Change In Psychotherapy Research Articles

Therapist responsiveness in psychotherapy: Introduction to the special issue

Therapist responsiveness denotes that therapists provide therapeutic interventions within an emerging context of client manifestations and moment-by-moment internal and external changes. So far, psychotherapy research on explaining how therapy works falls short of operationalizing the sequence of events constituted by therapist responsiveness. The present special section of Psychotherapy Research addresses this conceptual and methodological gap and proposes six original contributions, using several validated assessment protocols, both from a quantitative and qualitative viewpoint, to study therapist responsiveness in psychotherapy. It aims at providing a rigorous conceptual and methodological basis for studying a core principle of change in psychotherapy for the future.

Change in emotion-based narrative as a potential mechanism of change in a brief treatment for borderline personality disorder

Background: The move from inconsistent and problematic autobiographical narrative to a more coherent and reality-based narrative construction of the Self has been discussed as potential mechanism of change in psychotherapies for personality disorders. So far, little empirical evidence exists that demonstrates in a time-dependent design the role of narrative construction in the treatment of borderline personality disorder, in particular when it comes to understanding the integration of body-related information from the affective system with the autobiographical narrative. The present study aims at demonstrating change in emotion-based narrative markers over brief psychiatric treatment and to assess the impact of these changes on subsequent symptom change. Methods: A total of N = 57 clients with borderline personality disorder were assessed at three timepoint over the course of four months of brief psychiatric treatment, within the context of a secondary process-outcome analysis of a randomized controlled trial. Symptom change was assessed using the OQ-45.2 and emotion-narrative change was assessed using the Narrative-Emotion Process Coding System to code client’s in-session speech in terms of problem, transition and change markers. Results: All three emotion-based marker categories evidenced significant changes in the assumed direction. The reduction in problem emotion-based narrative markers (e.g., empty story telling) between session 1 and 5 into the treatment predicted the symptom reduction assessed between session 5 and 10. Conclusions: Emotion-based narrative construction may be a suitable method to study the pathway of change toward a more coherent and reality-based narrative construction of the Self-in-interaction-with-the-Other. Reduction of emotion-based problem-marker may be a promising candidate for a mechanism of change in treatments for personality disorders which should be tested in a time-dependent controlled design.

The family alliance as a facilitator of therapeutic change in systemic relational psychotherapy for borderline personality disorder: A case study.

Managing the Therapeutic Alliance is often complex when it comes to the treatment of borderline personality disorder (BPD), but the alliance is crucial for the success of the therapy. Combined individual and family interventions have been shown to be very useful in treating of these cases. This study has two objectives. First, to describe how the family therapeutic alliance facilitates therapeutic change through family psychotherapy for families with a member diagnosed with BPD. Second, to analyze how the therapeutic change achieved through combined individual and family systemic relational psychotherapy affects the individual functioning of the patient with BPD. This single case study used the System of Observation of Family Therapy Alliances (SOFTA-o) to analyze the therapeutic alliance, along with two semi-structured clinical interviews, one at the beginning and one at the end of therapy. Results show a dynamic and positive evolution of the therapeutic alliance throughout the therapeutic process and how this alliance facilitated therapeutic change, both reducing the symptomatology of the patient with BPD and improving family communication and functioning. Results contribute to highlighting the importance of including family therapy as an intervention unit in protocols for patients with BPD.

Issues in achieving a unifying consensus on mechanisms and processes of change in psychotherapy.

Issues in achieving a unifying consensus on mechanisms and processes of change in psychotherapy.

