Mechanisms Of Change In Psychotherapy Research Articles

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.

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.

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.

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.

Mentalization-enhancing therapeutic interventions in the psychotherapy of anorexia nervosa: An analysis of use and influence on patients’ mentalizing capacity

ABSTRACT Objective Improvement in patients’ mentalizing capacities is considered a possible mechanism of change in psychotherapy. This improvement might take place via mentalization-enhancing interventions (MEIs) performed by psychotherapists. The study aimed to explore the use of MEIs in two evidence-based psychotherapeutic treatments for patients with anorexia nervosa (enhanced cognitive-behavior therapy, focal psychodynamic therapy) and their association with the patients’ capacity to mentalize in sessions (“in-session reflective functioning” / in-session RF). Additionally, it was explored, if the amount of MEIs used could either predict change in in-session RF or outcome (end of treatment, one year follow-up). Method 84 audiotapes from psychotherapy sessions of 28 patients of the ANTOP-study (three sessions per patient) were transcribed and rated with both the MEI Rating Scale and the In-Session RF Scale by trained raters. Results MEIs were applied in both treatments. A moderate correlation between the amount of MEIs and patients’ in-session RF as well as its change over the course of treatment was found, but no relation to change in BMI or eating disorder symptoms. Conclusion A greater use of MEIs was related to patients’ in-session-mentalizing. However, there seems to be no simple relation between RF as shown in sessions and symptom change.

Examining Change in the Frequency of Adaptive Actions as a Mediator of Treatment Outcomes in Internet-Delivered Therapy for Depression and Anxiety.

Adaptive actions, including healthy thinking and meaningful activities, have been associated with emotional wellbeing. The Things You Do Questionnaire—21 item (TYDQ-21) has recently been created to measure the frequency of such actions. A study using the TYDQ-21 found that adaptive actions increased across Internet-delivered therapy for symptoms of depression and anxiety, and higher TYDQ-21 scores were associated with lower psychological distress at post-treatment. The current study examined the relationships between adaptive actions and psychological distress among adults (n = 1114) receiving Internet-delivered therapy as part of routine care in Canada, and explored whether adaptive actions mediated reductions in depression and anxiety. As hypothesised, adaptive actions increased alongside reductions in depression and anxiety symptoms from baseline to post-treatment. Treatment effects were consistent when the intervention was provided with regular weekly therapist support or with optional weekly therapist support, and some (but not all) types of adaptive actions had a mediating effect on change in depressive symptoms. The present findings support further work examining adaptive actions as a mechanism of change in psychotherapy, as well as the utility and scalability of Internet-delivered treatments to target and increase adaptive actions with the aim of improving mental health.

Inter-brain plasticity as a biological mechanism of change in psychotherapy: A review and integrative model.

Recent models of psychopathology and psychotherapy highlight the importance of interpersonal factors. The current review offers a biological perspective on these interpersonal processes by examining inter-brain synchrony—the coupling of brain activity between people interacting with one another. High inter-brain synchrony is associated with better relationships in therapy and in daily life, while deficits in the ability to achieve inter-brain synchrony are associated with a variety of psychological and developmental disorders. The review suggests that therapy improves patients’ ability to achieve such synchrony through inter-brain plasticity—a process by which recurring exposure to high inter-brain synchrony leads to lasting change in a person’s overall ability to synchronize. Therapeutic sessions provide repeated situations with high inter-brain synchrony. This can lead to a long-term increase in the ability to synchronize, first with the therapist, then generalized to other interpersonal relationships, ultimately leading to symptom reduction. The proposed inter-brain plasticity model offers a novel biological framework for understanding relational change in psychotherapy and its links to various forms of psychopathology and provides testable hypotheses for future research. Understanding this mechanism may help improve existing psychotherapy methods and develop new ones.

