Enhancing Psychotherapy Outcomes by Encouraging Patients to Regularly Self-Monitor, Reflect on, and Share Their Affective Responses Toward Their Therapist: Protocol for a Randomized Controlled Trial

Evidence of Measurement Invariance in the Working Alliance Inventory Across In-Person and Videoconferencing Psychotherapy

OBJECTIVE

The Working Alliance Inventory-Short Revised (WAI-SR) is a self-report measure of therapeutic alliance from the patient's perspective. This study aimed to examine the factor structure of the WAI-SR and evaluate its measurement invariance across in-person and videoconferencing psychotherapy sessions.

METHOD

The study sample consisted of 1043 adult patients. Exploratory and confirmatory factor analyses were conducted to evaluate the WAI-SR dimensions and structure. Measurement invariance was tested using multi-group confirmatory factor analysis, multiple indicator multiple causes model analysis, and item bias analysis.

RESULTS

The findings supported a three-factor structure of the WAI-SR, encompassing goal, task, and bond dimensions. Results demonstrated configural, metric, scalar, and residual invariance across in-person and videoconferencing formats. The factor structure remained consistent after accounting for patient age and gender. Additionally, no differential item functioning or bias was observed between groups. The WAI-SR exhibited excellent internal consistency and composite reliability.

CONCLUSIONS

The WAI-SR is a reliable and valid tool for assessing therapeutic alliance across both in-person and videoconferencing sessions. The equivalence in measurement properties and mean scores across modalities highlights the adaptability of therapeutic alliance to virtual environments, supporting the broader use of telehealth in psychotherapy.

Development and validation of an 8-item version of the Real Relationship Inventory-Client form

OBJECTIVE

To develop and validate a very brief version of the 24-item Real Relationship Inventory-Client (RRI-C) form.

METHOD

Two independent samples of individual psychotherapy patients (Nsample1 = 700, Nsample2 = 434) completed the RRI-C along with other measures. Psychometric scale shortening involved exploratory factor analysis, item response theory analysis, confirmatory factor analysis (CFA), and multigroup CFA. Reliability and convergent and discriminant validity of the scale and subscales were also assessed.

RESULTS

The 8-item RRI-C (RRI-C-SF) preserves the two-factor structure: Genuineness (k = 4, α = .86) and Realism (k = 4, α = .87), which were correlated at r = .74. CFA provided the following fit indices for the bifactor model: X2/df = 2.16, CFI = .99, TLI = .96, RMSEA = .07, and SRMR = .03. Multigroup CFA showed that the RRI-C-SF was invariant across in-person and remote session formats. The RRI-C-SF demonstrated high reliability (α = .91); high correlation with the full-length scale (r = .96); and excellent convergent and discriminant validity with measures of other elements of the therapeutic relationship, personality characteristics, current mental health state, and demographic-clinical variables. Clinical change benchmarks were calculated to serve as valuable tools for both research and clinical practice.

CONCLUSION

The RRI-C-SF is a reliable measure that can be used for both research and clinical purposes. It enables a nuanced assessment of the genuineness and the realism dimensions of the real relationship.

Effectiveness of a Novel Web-Based Intervention to Enhance Therapeutic Relationships and Treatment Outcomes in Adult Individual Psychotherapy: Randomized Controlled Trial and Analysis of Predictors of Dropouts

BACKGROUND

Routine process and outcome monitoring interventions added to psychotherapy are known to improve treatment outcomes, although they vary in format and effectiveness.

OBJECTIVE

This study aimed to evaluate whether a therapist-independent, internet-based routine process monitoring and feedback system could significantly reduce psychological distress and enhance the quality of the therapeutic relationship compared with a treatment-as-usual control group among individuals already engaged in individual psychotherapy.

METHODS

We randomized 475 participants into either the intervention group, which received access to an internet-based routine process monitoring and feedback system in addition to psychotherapy, or the control group, which received only psychotherapy. The trial lasted for 10 weeks. Follow-up assessments at 5 weeks and 10 weeks used the Clinical Outcomes in Routine Evaluation-Outcome Measure as the primary outcome, with the Working Alliance Inventory-Short Revised and the Real Relationship Inventory-Client form as secondary outcomes.

