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Journal: Psychotherapy research : journal of the Society for Psychotherapy Research

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Abstract One requirement for psychotherapy research is an accurate assessment of therapeutic interventions across studies. This study compared frequency and depth of therapist interventions from a dynamic perspective across four studies, conducted in four countries, including three treatment arms of psychodynamic psychotherapy, and one each of psychoanalysis and CBT. All studies used the Psychodynamic Intervention Rating Scales (PIRS) to identify 10 interventions from transcribed whole sessions early and later in treatment. The PIRS adequately categorized all interventions, except in CBT (only 91-93% categorized). As hypothesized, interpretations were present in all dynamic therapies and relatively absent in CBT. Proportions of interpretations increased over time. Defense interpretations were more common than transference interpretations, which were most prevalent in psychoanalysis. Depth of interpretations also increased over time. These data can serve as norms for measuring where on the supportive-interpretive continuum a dynamic treatment lies, as well as identify potentially mutative interventions for further process and outcome study.

Concepts: Therapy, Psychometrics, Cognitive behavioral therapy, Psychotherapy, Psychoanalysis, Sigmund Freud, Psychodynamic psychotherapy, Psychodynamics

27

Abstract The current study is the first to evaluate the effectiveness of a brief relational-cultural model of therapy in a community-based mental health center for women. The study was distinctive in its use of a hybrid model that employed elements of randomized control and naturalistic design. Results showed that the entire treatment group of 91 women improved significantly on all eight outcome measures. Therapeutic gains were maintained at 3- and 6-month follow-ups. The results lend support to the importance of including relational-cultural factors in the treatment of women. An adherence scale/manual was developed and implemented and will allow for replication.

Concepts: Medicine, Therapy, Classification of Pharmaco-Therapeutic Referrals, The Current

22

Although there is an established link between patients' early positive outcome expectation for and their actual improvement from therapy, there is little research on patients' change in outcome expectation across therapy and both patient and therapist correlates of early outcome expectation level and change. The present study examined: (i) the overall trajectory of change in patients' outcome expectation through cognitive-behavioral therapy (CBT) for depression; (ii) patient characteristics as predictors of both initial outcome expectation and change in outcome expectation; and (iii) between-therapist effects in outcome expectation change.

Concepts: Present, Time, Illness, Clinical psychology, Cognitive behavioral therapy, Major depressive disorder, Psychotherapy, Psychoanalysis

10

Although the past decade has witnessed growing research interest in positive psychological interventions (PPIs), their potential as adjunctive interventions for psychotherapy remains relatively unexplored. Therefore, this article expands the frontiers of PPI research by reporting the first randomized controlled trial to test a gratitude writing adjunctive intervention for psychotherapy clients. Participants were 293 adults seeking university-based psychotherapy services. Participants were randomly assigned to one of three conditions: (a) control (psychotherapy only), (b) a psychotherapy plus expressive writing, and © a psychotherapy plus gratitude writing. Participants in the gratitude condition wrote letters expressing gratitude to others, whereas those in the expressive writing condition wrote about their deepest thoughts and feelings about stressful experiences. About 4 weeks as well as 12 weeks after the conclusion of the writing intervention, participants in the gratitude condition reported significantly better mental health than those in the expressive and control conditions, whereas those in the expressive and control conditions did not differ significantly. Moreover, lower proportions of negative emotion words in participants' writing mediated the positive effect of condition (gratitude versus expressive writing) on mental health. These findings are discussed in light of the use of gratitude interventions as adjunctive interventions for psychotherapy clients.

Concepts: Psychology, Epidemiology, Randomized controlled trial, Linguistics, Writing, Clinical psychology, Psychiatry, Control

4

The dose-response effect refers to the relationship between the dose (e.g., length, frequency) of treatment and the subsequent probability of improvement. This systematic review aimed to synthesize the literature on the dose-response effect in routine psychological therapies delivered to adult patients with mental health problems. Twenty-six studies were eligible for inclusion. Different methodological approaches have been used to examine the dose-response effect; including survival analysis, multilevel modelling and descriptive cluster analyses. Replicated and consistent support was found for a curvilinear (log-linear or cubic) relationship between treatment length and outcomes, with few exceptions such as eating disorders and severe psychiatric populations. Optimal doses of psychotherapy in routine settings range between 4 and 26 sessions (4-6 for low intensity guided self-help) and vary according to setting, clinical population and outcome measures. Weekly therapy appears to accelerate the rate of improvement compared to less frequent schedules. Most of the reviewed evidence is from university counselling centres and outpatient psychotherapy clinics for common mental health problems. There is scarce and inconclusive evidence in clinical samples with chronic and severe mental disorders.

