged as high risk for suicide (N = 200). Completeness and quality were coded, as well as information about patient and provider interactions regarding safety plan use. RESULTS Safety plans were mostly complete and of moderate quality, although variability existed, particularly in quality. Limited evidence of follow-up regarding safety planning was found in the medical charts. Higher quality was associated with fewer subsequent psychiatric hospitalizations. CONCLUSION Variability in implementation fidelity and infrequent follow-up suggest a need for additional training and support regarding the use of safety plans for suicide prevention.
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Affiliation(s)
- Jennifer M Gamarra
- 1 National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA.,2 Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA.,5 Department of Psychology, University of California, Los Angeles, CA, USA
| | - Matthew T Luciano
- 1 National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA.,4 Department of Psychology, University of Memphis, TN, USA
| | - Jaimie L Gradus
- 1 National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA.,2 Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA.,3 Department of Psychiatry and Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Shannon Wiltsey Stirman
- 1 National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA.,2 Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA.,6 National Center for PTSD, VA Palo Alto Healthcare System, Palo Alto, CA, USA
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50
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Kushner SC, Quilty LC, Uliaszek AA, McBride C, Bagby RM. Therapeutic alliance mediates the association between personality and treatment outcome in patients with major depressive disorder. J Affect Disord 2016; 201:137-44. [PMID: 27219531 DOI: 10.1016/j.jad.2016.05.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 04/30/2016] [Accepted: 05/13/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patient personality traits have been shown to influence treatment outcome in those with major depressive disorder (MDD). The trait agreeableness, which reflects an interpersonal orientation, may affect treatment outcome via its role in the formation of therapeutic alliance. No published studies have tested this hypothesis in patients with MDD. METHOD Participants were 209 outpatients with MDD who were treated in a randomized control trial. Mediation analyses were conducted to examine the role of therapeutic alliance in the association between pretreatment personality and the reduction of depression symptom severity during treatment. Separate models were estimated for patient- versus therapist-rated therapeutic alliance. RESULTS We found a significant indirect effect of agreeableness on the reduction of depression severity via patient-rated therapeutic alliance. Results were replicated across two well-validated measures of depression symptom severity. Results also partially supported indirect effects for extraversion and openness. Therapist ratings of alliance did not mediate the association between personality and treatment outcomes. LIMITATIONS Patients were recruited as part of a randomized control trial, which may limit the generalizability of results to practice-based clinical settings. Due to constraints on statistical power, intervention-specific mediation results were not examined. CONCLUSIONS These results highlight the importance of personality and the role it plays in treatment process as well as outcome.
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Affiliation(s)
| | - Lena C Quilty
- University of Toronto, Canada; Centre for Addiction and Mental Health, Canada
| | - Amanda A Uliaszek
- University of Toronto, Canada; Centre for Addiction and Mental Health, Canada
| | - Carolina McBride
- University of Toronto, Canada; Centre for Addiction and Mental Health, Canada
| | - R Michael Bagby
- University of Toronto, Canada; Centre for Addiction and Mental Health, Canada.
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