Seeing the past in a new light: change in reports of childhood abuse and neglect before and after inpatient psychotherapy and its relevance for change in depression symptoms

ABSTRACT Objective As changes in mental representations have been discussed as mechanisms of change in psychotherapy, the question arises whether recollections of childhood abuse and neglect are altered as well and how they relate to symptom changes. Method Individuals in psychosomatic inpatient treatment (N = 488, 60.5% women) filled out the Childhood Trauma Questionnaire (CTQ) and Patient Health Questionnaire (PHQ-9). Changes in both were investigated with correlations and t-tests. Linear regression analysis was used to test whether CTQ changes predicted symptom changes. Network analysis was performed to ascertain structural connections between somatic and emotional-cognitive depression symptoms and CTQ subscales before and after treatment. Results After treatment (duration in days: M = 52.83, SD = 20.94), patients reported fewer depression symptoms (d = 0.84), while CTQ scores increased slightly (d = 0.11). Changes in the CTQ predicted recovery from depression symptoms in a statistically significant way (β = .133, p = .001). We did not observe changes in the overall network structure between baseline assessment and discharge. Conclusion The findings suggest that the evaluation of past experiences can change over multiple weeks of psychotherapy. Further, these updated mental representations, indicating a greater recognition of past adversity, may contribute to symptom relief.

Ethics in Psychotherapy: Informed Consent, Digital Professionalism, and Sexual Misconduct.

Ethics in Psychotherapy: Informed Consent, Digital Professionalism, and Sexual Misconduct.

Mentalizing Mediates the Association between Narcissism and Psychotherapeutic Treatment Outcome in a Mixed Clinical Sample

Introduction: Pathological narcissism has been a challenge for the success of psychological treatment, whereas mentalizing has turned out to be an important mechanism of change in psychotherapy. This study focused on the classic narcissistic self (CNS) (i.e., narcissistic grandiosity) as predictor of the outcome. It further investigated whether mentalizing mediates this relation. Methods: A mixed clinical sample of 205 patients was investigated. The CNS scale of the Narcissism Inventory and the Mentalization Questionnaire was used to measure the features of narcissistic grandiosity and the capacity to mentalize, respectively. The symptom outcome was assessed with the Hamburg Modules for the Assessment of Psychosocial Health. Results: Contrary to our expectations, we did not find a direct association between narcissistic grandiosity and a decrease in symptoms. However, mentalizing was found to mediate the association between the CNS as well as between the narcissistic furor and outcome. Conclusion: Our results confirm the ambiguity concerning the clinical significance of narcissistic grandiosity. However, in order to improve the treatment outcome in patients with narcissistic features, especially narcissistic furor, individualized treatment plans might consider introducing interventions that enhance the capacity to mentalize.

Therapists' Views of Mechanisms of Change in Psychotherapy: A Mixed-Method Approach.

The question of what works in psychotherapy has been a subject of debate in the recent years, occupying both clinicians and researchers. In this study, we aimed to assess the current perspectives held by clinicians regarding the processes which produce changes in psychotherapy, as well as the predictors of specific views. Licensed therapists (n = 107), consisting mainly of psychodynamically and integratively oriented psychologists, were asked to write in their own words what they think works in psychotherapy. Thematic analysis was employed to assess the main mechanisms of change as perceived by the therapists. Differences in the prevalence of specific themes were assessed using Friedman and Wilcoxon signed-rank tests. Univariate logistic regressions were employed to assess the factors that predict the probability of reporting a specific mechanism of change. The results indicated that the therapeutic bond was the most highly reported mechanism of change, followed by theory-driven mechanisms of change, therapist characteristics, therapist professionalism, and client motivation. Male therapists were more likely to indicate the professionalism as a mechanism of change compared to female therapists. Higher education was associated with lower reports of therapists’ characteristics as the mechanisms of change. These results suggest that therapists acknowledge the importance of the working alliance, and that the perception of the mechanism of change is associated with various factors which comprise therapist orientation. Limitations and directions for future research are discussed.

Emotional clarity and tolerance of emotional distress as mechanisms of change in short-term psychodynamic psychotherapy for chronic depression.