Clinical Utility of the CORE-OM and CORE-10

This study explores the clinical utility of the Clinical Outcomes in Routine Evaluation–Outcome Measure (CORE-OM), and the Clinical Outcomes in Routine Evaluation–10 (CORE-10). This is an exploratory, naturalistic longitudinal study conducted in two psychotherapy services that offer training for psychology students in Ecuador. These services provide affordable and free short-term psychotherapy based on a constructivist approach. In total, 259 adult clients presenting non-severe mental disorders and symptoms and/or relational problems were included, 147 were women (57%); ages ranged from 18 to 66 with mean 28.70 years. At first contact we collected socio-demographic data and responses to the Clinical Outcomes in Routine Evaluation- Outcome Measure, Outcome Questionnaire-45.2 and the Schwartz Outcome Scale-10-E. Data were analyzed with statistical estimation using bootstrap 95% confidence intervals to assess clinical utility and psychometric adequacy of the measures for similar services and clients. The measures showed good acceptability and adequate internal consistency, similar to findings from the United Kingdom and Spain. There were strong correlations between all scale scores of the CORE-OM except for risk. Adequate convergent validity was found for the CORE-OM with the other two measures. There were no significant gender, age, or education effects for initial scores. Comparing help-seeking and non-help-seeking populations, large effect sizes were found for the CORE-OM total, non-risk, and risk scores, and medium effect size for the CORE-10 scores. Cut-off scores for the CORE-OM and CORE-10 were 1.26 and 1.51, respectively. The measures showed sensitivity to change with large effect sizes for all scores, except for risk, which shows a medium effect size. The CORE-OM and CORE-10 are suitable for clinimetric use, the former for broad assessment of psychological state and the latter for tracking changes in psychotherapy. Recommendations are made for assessment structure designs and data interpretation for routine use particularly in Latin America.

Revisiting Empathy, Motivational Systems, and a Theory of Cure

ABSTRACT Lichtenberg’s chapter on “Empathy, Motivational Systems, and a Theory of Cure” was a brilliant effort to integrate his new paradigm of multimotivational systems with Kohut’s empathic approach to psychotherapy. Lichtenberg shows how the clinical dialogue with patients can be monitored by using empathic perception to track shifts in motivational systems. At any given moment, a particular motivational system may become dominant. Successfully identifying the dominant motivation through empathic perception creates in patients a feeling of being understood without judgment. This ambience of safety allows for a shift that activates an exploratory motivation with patients and a spirit of inquiry. An observational platform is created where experience from the past with attachment figures and interaction in the here and now in therapy can be explored from new perspectives. Recent research in psychotherapy that uses monitoring the clinical dialogue with patients by tracking shifts in motivational systems supports the view of its positive effects. Lichtenberg’s “theory of cure” is based on the premise that an empathic perception that monitors shifts in motivational systems will mobilize intrinsic self-righting capacities in patients. I note that there is controversy about what mutative factors in psychotherapy are most important: building an ambience of safety and trust or creating new insights into personal and internal conflicts through the use of language and symbolic representations. Both factors are crucial for positive changes in psychotherapy, and their importance will vary from patient to patient and from one patient–therapist relation to another. I note that Wilma Bucci’s multiple code theory that sees experience coded at subsymbolic and verbal symbolic levels supports this view. I close by proposing that we can build on Lichtenberg’s multimotivational system by adding a trans-survival need to give meaning to our lives.

Developing reflexivity and self-compassion in group psychotherapy: A dialogical and narrative approach

ABSTRACT In this paper, we apply dialogical concepts to understand the development of self-reflexivity and self-compassion during psychotherapy. Specifically, we present a study that mapped clients’ voices and explored their changes in group psychotherapy. Thematic narrative analysis was used to study 20 two-hour group therapy sessions of a systemic informed approach. The analysis involved mapping of the voices of each group member, categorizing them as compassionate and/or reflexive and a sequential depiction of the group voices through timelines. The last step of the analysis included studying the development of self-reflexive and self-compassionate voices through time. It showed an important change, not on the number of clients’ self-reflexive voices that appeared during psychotherapy, but mostly on the quality of the self-reflexive voices in favor of voices that were both self-reflexive and self-compassionate. This change seems to take place as a result of the internalization and “rehearsal” of more kind and compassionate voices that appear in the group dialogues. Hence, this study suggests that, in parallel with focusing on the presence and amount of the reflexive processes that occur in psychotherapy, psychotherapy research should also focus on the changes in the quality of these processes, and particularly the development of self-compassion in psychotherapy.

Psychotherapy focusing on dialogical and narrative perspectives: a systematic review from qualitative and mixed-methods studies.

