Adherence, flexibility, and outcome in psychodynamic treatment of depression

Therapeutic techniques and session impact: A practice-research network study in private practice

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.

Convergence in patient and therapist alliance ratings early in treatment with Personality Assessment Inventory clinical scales and subscales

We examined discrepancies in 81 patient-therapist dyads' alliance ratings early in treatment (3rd or 4th session) in relation to Personality Assessment Inventory clinical scales, subscales and global psychopathology. Results indicated that PAI global psychopathology (mean clinical elevation) and the scales of Aggression [AGG], Somatization [SOM], and Anxiety-Related Disorders [ARD] were significantly, negatively associated with an absolute difference of patient and therapist alliance ratings at Session 3. Higher initial scores on these clinical scales at treatment onset are associated with less difference (i.e., more convergence) in patient/ therapist ratings of alliance at Session 3. Correlations between PAI clinical subscales and absolute differences of patient and therapist alliance ratings at Session 3 also demonstrated statistically significant inverse relationships for several PAI subscales of Aggression- Attitude [AGG-A], Aggression-Physical [AGG-P], Somatic- Health Concerns [SOM-H], Anxiety-Related Disorders-Traumatic Stress [ARD-T], Anxiety-Related Disorders- Obsessive Compulsive [ARD-O], Borderline Features-Affective Instability [BOR-A], Borderline- Self-Harm [BOR-S], Anxiety-Physiological [ANX-P], Depression-Physiological [DEP-P] and Antisocial-Stimulus Seeking [ANT-S]. Again, higher scores on these subscales at treatment onset are associated with less difference (i.e., more convergence) in patient/therapist ratings. We also examined group differences between patients rating alliance higher (Group 1) and therapists rating alliance higher (Group 2) and found that Group 1 had significantly lower scores on Mania-Activity Level [MAN-A]. Clinical implications of results are discussed.

Is it me, is it you or is it both of US? Applying the social relations model to disentangle the components of the therapeutic bond

OBJECTIVE

The study investigated the contribution of therapists and patients to the therapeutic bond and their associations (at the within and between levels) to treatment outcome. On this aim, the social relations model (SRM, aimed to analyze dyadic interpersonal data) was implemented.

METHOD

A novel design for individual psychotherapy studies was adopted, a many-with-many asymmetrical block dyadic design, in which several patients interact with several therapists. Hierarchical linear models were computed to study through variance partitioning the different components of the SRM and their association to treatment outcome.

RESULTS

All SRM components (with significant effects at therapist- and patient- within and between levels) resulted in significant contributions to the bond. However, only components at the within- and between-therapist, and within-patient levels resulted in significant associations with outcome.

CONCLUSION

Given the dyadic nature of the bond, our results support not only studying and offering clinical training on interpersonal therapeutic skills but also on constant monitoring and feedback of the relationship at the more idiosyncratic level.

Patient personality characteristics and therapeutic integration: treating borderline personality and emotionally dysregulated-dysphoric personality features

This study examines the relationship between patient personality characteristics and therapeutic integration. Within a sample of patients (N=93) receiving outpatient psychodynamically- oriented psychotherapy, we assessed patient Borderline and Emotionally Dysregulated personality features through the Shedler-Westen Assessment Procedure (SWAP-200), and therapeutic technique using the Comparative Psychotherapy Process Scale (CPPS) during an early treatment session. We examined personality dimensionally, psychotherapy interventions across different theoretical orientations, as well as psychotherapy integration. These analyses revealed an overlap between the Borderline Clinical Prototype and the Emotionally Dysregulated-Dysphoric Q-factor, with the former associated with higher use of integration and the latter associated with higher use of either psychodynamicinterpersonal or cognitive-behavioural interventions. Secondary analyses also indicated the greater presence of interventions oriented towards emotional exploration and to the didactic instruction of effective symptom coping techniques across both of these personality subtypes early in treatment. The key differences between these personality types, as well as the theoretical, empirical, and clinical implications of these findings are discussed.

Personality assessment inventory items in relation to patient- and therapist-rated alliance

Based on the results of prior research, we examined relationships between Personality Assessment Inventory (PAI) items on clinical scales of antisocial features (ANT) and anxiety-related disorders (ARD) with patient- and therapist-rated alliance early in treatment (third or fourth session). We also explored the relationship between the PAI treatment rejection scale (RXR) and early session therapist-rated alliance, despite null findings in previous work. We used PAI protocols from a clinical outpatient sample (N = 80). Data were analysed using backwards linear regressions. Results indicated that a group of ANT items from different ANT subscales predicted patient-rated therapeutic alliance, F(8,59) = 5.182, p = .000, R² of .413, f²  = 0.70. Additionally, a group of ARD items from different ARD subscales significantly predicted therapist-rated alliance, F(6,62) = 3.007, p = .012, R² of .225, f²  = 0.29. No significant relationships were found for RXR items and therapist-rated alliance, consistent with prior findings. Clinical implications are discussed.