The aim of this naturalistic process study was to investigate the relationship between emotional clarity and tolerance of emotional distress and depressive symptoms over the course of short-term psychodynamic psychotherapy for chronically depressed patients. Weekly self-reports of emotional clarity, tolerance of emotional distress, and depressive symptoms (PHQ-9) were provided by 252 patients with chronic depression who were admitted to a 13-week inpatient treatment program. Latent curve modeling with structured residuals (LCM-SR) was applied to investigate the between- and within-person effects of week-to-week change in emotional clarity and tolerance of emotional distress as predictors of subsequent depression. The relationship between emotional clarity and tolerance of emotional distress was also investigated. At the within-person level, higher level of emotional clarity and tolerance of emotional distress predicted subsequent lower level of depression. A reciprocal relationship was found for tolerance of emotional distress (lower level of depression predicted subsequent level of tolerance emotional distress) but not for emotional clarity. No within-person effect between emotional clarity and tolerance of emotional distress was found. The results indicate that emotional clarity and tolerance of emotional distress may be mechanisms of change in short-term psychodynamic psychotherapy for chronic depression. The results are consistent with previous findings of the importance of emotional clarity and tolerance of emotional distress in psychotherapy. This study demonstrated the utility of LCM-SR as a method to identity mechanisms of change in psychotherapy. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

How a transdiagnostic approach can improve the treatment of emotional disorders: Insights from clinical psychology and neuroimaging.

Multiple psychological treatments for emotional disorders have been developed and implemented, improving the quality of life of individuals. Nevertheless, relapse and poor response to psychotherapy are common. This article argues that a greater understanding of both the psychological and neurobiological mechanisms of change in psychotherapy is essential to improve treatment for emotional disorders. It aims to demonstrate how an understanding of these mechanisms provides a basis for (i) reconceptualizing some mental disorders, (ii) refining and establishing the evidence for existing therapeutic techniques and (iii) designing new techniques that precisely target the processes that maintain these disorders. Possible future directions for researchers and practitioners working at the intersection of neuropsychology and clinical psychology are discussed.

Psychotherapeutic Change Mechanisms and Causal Psychotherapy: Applications to Child Abuse and Trauma.

The study of change mechanisms in psychotherapy needs to be integrated with the causality of behavior, which leads to the concept of causal psychotherapy. Causal psychotherapy is posited as a useful adjunct to standard, evidence based psychotherapies for child and youth victims of abuse and trauma. The article illustrates six processes that could be involved in causal psychotherapy in this context, from the distal to the proximal. They include the distal mechanism of activation-inhibition coordination. The most proximal one relates to executive function. The intermediate levels include ones related to co-regulation (e.g., self control), analysis-synthesis, objectivity-subjectivity, and psychological reserve, which is a new concept in the domain of psychological change mechanisms. Each of the variables can vary from high to low, with the low end being more problematic. Psychotherapy can aim to bring the patient toward adaptive levels. The literature review focuses on psychotherapeutic change mechanisms, and standard psychotherapies for child/youth abuse/trauma, especially trauma-focused cognitive behavior therapy (TF-CBT). Then, it considers causal aspects of child/youth abuse and trauma, including PTSD. The discussion relates causal therapy to the question of unifying psychology and psychotherapy under the rubric of causality as a core integrative mechanism.

Empirical Conceptualization of Common Factors in Psychotherapy: Factor Structure of the WEB

Our goal was to explore the association pattern of 26 common factors and thereby contribute conceptually to the debate on change mechanisms in psychotherapy with an empirically derived conception of superordinate common factors (global common factors). In addition, we tested reliability and validity aspects of a new instrument to assess common factors. The activation of common factors during in- and outpatient psychotherapy was assessed in 502 patients using a weekly process measure ('Wochenerfahrungsbogen', WEB). The factor structure of the WEB was determined by exploratory factor analysis and verified by confirmatory factor analyses. The four factors Coping, Therapeutic Alliance, Cognitive Integration, and Affective Processing accounted for 59.8 % of the total variance. Subsequent confirmatory factor analyses, using in- and outpatient samples, confirmed this structure. The study provided an empirically based integrative categorisation of common factors. Results on reliability (internal consistency) and construct validity indicate that the WEB is an appropriate measurement instrument to investigate global common factors.