RESULTS

Per-protocol analyses (n=166) showed that psychological distress decreased in both groups, but there was no significant advantage for the intervention group. The intervention group experienced a decline in the genuineness dimension score of the real relationship, with an effect size of d=-0.27, compared with d=0.01 in the control group. In the intervention group (but not in the control group), dropouts showed significantly lower real relationship levels (P=.002), working alliance quality (P=.051), and emotional disclosure (P=.01) compared with those who completed the study. Additionally, logistic regression revealed distinct predictors of dropout within the control group and intervention group.

CONCLUSIONS

The findings do not provide conclusive evidence for the efficacy of the new internet-based intervention in enhancing self-monitoring and prompting reflection on patients' emotional responses to their therapists. However, the intervention appears to influence patients' perceptions of the genuineness dimension in the therapeutic relationship, warranting further investigation. We hypothesize that this alteration in the genuineness dimension could be attributed to the intervention facilitating a more realistic and accurate perception of the therapeutic relationship among participants.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06038747; https://clinicaltrials.gov/study/NCT06038747.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/55369.

The Brief Version of the Mentalization Scale (MentS-12): Evidence-Based Assessment of Mentalizing Capacity

Recognizing the need for a concise self-report measure of mentalizing capacity, we developed a 12-item iteration of the well-established Mentalization Scale (MentS). Using college student and community samples of Serbian adults (N = 566), we performed a precise selection of items and then examined the psychometric attributes of the shortened scale (MentS-12). The new scale maintains the original three-dimensional structure: self-related mentalization, other-related mentalization, and motivation to mentalize. MentS-12 proves to be both reliable and structurally consistent. To improve its utility in therapeutic contexts, we determined clinical change thresholds for both the complete and abbreviated forms. We hope that its feasibility stimulates the integration of the MentS-12 in longitudinal research projects and real-world clinical settings.

Patients' perspective on the therapeutic relationship and session quality: the central role of alliance

In this study, we examined how four components of the therapeutic relationship-working alliance, real relationship, and positive and negative affective reactions of the patient toward their therapist-relate to each other and to the psychotherapy session outcome, from the patient's point of view. Our simple comprised 700 adult patients in individual psychotherapy who were recruited and participated online. They underwent a baseline evaluation of their most recent therapy session, which encompassed a series of validated self-report measures focused on specific elements of the therapeutic relationship. The results revealed that, from the patient's perspective, working alliance, real relationship, and positive affective reactions toward the therapist were positively correlated with session outcome, while negative affective reactions were negatively correlated. All components predicted session outcome when simultaneously included in a regression model. Collectively, these four components accounted for 30% of the variance in session outcome. Factor analysis revealed four distinct factors, underlying perceptions of the therapeutic relationship. Notably, the bond dimension of the alliance was sufficiently different from the task and goal dimensions, warranting consideration as a distinct construct. These findings, although cross-sectional, lay the groundwork for a more nuanced investigation of multiple dimensions of the therapeutic relationship.

Therapeutic relationship elements and therapy session outcomes: Protocol for a longitudinal study of the patient's perspective

BACKGROUND

There is a growing recognition of the key role of the therapeutic relationship in the outcomes of psychotherapy. However, current understanding of its specific components, their interplay and related patient-therapist dynamics is limited.

OBJECTIVE

(a) To validate two self-report measures to assess subjective affective reactions of patients toward their psychotherapists during specific therapy sessions, and (b) to explore the relationships and dynamics among four elements of the therapeutic relationship: patient reactions toward the therapist, working alliance, alliance ruptures and repairs, and the real relationship.

METHODS

This study uses a nonrandomized, two-time point longitudinal design. The target population is adult patients currently engaged in individual psychotherapy for heterogeneous mental conditions. Participants are recruited through two online recruitment platforms: Research for Me and ResearchMatch. Data collection involves administering two surveys through the Qualtrics online survey platform. The baseline survey assesses information about the most recent therapy session and the preceding week, while the follow-up survey collects data on the subsequent therapy session and the days leading up to it.