This systematic review identified qualitative and mixed-methods empirical studies on psychotherapy from dialogical and narrative approaches, aiming to address the following questions: (1) How are subjectivity and intersubjectivity qualitatively understood in dialogical and/or narrative psychotherapies studied using dialogical and narrative approaches? (2) How do therapeutic changes occur, including their facilitators and barriers? (3) What psychotherapeutic resources are available for psychotherapists in these types of studies? The articles were selected according to the Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the eligibility criteria proposed by the PICOS strategy (participants, interventions, comparators, outcomes, and study design) from 163 records identified in the Web of Science Core Collection databases. The systematic review process allowed the selection of 16 articles. The results provided insights into the understanding of subjectivity, intersubjectivity, change in psychotherapy, its facilitators, and barriers from these perspectives. It also offered some therapeutic interventions that can be implemented in psychotherapies, integrating dialogical and/or narrative aspects. The centrality of dialogical exploration of patient/client resources, therapists as interlocutors fostering client agency, polyphony serving as scaffolding for change, and interconnection with the sociocultural environment are discussed. The integration of this latter topic has been a challenge for these types of studies, considering the active construction of shared meanings. The dialogical and narrative approaches focus psychotherapy on transforming meanings through dialogue and re-authoring stories, evolving within cultural and historical contexts. Thus, this study highlights the relevance of these perspectives in contemporary psychotherapy, emphasizing dialogue in co-creation within an intersubjective framework.

Perinatal Psychotherapy Use and Costs Before and After Federally Mandated Health Insurance Coverage

Insurance coverage affects health care access for many delivering women diagnosed with perinatal mood and anxiety disorders (PMADs). The Mental Health Parity and Addiction Equity Act (MHPAEA; passed in 2008) and the Patient Protection and Affordable Care Act (ACA; passed in 2010) aimed to improve health care access. To assess associations between MHPAEA and ACA implementation and psychotherapy use and costs among delivering women overall and with PMADs. This cross-sectional study conducted interrupted time series analyses of private insurance data from January 1, 2007, to December 31, 2019, for delivering women aged 15 to 44 years, including those with PMADs, to assess changes in psychotherapy visits in the year before and the year after delivery. It estimated changes in any psychotherapy use and per-visit out-of-pocket costs (OOPCs) for psychotherapy associated with MHPAEA (January 2010) and ACA (January 2014) implementation. Data analyses were performed from August 2022 to May 2023. Implementation of the MHPAEA and ACA. Any psychotherapy use and per-visit OOPCs for psychotherapy standardized to 2019 dollars. The study included 837 316 overall deliveries among 716 052 women (mean [SD] age, 31.2 [5.4] years; 7.6% Asian, 8.8% Black, 12.8% Hispanic, 64.1% White, and 6.7% unknown race and ethnicity). In the overall cohort, a nonsignificant step change was found in the delivering women who received psychotherapy after MHPAEA implementation of 0.09% (95% CI, -0.04% to 0.21%; P = .16) and a nonsignificant slope change of delivering women who received psychotherapy of 0.00% per month (95% CI, -0.02% to 0.01%; P = .69). A nonsignificant step change was found in delivering individuals who received psychotherapy after ACA implementation of 0.11% (95% CI, -0.01% to 0.22%; P = .07) and a significantly increased slope change of delivering individuals who received psychotherapy of 0.03% per month (95% CI, 0.00% to 0.05%; P = .02). Among those with PMADs, the MHPAEA was associated with an immediate increase (0.72%; 95% CI, 0.26% to 1.18%; P = .002) then sustained decrease (-0.05%; -0.09% to -0.02%; P = .001) in psychotherapy receipt; the ACA was associated with immediate (0.77%; 95% CI, 0.26% to 1.27%; P = .003) and sustained (0.07%; 95% CI, 0.02% to 0.12%; P = .005) monthly increases. In both populations, per-visit monthly psychotherapy OOPCs decreased (-$0.15; 95% CI, -$0.24 to -$0.07; P < .001 for overall and -$0.22; -$0.32 to -$0.12; P < .001 for the PMAD population) after MHPAEA passage with an immediate increase ($3.14 [95% CI, $1.56-$4.73]; P < .001 and $2.54 [95% CI, $0.54-$4.54]; P = .01) and steady monthly increase ($0.07 [95% CI, $0.02-$0.12]; P = .006 and $0.10 [95% CI, $0.03-$0.17]; P = .004) after ACA passage. This study found complementary and complex associations between passage of the MHPAEA and ACA and access to psychotherapy among delivering individuals. These findings indicate the value of continuing efforts to improve access to mental health treatment for this population.

Increasing psychological flexibility is associated with positive therapy outcomes following a transdiagnostic ACT treatment.

