Intersession Processes Research Articles

Technical Challenges of a Mobile Application Supporting Intersession Processes in Psychotherapy

Abstract The usage of mobile applications in healthcare is gaining popularity in recent years. The ubiquity of a sophisticated mobile appliance that is applicable to sample ecological patient data in real life by acquiring both mental state and environmental data has enabled new possibilities for researchers and healthcare providers. Collecting data using the mentioned approach is often called Ecological Momentary Assessment (EMA) and is characterized by an unidirectional data flow towards the platform provider. A more challenging approach, in turn, is called Ecological Momentary Intervention (EMI). The latter requires a bidirectional data flow in order to enable the possibility of sending feedback to the patients and controlling their experiences through interventions. Although both approaches are established parts of IT-supported treatments in the field of psychology and psychotherapy until now, the so-called intersession process has not been technically supported appropriately yet. Therefore, the Intersession-Online platform was developed in order to (a) assess intersession processes systematically, (b) monitor a patient, and (c) intervene by suppressing negative thoughts concerning the therapy. In this paper, the technical requirements, architecture, and features of the mobile application of the Intersession-Online platform are presented. In this context, the development of a patient data sampling mechanism, which consists of a sophisticated, inter-questionnaire dependent sampling schedule and synchronization strategy is particularly illustrated and discussed. Altogether, the technical challenges will show that a mobile application supporting intersession processes in psychotherapy is an endeavor which requires many considerations. However, on the other, such a mobile application may be the basis for new technical as well as psychological insights.

Process-symptom-bridges in psychotherapy: An idiographic network approach.

Aimreal-time monitoring of psychotherapeutic processes was recently described as a promising, new way of tracking periods of change in ongoing treatments. This approach generates complex, multivariate datasets that have to be presented in an intuitive way for clinicians to aid their clinical decision-making. Using network modeling and new approaches in centrality analyses, we examine “bridge nodes” between symptom stress and aspects of the psychotherapeutic process between therapy session (intersession processes, ISP). Method:we recorded intersession processes as well as depressive and anxiety symptoms using daily questionnaires in ten cases. Regularized, thresholded intraindividual dynamic networks were estimated. We applied bridge centrality analysis to identify individual bridges between psychotherapeutic processes and symptoms in the resulting models. Case-wise interpretations of bridge centrality values are offered.Resultsbridge centrality analysis revealed individual bridge nodes between intersession processes and symptom severity. Strength and direction of bridges varied substantially across individuals.Conclusiongiven current methodological challenges, idiographic network studies are feasible and offer important insights for psychotherapy process research. In this case, we demonstrated how patients deal with periods of increased symptom stress. In this case we have described how patients deal with their therapy under increased symptom load. Bridges between psychotherapeutic processes and symptom stress are a promising target for monitoring systems based on ISP. Future studies should examine the clinical utility of network-based monitoring and feedback in ongoing therapies. In the near future, process feedback systems based on idiographic models could serve clinicians to improve treatments.

Daily dynamic assessment and modelling of intersession processes in ambulatory psychotherapy: A proof of concept study

Background: the typical mode of assessment in studies on intersession processes (ISP) in psychotherapy is using cross-sectional or weekly measurements. Daily dynamics of intersession processes have not yet been studied. Method: intersession process data from 22 ambulatory psychotherapy cases were collected in a naturalistic study with high temporal resolution, resulting in a total of 1026 daily measurements. Multilevel vector autoregressive (VAR) modelling was applied to discover the temporal course and causal influences among intersession processes. Centrality analysis was applied to discover unique functions of various intersession process variables. Results: a group-level network structure was discovered, offering first insights on the role of different intersession processes during psychotherapy. Centrality analysis revealed unique roles for various aspects of the intersession process. Temporal distance from the last session had only weak influence on the ISP. Conclusions: using short, daily measures, the unique role of various aspects of the ISP were uncovered. Some aspects of the ISP, like recalling session contents or reflection on future session contents, are facilitators of overall ISP intensity. Other aspects like thoughts on payment or appointments or negative treatment-related emotions are likely to suppress ISP.

In here and out there: Systemic alliance and intersession processes in psychotherapy.

In here and out there: Systemic alliance and intersession processes in psychotherapy.

How do patients with anorexia nervosa “process” psychotherapy between sessions? A comparison of cognitive–behavioral and psychodynamic interventions

Objective: Patients’ processing of psychotherapy between sessions (“inter-session process” (ISP)) has been repeatedly shown to be related to outcome. The aim of this study was to compare ISP characteristics of cognitive–behavioral vs. psychodynamic psychotherapy in the treatment of anorexia nervosa (AN) and their relation to outcome. Methods: Data of 106 patients participating in a randomized-controlled trial who received either 40 sessions of enhanced cognitive–behavioral therapy (CBT-E) or focal psychodynamic therapy (FPT) were analyzed. The ISP was measured with the Inter-session Experience Questionnaire (IEQ). Three outcome classes were distinguished: full recovery, partial recovery, and still fulfilling all AN criteria. Results: Patients receiving CBT-E reported more on “applying therapy” in the initial and the final treatment phase compared to FPT patients. In terms of process–outcome relations, higher levels of “recreating the therapeutic dialogue between sessions,” “recreating the therapeutic dialogue with negative emotions” as well as “applying therapy with negative emotions” in the final phase of treatment predicted negative outcome in FPT, whereas overall higher levels of negative emotions predicted negative outcome in CBT-E. Conclusions: In outpatient treatment in AN, the processing of therapy as measured by the IEQ showed surprisingly few differences between CBT-E and FPT. However, different ISP patterns were predictive of outcome, pointing to different mechanisms of change.