DISCUSSION

This research offers three main contributions: (a) it furthers evidence-based assessment in psychotherapy by creating and validating two novel, succinct self-report tools; (b) it enhances theoretical understanding within therapeutic relationship research by exploring the significant impact of patients' perceptions of relationship elements on session outcomes variability; and (c) it will identify therapeutic relationship elements that can either enhance or hinder the overall relationship quality and session outcomes.

ETHICS AND DISSEMINATION

The study protocol was approved by the Institutional Review Board of the University of North Carolina at Chapel Hill. The results will be published in indexed peer-reviewed journals and presented at relevant psychology and psychiatry conferences.

Therapeutic relationship elements and therapy session outcomes: Protocol for a longitudinal study of the patient's perspective

Background

There is a growing recognition of the key role of the therapeutic relationship in the outcomes of psychotherapy. However, current understanding of its specific components, their interplay and related patient-therapist dynamics is limited.

Objective

(a) To validate two self-report measures to assess subjective affective reactions of patients toward their psychotherapists during specific therapy sessions, and (b) to explore the relationships and dynamics among four elements of the therapeutic relationship: patient reactions toward the therapist, working alliance, alliance ruptures and repairs, and the real relationship.

Methods

This study uses a nonrandomized, two-time point longitudinal design. The target population is adult patients currently engaged in individual psychotherapy for heterogeneous mental conditions. Participants are recruited through two online recruitment platforms: Research for Me and ResearchMatch. Data collection involves administering two surveys through the Qualtrics online survey platform. The baseline survey assesses information about the most recent therapy session and the preceding week, while the follow-up survey collects data on the subsequent therapy session and the days leading up to it.

Discussion

This research offers three main contributions: (a) it furthers evidence-based assessment in psychotherapy by creating and validating two novel, succinct self-report tools; (b) it enhances theoretical understanding within therapeutic relationship research by exploring the significant impact of patients' perceptions of relationship elements on session outcomes variability; and (c) it will identify therapeutic relationship elements that can either enhance or hinder the overall relationship quality and session outcomes.

Ethics and dissemination

The study protocol was approved by the Institutional Review Board of the University of North Carolina at Chapel Hill. The results will be published in indexed peer-reviewed journals and presented at relevant psychology and psychiatry conferences.

Assessing the patient's affective perception of their psychotherapist: validation of the in-Session Patient Affective Reactions Questionnaire

Background

Psychotherapists need effective tools to monitor changes in the patient's affective perception of the therapist and the therapeutic relationship during sessions to tailor therapeutic interventions and improve treatment outcomes. This study aims to evaluate the factor structure, reliability, and validity of the in-Session Patient Affective Reactions Questionnaire (SPARQ), a concise self-report measure designed for practical application in real-world psychotherapy settings.

Methods

Validation data was gathered from (N = 700) adult patients in individual psychotherapy. These patients completed the SPARQ in conjunction with additional measures capturing sociodemographic details, characteristics of therapeutic interventions, individual personality traits, mental health symptom severity, elements of the therapeutic relationship, and session outcomes. This comprehensive approach was employed to assess the construct and criterion-related validity of the SPARQ.

Results

The SPARQ has a two-factor structure: Positive Affect (k = 4, ω total = .87) and Negative Affect (k = 4, ω total = .75). Bifactor confirmatory factor analysis (CFA) yielded the following fit indices: X2[df] = 2.53, CFI = .99; TLI = .98; RMSEA = .05; and SRMR = .02. Multi-group CFAs demonstrated measurement invariance (i) across patients who attended psychotherapy sessions in person versus in remote mode, and (ii) across patients with and without psychiatric diagnoses confirmed metric invariance. Furthermore, the SPARQ showed meaningful correlations with concurrently administered measures.

Discussion

The SPARQ proves to be a valuable instrument in clinical, training, and research contexts, adept at capturing patients' session-level affective responses towards their therapist and perceptions of the therapeutic alliance. Comprehensive descriptive statistics and a range of score precision indices have been reported, intended to serve as benchmarks for future research.