Increasing psychological flexibility is considered an important mechanism of change in psychotherapy across diagnoses. In particular, Acceptance and Commitment Therapy (ACT) primarily aims at increasing psychological flexibility in order to live a more fulfilling and meaningful life. The purpose of this study is to examine 1) how psychological flexibility changes during an ACT-based treatment in a transdiagnostic day hospital and 2) how this change is related to changes in symptomatology, quality of life, and general level of functioning. 90 patients of a psychiatric day hospital participated in the study. Psychological flexibility, symptomatology, and quality of life were assessed at three measurement time points (admission, discharge, and 3-month follow-up). The level of functioning was assessed at admission and discharge. Differences in psychological flexibility were tested via two-sided paired samples t-tests. Correlations of residualized change scores were calculated to detect associations between changes in psychological flexibility and other outcomes. Psychological flexibility increased significantly from pre-treatment to post-treatment (d = .43, p <.001) and from pre-treatment to follow-up (d = .54, p <.001). This change was significantly correlated to a decrease in symptomatology (r = .60-.83, p <.001) and an increase in most dimensions of quality of life (r = -.43 - -.75, p <.001) and general level of functioning (r =-.34, p = .003). This study adds further evidence for psychological flexibility as a transdiagnostic process variable of successful psychotherapy. Limitations are discussed.

Direct retrospective measurement of therapeutic changes: an example using the Czech version of the Questionnaire of Personal Changes (Q-PC)

Objective: The study aimed to test the psychometric properties of the Czech translation of the Questionnaire of Personal Changes (Q-PC), a measure designed for retrospective (direct) measurement of change in psychotherapy. Methods: A sample of group psychotherapy clients (N = 222) and a nonclinical sample (N = 167) sample were used. Clients in the clinical sample were administered the Q-PC in addition to several pre–post outcome measures. Confirmatory factor analysis, correlational analysis, and structural equation modeling were used to test the Q-PC’s factor structure, longitudinal measurement invariance, reliability, convergent validity, sensitivity to change, and other psychometric properties. Results: The Q-PC demonstrated a unidimensional structure that was strictly invariant between two follow-up measurement waves. The measure also demonstrated excellent reliability and sensitivity to change and good convergent validity. Furthermore, it demonstrated a similar relationship to baseline severity as the pre–post outcome measures. Conclusions: The retrospective measurement of change is a promising approach that has the potential to complement the traditional pre–post measurement of change.

Thinking Transtheoretically About Alliance and Rupture: Implications for Practice and Training.

Repairing alliance ruptures has the potential to serve as a powerful mechanism of change in psychotherapy. In this article, a transtheoretical individual-specific framework for repairing alliance ruptures is proposed. According to the proposed framework, at the intake session, the therapist evaluates the trait-like tendencies of individual patients to face ruptures in interpersonal relationships. We propose a typology based on which patients are assigned to one of the following therapeutic strategies: (a) a treatment where alliance rupture and repair is the main mechanism of change (Type A), (b) an added module that augments another treatment, focusing on rupture and repair (Type B), or (c) treatment where no rupture resolution work is carried out (Type C). The proposed framework is based on cumulative clinical knowledge, and its validity and utility need to be assessed in future research.

Is respiratory sinus arrhythmia a modifiable index of symptom change in cognitive behavioral therapy for youth? A pooled-data analysis of a randomized trial

Objective We evaluated whether respiratory sinus arrhythmia (RSA) reactivity and resting RSA—physiological markers reflecting the increase in heart rate with inspiration and decrease during expiration related to parasympathetic influence on the heart—are modifiable and predict symptom change during youth psychotherapy. Methods: Diverse youth (N = 158; ages 7–15; 48.1% female) received the Modular Approach to Therapy for Children and completed pre-treatment (pre), post-treatment (post), and 18-months postbaseline (18Mo) assessments. We measured resting RSA, RSA reactivity during stress induction, and psychopathology symptoms. Results: Pre-to-post and pre-to-18Mo, reactivity decreased, and resting RSA increased. Changes in reactivity and resting RSA, separately, did not predict reduced psychopathology. Yet, decreased reactivity combined with increased resting RSA predicted reduced psychopathology over time, suggesting that observed RSA changes were beneficial for some. Higher dosage of a module utilizing slow-breathing, muscle-relaxation, and imagery predicted greater pre-to-18Mo changes in reactivity and resting RSA, whereas a similar module with less emphasis on slow-breathing did not. Conclusions: Findings raise the possibility that youth reactivity and resting RSA could be modifiable during cognitive behavioral therapy and contribute to the amelioration of psychopathology. More studies are needed to determine whether resting RSA and RSA reactivity are modifiable indices of symptom change in slow-breathing practices and psychotherapy. ClinicalTrials.gov Identifier NCT03153904, registered May 15, 2017.