Therapist Adherence to Two Treatments for Adolescent Suicide Risk: Association to Outcomes and Role of Therapeutic Alliance

In psychotherapy research, adherence refers to the extent to which therapists deliver a treatment as intended. This study examined whether therapist adherence to two different manualized treatments was associated with improved client outcomes and whether the association was moderated by therapeutic alliance. The study sample included 320 video recordings of therapy sessions from 118 cases in a randomized controlled trial (RCT) comparing attachment-based family therapy (ABFT) with family-enhanced nondirective supportive therapy (FE-NST). Recordings were selected from early, middle, and late stages of treatment. The adherence measure consisted of 24 items representing essential therapist interventions from both treatments. Trained raters coded tapes from both therapies. Adolescent self-report of alliance was measured at session 4. Adherence to ABFT was associated with a significant increase in family cohesion at mid-treatment but not at posttreatment. Adherence to FE-NST was significantly associated with an increase in suicide ideation posttreatment. Using therapeutic alliance as a moderator, adherence to ABFT was significantly associated with a reduction in suicide ideation, family conflict, and higher client satisfaction posttreatment. Alliance did not positively affect the association of FE-NST adherence to outcomes. Findings suggest that adherence to ABFT interventions may be better linked to treatment outcomes when adolescents feel a strong alliance with their therapist. Implications for future research and therapist training are explored.

Challenging rigidity in Anorexia (treatment, training and supervision): questioning manual adherence in the face of complexity

BACKGROUND

Anorexia Nervosa is a debilitating illness. While there have been many advancements to treatment protocols and outcomes for people with eating disorders, the field acknowledges there remains considerable room for improvement. This timely Special Edition of the Journal of Eating Disorders has invited those of us in the field to consider a range of topics in aid of this task, including potential modifications and implementation of evidence-based practice, specific and common psychotherapy factors, treatment manuals, adherence and individualising treatment approaches for individuals and families. BODY: In this paper, we briefly outline the key manualised treatments currently available to treat children, adolescents and adults with Anorexia Nervosa, considering the benefits, potential reasons for adaptations and limitations. We then review the current evidence for training strict adherence to treatment manuals which is often a key focus in training and supervision, questioning the association of increased treatment adherence with improved therapeutic outcome. We then summarise some key evidence behind other therapeutic factors which have been demonstrated to affect outcome regardless of which manual is implemented, such as readiness to change and therapeutic alliance.

CONCLUSION

The paper concludes with implications and considerations for future research, clinical guidelines, training and supervision, highlighting the need to consider the therapeutic relationship and processes alongside manual content to conduct best evidence-informed practice.

Personality Assessment Inventory Clinical Scales in Relation to Patient and Therapist Rated Alliance Early in Treatment

We examined relationships between the Personality Assessment Inventory (PAI) clinical scales (e.g., Somatic Complaints [SOM]) and subscales (e.g., Conversion [SOM-C]) with patient- and therapist-rated alliance early in treatment (third or fourth session). We also replicated and extended findings from a previous study examining PAI treatment scales (Treatment Rejection, Treatment Process Index) and early session therapist-rated alliance. We used PAI protocols from a clinical outpatient sample (N = 84). Data were analyzed using stepwise linear regressions. Results suggest that patients who report lower early session alliance also report more antisocial features (β = -.219, p = .050, f² = 0.05) specifically more antisocial behaviors (β = -.315, p = .004, f² = 0.11). Additionally, therapists report higher early session alliance with patients who report more anxiety-related disorders (β = .274, p = .012, f² = 0.08), specifically traumatic stress (β = .325, p = .003, f² = 0.12). No significant relationships were found between patient- or therapist-rated alliance and Treatment Rejection and Treatment Process Index, consistent with prior findings. Clinical implications are discussed.