Insight as a dual-perspective construct: Convergence between patients' and professional evaluators' perspective on baseline level of insight and on changes in insight.

Insight gained by patients during treatment has been theorized to be a central mechanism of change in psychotherapy, but empirical studies examining the association between patients' insight and psychopathological symptoms have produced mixed results. The present study addresses these inconsistencies by investigating convergence between the perspectives of patient and professional evaluator on insight and disentangling two potentially distinct components of insight: pretreatment individual differences and changes in insight during treatment. A sample of 393 patients receiving psychodynamic psychotherapy completed pre- and posttreatment measures on symptoms and insight. Professional evaluators evaluated patients' insight based on clinical interviews pre- and posttreatment. Polynomial regression and response surface analyses were used to examine congruence. The results indicate that when there was agreement between the patient and the evaluator on insight, both baseline level of insight and the changes in insight during treatment were found to be related to symptomatic change, although showing different patterns of association. Lower baseline levels of insight were significantly associated with greater symptomatic improvement than were higher levels of insight. At the same time, greater increase in insight during treatment was moderately significantly associated with greater reduction in symptoms, as long as the changes in insight were not minimal. The findings underscore the importance of assessing the congruence between patients' and professional observers' perspectives on patient insight and the potentially distinct roles of between-patients baseline differences and within-patient changes in insight during treatment. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Initial validation of the Defense Mechanisms Rating Scales Q-sort: A Comparison of Trained and Untrained Raters

Objectives: Defense mechanisms underlie a range of healthy and pathological psychological phenomena and are important mechanisms of change in psychotherapy. Thus, the identification of defense mechanisms in clinical work is crucial, however, measures commonly used for their assessment have various limitations. The Defense Mechanisms Rating Scale Q-set (DMRS-Q; Di Giuseppe, 2014) was developed to address these problems, and to provide an easy-to-use, valid, and reliable tool for the assessment of defense mechanisms. The present study aimed to evaluate the reliability of the DMRS-Q when used by trained versus untrained coders, and to examine the criterion validity of the DMRS-Q in relation to its original observer-rated version, the Defense Mechanisms Rating Scale (DMRS; Perry, 1990). Methods: Collateral sessions ( n = 13) with parents of children with externalizing problems were coded with the DMRS-Q by trained and untrained raters, and on the DMRS by an expert rater. Results: We found that both trained and untrained coders were able to assess most defense categories and levels with moderate to excellent reliability on the DMRS-Q, and that untrained coders’ reliability was comparable although slightly lower than untrained coders’ reliability. Moreover, our results indicate the generally good criterion validity of the DMRS-Q when compared to the original DMRS. Discussion: These findings suggest that the DMRS-Q is a promising measure that can be used by clinicians and researchers at all levels of training and with minimal knowledge of defense mechanisms as a reliable and valid method to assess defense mechanisms in clinical settings.

Investigating patient-specific mechanisms of change in SET vs. EFT for depression: study protocol for a mechanistic randomized controlled trial

BackgroundMajor depressive disorder (MDD) is the leading cause of disability worldwide and one of the most heterogeneous mental health disorders. Although there are effective treatments for MDD, about 50% of patients do not respond to treatment. One of the greatest challenges in improving current treatments is identifying the mechanisms responsible for therapeutic change in MDD. The proposed study aims to identify patient-specific mechanisms of change in two treatments for MDD by investigating whether subpopulations of patients differ in the mechanisms of change that operate when receiving a given treatment. Based on theories of targeting weakness and building on strength, we will examine whether the mechanism of change operating when a treatment is provided depends on whether the treatment targets the patient’s strength or weakness.MethodTo test our hypothesis that two treatments, supportive-expressive treatment (SET) and emotion-focused treatment (EFT), differ in their mechanisms of change and to explore whether focusing on the patient’s strength or weakness will result in better treatment outcome, we conduct a mechanistic randomized controlled trial. One hundred and twenty-four individuals diagnosed with MDD are randomized to 16 sessions of either SET or EFT. The two treatments are theorized to differ in their main mechanism of change: SET places emphasis on insight as its main mechanism of change, and EFT places emphasis on emotional processing. Both can serve as strength- or weakness-focused treatments, based on the patient’s baseline levels of insight and emotional processing. The primary outcome is the Hamilton Rating Scale for Depression. Additional measures include self-report measures and clinical interviews, hormonal, motion, acoustic, physiological, and neuroimaging assessments, performance on cognitive tasks, and narrative material (collected from the sessions and interviews).DiscussionThe RCT will expand our understanding of mechanisms of change in psychotherapy, from one-size-fits-all to patient-specific mechanisms of change. By informing therapists about which of the two approaches is most effective with patients based on their baseline characteristics, the RCT will contribute to progress toward personalized treatment.Trial registrationclinicaltrials.gov Identifier: NCT04576182 submitted on October 1st 2020. Funding: The Israel Science Foundation. Trial status: Recruitment is ongoing.