The Intersession Process in Psychotherapy for Anorexia Nervosa: Characteristics and Relation to Outcome.

The "inter session process" (ISP) is defined as therapy-related conscious thoughts, memories, and emotions that patients and therapists experience between psychotherapy sessions. It indicates how the participants process and use treatment. The main aim of this study is to describe the ISP characteristics of patients in outpatient treatment for anorexia nervosa (AN). An additional aim is to explore the relation between patients' ISP and treatment outcome. Patients taking part in a randomized controlled trial on outpatient psychotherapy for AN (ANTOP) filled in the Intersession Experience Questionnaire before each of the 40 psychotherapy sessions. Trajectories of different aspects of the ISP were analyzed with growth curve models based on orthogonal polynomials and tested for differences between 3 outcome categories (recovery, partially recovered, full syndrome AN). Data from 108 cases were available for analysis. ISP facets showed diverse, mostly nonlinear, trajectories over the course of treatment. Less favorable outcomes were associated with higher levels of patients' experiencing negative emotions when recalling therapeutic dialogue, thinking about therapy during dreaming/drowsy states, and applying therapeutic learning (in the second half of treatment). Findings confirm an overall relation between ISP and treatment outcome. In outpatient treatment in AN, patients with a less successful course seem to be more preoccupied with therapy and therapist between sessions. For the ISP facet "applying therapeutic learning," findings point to an optimal range dependent on treatment phase. Growth curve modeling is required to describe the nonlinear trajectories of ISP facets.

Working through: In-session processes that promote between-session thoughts and activities.

This study examined whether clients' ratings of the working alliance as well as their perception of cognitive-behavioral (CB) and psychodynamic-interpersonal (PI) techniques (delivered by therapists who used both) were associated with clients' intersession processes (i.e., their thoughts about therapy and therapeutic activity between sessions). Seventy-five clients who were currently in therapy at a large university counseling center participated in the current study. Multilevel regression analyses demonstrated that alliance and clients' perceptions of their therapists' use of PI techniques were positively associated with clients' general thoughts about therapy between sessions. Also, stronger alliances were associated with more therapeutic activities between sessions and more positive (and less negative) thoughts about therapy between sessions. In addition, clients at later sessions who described their therapists as using more PI techniques also reported engaging in more therapeutic activities between sessions (after controlling for the variance in the other variables, such as use of CB techniques). Clients' perceptions of their therapists' use of CB techniques in the most recent session were not related to thinking about therapy or therapeutic activities after controlling for the variance in the other variables.

Internalization of the Therapeutic Process: Differences Between Borderline and Neurotic Patients

Intersession process in psychotherapy refers to the thoughts, memories, and feelings about each other and about their therapy sessions that participants experience during the intervals between sessions. This study compared the intersession process experienced by patients who had been diagnosed with severe borderline personality disorders (BPD) with others who had not. A total of 76 patients with neurotic disturbances and 20 patients with BPD were treated in a therapeutic day clinic and completed the Intersession Experience Questionnaire (IEQ) before sessions of individual psychotherapy and the Session Questionnaire (Stundenbogen) after those sessions. Comparison of the two groups on these measures of intersession process and postsession outcome showed markedly different patterns in patients' evaluations and internalizations of in-session therapeutic experiences: most prominently, that BPD patients internalize therapy sessions with much more negative and contradictory emotions.

The Intersession Questionnaire--an inventory for the measurement of patients' processing of psychotherapy between sessions

In the intervals between psychotherapy sessions, patients often make use of the experiences that they have during sessions with their therapists, but these "intersession processes" (ISP) have been largely neglected in psychotherapy research. This study presents a German version of the Intersession Experience Questionnaire (IEQ, Orlinsky et al. ) called the Inter-Session-Fragebogen (ISF). The ISF was used to study a total of 3.778 intersession intervals in 249 therapy episodes involving 229 patients. The factor structure of the ISF appears to be stable over therapy (up to 25 or even 50 sessions), and also over therapy settings (outpatient, day clinic, inpatient). Just as in the original American samples, there were evidently cross-culturally invariant factors like "Recreating the therapeutic situation", "Applying therapy," and "Relationship fantasies". The emotional qualities of ISP are assessed by two independent factors, called "Remoralizing emotions" and "Negative emotions" (regarding therapy). Differences between therapy settings are evident concerning intensity and trajectories of the factor scores over time.