Enhancing mentalization by specific interventions within mentalization-based treatment of adolescents with conduct disorder.

Mentalization is discussed as a mechanism of change in psychotherapy due to its positive effects on psychological functioning. In order to specifically apply mentalization-based interventions, a better understanding of the relationship between interventions and in-session mentalization is needed. The study aimed to explore the association between interventions and effective mentalizing. Fifteen therapy sessions of three therapies with male adolescents with conduct disorder were transcribed and rated with the Reflective Functioning (RF) Scale and a newly developed Mentalization-based Treatment (MBT) intervention coding manual. The coded interventions were categorized into intervention levels according to the MBT manual. Fisher's exact tests were performed to test differences in frequencies of interventions in high-RF sequences (RF score ≥ 4) compared with remaining therapy sequences (RF score ≤ 3). Specific MBT interventions such as demand questions, affectelaboration, empathic validation, change of subject, challenge, patienttherapist relation and mentalizing for the patient were related to effective mentalizing. Moreover, intervention levels such as supportive & empathic, basic- mentalizing & affect mode and relational mentalizing were positively associated with effective mentalizing. MBT interventions seem to promote effective mentalizing at various intervention levels. Interventions that enhance effective mentalizing seem to be patient specific. In line with MBT theory, their effect on effective mentalizing might depend on various variables, such as the patients' arousal and pre-mentalizing mode.

Trajectories of change in weekly and biweekly therapy.

Higher therapy session frequency has been found to result in faster recovery, but few studies have considered that clients follow diverse trajectories of change in psychotherapy. It is unknown how session frequency may affect the sizes and shapes of change trajectories. The present study examined clients' change trajectories in weekly and biweekly therapy in a naturalistic setting, as well as predictors of these trajectories. Using a sample of 5,102 clients receiving 3-10 therapy sessions at a university counseling center, we identified 886 clients attending approximately weekly therapy and 1,753 clients attending approximately biweekly therapy. We examined the change trajectories of the weekly and biweekly samples using latent growth mixture modeling (LGMM). Three trajectories were identified in weekly therapy: slow change (78.33%), early improvement (17.61%), and worse before better (4.06%), and in biweekly therapy: slow change (80.38%), early improvement (13.52%), and worse before better (6.1%). The worse before better subgroup in weekly therapy experienced greater deterioration than those in biweekly therapy. The slow change and early improvement subgroups in weekly therapy showed treatment outcome comparable to those of their respective counterparts in biweekly therapy. Clients' intake symptoms, including eating concerns, frustration/anger, depression, and academic concerns, significantly predicted change trajectories. Compared to biweekly therapy, weekly therapy leads to higher chances of early improvement and shortens the duration of suffering but results in greater deterioration for individuals who deteriorate in therapy. The impact of session frequency on treatment outcome varies across clients, and session frequency should be adjusted individually. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

A Relational Dialogue with Maurizio Andolfi: Master Family Therapist and Social Psychiatrist

Maurizio Andolfi, MD, an internationally renowned Master Family Therapist and Social Psychiatrist, was recently awarded an Honorary Fellowship in the World Association of Social Psychiatry for his many contributions to child psychiatry, family psychotherapy, and social psychiatry. This article offers an overview of Dr. Andolfi’s origins, professional training, and career achievements and identifies the key themes and techniques he elaborated throughout his career as a child psychiatrist, family psychotherapist, and social psychiatrist. The heart of this encounter with Dr. Andolfi is based on a comprehensive interview which is presented as a relational dialogue, inspired by his approach to relational psychology and relational therapy. A relational dialogue is an exchange between interlocutors who alternate fluidly in the roles of active listening and speaking to each other respectfully. Dr. Andolfi’s responses to a dozen questions are edited into a narrative with numerous direct quotes, organized by thematic labels in his own words, from what motivated him to become a psychiatrist and family psychotherapist to how he sees the relationship between family work and social psychiatry, and finally, to how he sees the nature of change and transformation in psychotherapy and how he now experiences authenticity with maturity and the voice of experience.

Homework as a driver of change in psychotherapy.