Therapy Processes Associated With Sudden Gains in Cognitive Therapy for Depression: Exploring Therapeutic Changes in the Sessions Surrounding the Gains.

Background: The frequency and clinical impact of Sudden Gains—large symptom improvements during a single between-session interval—in psychotherapy for depression have been well established. However, there have been relatively few efforts to identify the processes that lead to sudden gains.Aim: To explore therapy processes associated with sudden gains in cognitive therapy for depression by examining changes in the sessions surrounding the gains, and the session preceding the gain in particular.Methods: Using ratings of video-recordings (n = 36), we assessed the content, frequency and magnitude of within-session cognitive-, behavioral-, and interpersonal change, as well as the quality of the therapeutic alliance in the session prior to the gain (pre-gain session), the session after the gain (post-gain session) and a control session. After that, we contrasted scores in the pre-gain session with those in the control session. In addition, we examined changes that occurred between the pre- and post-gain session (between-session changes) and explored patients' attributions of change.Results: Although not statistically significant, within-session changes were more frequent and stronger in the pre-gain session compared to the control session. The largest difference between the pre-gain and control session was found in the behavioral domain, and reached the level of trend-significance. There were more, and more impactful between-session changes in the interval during which the gain occurred as compared to a control interval. Exploratory analysis of attributions of change revealed eight subcategories, all corresponding with the cognitive-, behavioral- and interpersonal- domain. The quality of the therapeutic alliance was high and almost identical in all sessions.Conclusion: In spite of its small sample size, our study provides relevant descriptive information about potential precipitants of, themes related to, and attributions given for sudden gains. Furthermore, our study provides clear suggestions for future research. A better understanding of session content in the sessions surrounding sudden gains may provide insight into the mechanisms of change in psychotherapy, hereby suggesting treatment-enhancing strategies. We encourage researchers to conduct research that could clarify the nature of these mechanisms, and believe the methods used in this study could serve as a framework for further work in this area.

Defense Mechanisms and Treatment Response in Depressed Inpatients.

The study investigated the extent to which defensive functioning and defense mechanisms predict clinically meaningful symptomatic improvement within brief psychodynamic psychotherapy for recurrent and chronic depression in an inpatient setting. Treatment response was defined as a reduction in symptom severity of 46% or higher from the baseline score on the Montgomery–Asberg Depression Rating Scale (MADRS). A subsample of 41 patients (19 responders and 22 non-responders) from an RCT was included. For each case, two sessions (the second and the penultimate) of brief inpatient psychodynamic psychotherapy (a manualized 12-session therapy program developed in Lausanne) were transcribed and then coded using the Defense Mechanism Rating Scales (DMRS) and the Psychotic Defense Mechanism Rating Scales (P-DMRS), an additional scale developed to study psychotic defenses. Results showed that defensive functioning and mature and immature defense changed during psychotherapy and predicted treatment response. Patient’s defenses observed throughout therapy also predicted treatment response at 12-month follow-up. The addition of psychotic defenses allows a better prediction of the treatment response. Overall, these results are in line with previous research and provide further validation of defensive functioning as a predictor of outcomes and a mechanism of change in psychotherapy.