4

To identify psychotherapy clients' motives for concealing suicidal ideation from their therapist, and their perceptions of how their therapists could better elicit honest disclosure.

4

It is estimated that between 3% and 15% of patients have a negative experience of psychotherapy, but little is understood about this.

Concepts: Experience, Knowledge

3

Objective: Empirical findings on self-serving biases amongst psychotherapists are inconsistent. We tested in a large naturalistic data set, if therapists are prone to illusory superiority when estimating their patients' outcome and whether this effect is buffered by therapists' effectiveness. Method: A post-hoc analysis with N = 69 therapists, who treated N = 1080 patients, was conducted. Therapists' and patients' mean ratings for therapeutic improvement in the Clinical Global Impression Scale (CGI) were compared. Using a multilevel modelling approach, we further investigated the relation between the patient-therapist divergence in the CGI and actual therapeutic change in the Global Severity Index (GSI) of the Brief Symptom Inventory and in the Satisfaction With Life Scale (SWLS). Results: Ratings in the CGI did not show significant differences between patients' and therapists' assessment of therapeutic change. Lower estimations by therapists, compared to patients' self-report, were associated with greater therapeutic change in GSI and SWLS. Conclusions: Therapists, on a whole, did not seem to be prone to illusory superiority when assessing therapeutic outcome. Contrary, the more modest the therapists' estimation of therapeutic outcome was, the greater the actual therapeutic change.

2

Aim: To investigate if therapists' personality influences their patients' treatment outcomes.Methods:N = 4,052 patients were treated by 69 therapists, including 36 Psychological Wellbeing Practitioners (PWPs) and 33 Cognitive Behavioural Therapists (CBTs). Therapists completed the NEO-PI-R personality inventory, they reported years of clinical experience, and expert assessors rated their clinical competence and reflective abilities. Their patients completed pre and post-treatment measures of depression (PHQ-9) and anxiety (GAD-7). Associations between therapist personality traits and patient treatment outcomes were examined using multilevel modelling, controlling for therapist demographics, clinical experience, technical competence and reflective ability.Results: Relative to other sources of variability, therapists accounted for 1% to 3% of overall variability in treatment outcomes. However, the magnitude of systematic heterogeneity in performance between therapists was around 6%, such that the best-performing therapists outperformed average therapists by a margin of moderate to large effects (g = .57-1.10). Clinical experience, technical competence and reflective ability were unrelated to treatment outcomes. Patients treated by PWPs with above-average agreeableness scores and CBTs with above-average openness to experience scores had poorer treatment outcomes.Conclusions: Therapist effects may be partly explained by the influence of their personality on their work with anxious and depressed patients.

2

Recent clinical research suggests that facilitating psychological flexibility and emotional processing and decreasing rumination and avoidance are important tasks of treatment for disorders characterized by entrenched patterns of psychopathology, such as major depressive disorder. The current study examined these processes as predictors of treatment outcomes in a subsample of depressed adult patients (n = 49) who had not fully responded to antidepressant medication and were randomized to receive cognitive-behavioral therapy (CBT). Target variables were coded from session recordings at baseline and in the vicinity of two therapeutic transition points: a sudden gain (improvement) and a transient spike in depression symptoms, or at similar periods for those without such transitions. Results indicated that psychological flexibility during the pre-sudden gain period predicted less depression at 12-month follow-up, beyond baseline symptoms and other co-occurring processes. Interaction analyses revealed that when flexibility was low during the post-spike period, avoidance and rumination predicted higher depressive symptoms, whereas emotional processing predicted lower symptoms at the 12-month follow-up. When flexibility was high, none of these variables were associated with outcome. Together, these findings highlight psychological flexibility as a key therapeutic target in CBT for treatment-resistant depression and might have implications for relapse prevention.