The utilization of Between-Session Homework (BSH) holds a longstanding tradition in the field of psychotherapy. Significantly, it serves as a pivotal catalyst for change within behavioral and cognitive-behavioral therapies, and has also garnered endorsement within psychodynamic and humanistic-experiential therapies. While our current conceptualization of BSH is characterized by assimilation and integration, diversity prevails in how BSH is incorporated into the treatment plan, spanning various therapy stages, thus necessitating a customized therapist-client interpersonal dynamic. Far from being a panacea, the employment of BSH emerges as a highly sophisticated and intricate clinical methodology, demanding a high degree of therapist proficiency and competence to facilitate client engagement. In this introductory paper, we present an issue of the Journal of Clinical Psychology: In Session that exemplifies the diverse modalities through which BSH can be integrated into clinical practice across various client demographics and within distinct psychotherapeutic paradigms. We place specific emphasis on the pivotal role of BSH and its interplay with proposed mechanisms of change throughout the course of treatment. Initially, we provide an overarching view of the subject and expound on empirical research substantiating the efficacy of BSH in psychotherapy. Subsequently, we delve into strategies for adeptly integrating and monitoring BSH within clinical practice. Our primary objectives encompass affording readers a more lucid comprehension of (1) the content and nature of homework; (2) the influence of BSH on treatment outcomes; and (3) the ways through which therapists can foster client engagement with BSH. Finally, we introduce the six papers comprising this issue.

Theory and Interpersonal Processes in Compassion Focused Therapy

This paper reviews key theories underlying the interpersonal process in Compassion Focused Therapy (CFT) and links these to purported mechanisms of action in CFT. The paper goes on to provide a concrete practice example of an exampled dialogue between a clinician and client and narrates the interpersonal processes and mechanisms of action in an attempt to elucidate how interpersonal processes can be leveraged to facilitate therapeutic change. In so doing, this paper seeks to advance scholarship on precise mechanisms of change in psychotherapy, especially interpersonal processes in psychotherapy. Furthermore this paper seeks to provide a useful account of how interpersonal theory can be enacted in a clinical interaction.

Leveraging the Clinical Importance of the Therapist as a Person in Family Therapy

ABSTRACT Many pioneering family therapists exuded exemplary personal characteristics that at many instances were incorporated into their clinical work and theoretical approaches to psychotherapy. While such therapist effects have been traditionally less researched compared with the vast literature on the efficacy of techniques, they are of increased empirical attention, especially given the common factors of psychotherapy change and related process research. To explicate these therapist effects, empirical studies within the fields of marriage and family therapy specifically and psychotherapy more broadly are reviewed concerning those personal characteristics that are linked to or are postulated to be associated with therapeutic success. Following a brief synthesis of this literature, two family therapy pioneers, Carl Whitaker and Salvador Minuchin, are reviewed, concerning their personality attributes and characteristics that were highlights of their approaches and their personal and professional lives. Following a comparison of these two therapists, the manuscript closes with reflections for future psychotherapy research, for training initiatives, and for clinicians.

The multi-level outcome study of psychoanalysis for chronically depressed patients with early trauma (MODE): rationale and design of an international multicenter randomized controlled trial

BackgroundWhether and how psychotherapies change brain structure and function is unknown. Its study is of great importance for contemporary psychotherapy, as it may lead to discovery of neurobiological mechanisms that predict and mediate lasting changes in psychotherapy, particularly in severely mentally ill patients, such as those with chronic depression. Previous studies have shown that psychoanalytic psychotherapies produce robust and enduring improvements in not only symptom severity but also personality organization in patients who have chronic depression and early life trauma, especially if therapy is delivered at a high weekly frequency.Methods/designPatients with chronic major depression and a history of early life trauma will be recruited, assessed, and treated across 3 international sites: Germany, Switzerland, and the United States. They will be randomized to one of two treatment arms: either (1) once weekly psychoanalytic psychotherapies, or (2) 3–4 times weekly psychoanalytic psychotherapies. They will have full clinical characterization as well as undergo MRI scanning at study baseline prior to randomization and again one year later. A group of matched healthy controls will undergo similar assessments and MRI scanning at the same time points to help discern whether study treatments induce brain changes toward or away from normal values. Primary study outcomes will include anatomical MRI, functional MRI, and Diffusion Tensor Imaging measures. Study hypotheses will be tested using the treatment-by-time interaction assessed in multiple general linear models with repeated measures analyses in an intent-to-treat analysis.DiscussionMODE may allow the identification of brain-based biomarkers that may be more sensitive than traditional behavioral and clinical measures in discriminating, predicting, and mediating treatment response. These findings could help to personalize care for patients who have chronic depression patients and early life trauma, and they will provide new therapeutic targets for both psychological and biological treatments for major depressive illness.