[Dementia with Lewy bodies]

Psychodynamic psychotherapy has a long tradition in the treatment of depression. Its effectiveness lies, according to previous studies on the same level as other bonafide therapies. The review first presents the guideline recommendations for the therapy od depression in Germany. Furthermore, classical and modern psychodynamic models of depression are introduced. From these, general and specific therapeutic aspects are derived. The presentation of the therapeutic approach begins with a section on how to deal with acutely depressive patients. In this regard, contextual factors such as medication and social support measures are described as well as how to deal with suicidal tendencies. In addition, typical pitfalls in dealing with these patients are described. In a further section, two particularly typical personality constellations in depressive patients are addressed (avoiding versus ambivalent-preoccupied patterns). These are derived from traditional models of depression as well as from clinical attachment research. Finally, measures for relapse prophylaxis and possible maintenance therapy strategies are presented.

Differential effects of alliance and techniques on Panic-Specific Reflective Function and misinterpretation of bodily sensations in two treatments for panic

ABSTRACTObjective: To examine whether working alliance quality and use of techniques predict improvement in Panic-Specific Reflection Function (PSRF), and misinterpretation of bodily sensations in treatments for panic disorder. Method: A sample of 161 patients received either CBT or PFPP (Panic-focused Psychodynamic therapy) within a larger RCT. Data were collected on patient-reported working alliance, misinterpretations, PSRF, observer-coded use of techniques, and interviewer-rated panic severity. Random-Intercept Cross-Lagged Panel Models assessed bi-directional associations, disentangling within- and between-patient effects, and accounting for prior change. Results: Higher alliance predicted subsequent within-patient improvement in PSRF in PFPP, but worsening in CBT. In both treatments, focus on interpersonal relationships predicted PRSF improvement (with stronger effects in CBT), while focus on thoughts and behaviors predicted worsening in PSRF. In CBT only, early focus on affect and moment-to-moment experience predicted reduced misinterpretation, while high focus on thoughts and cognitions predicted subsequent increase in misinterpretation. Conclusion: The quality of the alliance has differential effects on PSRF in distinct treatments. Interpersonal, rather than cognitive or behavioral focus, even when delivered differently within distinct treatments with high adherence, could facilitate improvement in PSRF. Additionally, early focus on affect and moment-to-moment experiences in CBT could reduce misinterpretations.

Enhancement of self compassion in psychotherapy: The role of therapists' interventions

Aim: Self Compassion (SC) has been consistently linked to decreased emotional distress and is offered as a mechanism of change in several therapeutic approaches. The current study aimed to identify therapists' interventions that enhance clients' SC within individual psychodynamic psychotherapy. We examined a diverse set of interventions as predictors of clients' SC, on treatment and session levels. We hypothesized that improvement in SC will be associated with greater use of directive or common factor interventions. Method: Client/therapist (N = 89) dyads from a university-based community clinic participated in the study. Therapists' interventions and changes in clients' SC level were monitored at each psychotherapy session. Results: Clients' SC in a given session was not predicted by therapist use of interventions from any of the three clusters in the previous session. However, positive change in SC across treatment was predicted by greater use of directive interventions. Furthermore, among clients with low pretreatment SC, a positive change in SC across treatment was predicted by lesser use of common factor interventions. Discussion: The results highlight the importance of understanding clients' pretreatment characteristics when selecting therapeutic interventions and suggest that the integration of directive interventions into the psychodynamic therapeutic practice may be beneficial in enhancing clients' SC.

Emotion Regulation and Parent Distress: Getting at the Heart of Sensitive Parenting among Parents of Preschool Children Experiencing High Sociodemographic Risk

OBJECTIVES

Sensitive parenting requires modulation of emotions in order to effectively organize and orient behavioral responses. There is considerable evidence that psychological distress can impair sensitive parenting practices, and also that psychological distress is associated with deficits in emotion regulation capacities. The negative effect that psychological distress has on parents' emotion regulation capacities may be a mechanistic pathway through which psychological distress impacts parenting, as dysregulated emotions may be more proximal to parenting behaviors than distress itself; however, this specific link between psychological distress, emotion regulation, and parenting is not often examined in parenting models.

METHODS

The current study tested these relations in a high sociodemographic risk community-sample, oversampled for violence exposure, of caregivers of preschoolers. Caregivers self-reported on their psychological distress and emotion regulation difficulties. Parent sensitivity was assessed via observations of parent-child interactions.

RESULTS

Results indicated that difficulties in emotion regulation were a mediator for the relation between parents' psychological distress and sensitive parenting behaviors. Difficulties in emotion regulation predicted decreased sensitivity above and beyond the effect of psychological distress.

CONCLUSIONS

These findings emphasize the importance of regulation of emotional reactions in order to orient and engage in sensitive parenting behaviors. Additionally, they suggest clinically that supporting parents' emotion regulation capacities specifically may promote more sensitive parenting in contexts of parental psychological distress.