Psychotherapy Outcome Research Articles

Increasing outcome measurement precision: Network analysis of items on the Outcome Questionnaire-45.

Psychotherapy outcome research mainly focuses on scale-level changes and constructs that were developed using cross-sectional statistical analysis, possibly concealing important findings on the level of single items, and limiting the clinical utility of outcome scales. Our goal was to explore changes in symptoms, interpersonal problems, and level of functioning in everyday life and to establish groups of items with similar rates of change that could be used to form more coherent targets for measuring different therapeutic outcomes. Triangulated maximally filtered graphs were used to model the network structure of the Outcome Questionnaire-45 in a data set of N = 12,075 university counseling center patients. Dynamic exploratory graph analysis was used to establish communities of items with similar rates of change. Five item communities (anxiety, hopelessness, interpersonal problems, well-being, and work impairment) were found. Compared to the original Outcome Questionnaire-45 subscales, they showed better fit to the data. The "hopelessness" community, which describes the extent of a patient's demoralization before the start of therapy, had a significantly higher rate of change compared to other communities. The discerned item communities provide clinicians with theoretically grounded, precise targets for outcome tracking, thereby enhancing the responsiveness and adaptability of treatment interventions to individual client trajectories. Such granularity enriches our understanding of therapeutic change, with direct implications for tailoring intervention strategies to maximize early therapeutic gains and sustain long-term recovery. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Effectiveness of group analytic and psychodynamic psychotherapy in routine secondary-care practice

Group psychotherapy has been shown to be effective across a diverse range of participants and settings. However, few quantitative studies have examined outcomes of Group Analytic Psychotherapy (GAP) specifically, or compared this with alternative treatments. In the present study we compare outcomes of weekly group analytic psychotherapy (GAP) and individual psychodynamic psychotherapy (PPT) at a psychotherapy service within the UK’s National Health Service. The service collected Clinical Outcomes in Routine Evaluation (CORE) outcome measures between 2010 and 2020 as part of routine clinical practice, furnishing a large observational dataset (N=600 clients). We found that clients showed clinically significant improvement following either GAP (Cohen’s d=0.77) or PPT (d=0.68), and the rate of change during therapy exceeded that during a pre-treatment waiting period. There were no clinically significant differences in effectiveness between GAP and PPT, of either short-term (<1 year) or long-term (> 1 year) duration. These results support a conclusion that both GAP and PPT are effective in routine clinical practice. We consider the advantages and limitations of quantitative outcome measurement from a group analytic perspective and highlight the possible pitfalls of attempting to optimise therapy based on overly narrow criteria.

The effects of cultural humility on therapeutic alliance and psychotherapy outcomes: A systematic review and meta‐analysis

AbstractAimThe present review and meta‐analysis sought to synthesise previous findings of studies examining the correlation between therapist cultural humility, the quality of the therapeutic alliance and psychotherapy outcomes.Materials and MethodsThree databases were searched for relevant citations, yielding 548 records for review. After the systematic review of these articles, a final sample of 13 citations was submitted for coding and analysis. A random‐effects meta‐regression model was used to synthesise correlations collected from the final sample of studies. Heterogeneity was assessed using Cochran's Q, I2 and τ2. Publication bias was assessed using contour‐enhanced funnel plots and Egger's test for asymmetry.ResultsThere was a statistically significant, positive correlation between cultural humility and alliance quality (r = .66, 95% CI = [0.64, 0.68]). Similarly, a smaller, yet still statistically significant and positive association between cultural humility and psychotherapy outcomes was also found (r = .39, 95% CI = [0.36, 0.42]). Moderators related to client race, gender and lesbian, gay and bisexual (LGB) status were also examined though nonsignificant.ConclusionSuch results suggest that therapist cultural humility is an important part of a strong working relationship and eventual positive outcomes in psychotherapy regardless of race, gender or LGB status. Thus, efforts should be made to foster cultural humility among therapists.

Are there unique facets of therapeutic alliance for users of digital mental health interventions? An examination with the eHealth Therapeutic Alliance Inventory

Therapeutic alliance (TA) is a well-established predictor of clinical outcomes in traditional psychotherapy. However, its association with outcomes in eHealth interventions has been inconsistent, which might be due to the absence of measurements specifically designed to capture TA in eHealth settings. The eHealth Therapeutic Alliance Inventory (ETAI) incorporates conventional as well as unique eHealth TA subscales, enabling to examine the contribution of new facets of TA beyond traditional concepts. This study investigates the predictive contribution of eHealth TA subscales compared to conventional TA subscales on clinical outcomes and evaluates the concurrent criterion validity of the ETAI. The study was conducted within the framework of a randomized controlled trial involving a 10-week digital parent training program aimed at addressing child disruptive behaviors. Parents were randomly assigned to either an enhanced-quality or a standard-quality program. Parents from 68 families completed the ETAI at five weeks' post-program initiation and at the post-intervention phase. The primary outcome was the improvement in child behavior, measured by the Eyberg Child Behavior Inventory. Positive Pearson correlations were found between all ETAI subscales covering unique eHealth TA aspects, measured at the 5-week time-point, and improvement in child behavior at post-intervention (rs ≥ 0.23, ps < 0.03). The conventional TA subscale showed no significant Pearson correlation with improvement in child behavior. When examining the unique contributions of ETAI-subscales to explain the improvement in child behavior, only ETAI-Perceived Emotional Investment subscale was found to have a unique contribution (β = 0.29, p = 0.019). In addition, scores on most ETAI subscales were significantly higher among parents using the enhanced-quality program compared with the standard program (Cohen's ds > 0.48), reinforcing ETAI's criterion validity. The development of TA scales that incorporates unique eHealth TA subscales show initial promise in predicting outcomes. Further research is needed to better understand how different factors of eHealth TA relate to clinical outcomes across diverse clinical targets and programs.

Predicting the outcome of psychotherapy for chronic depression by person-specific symptom networks.

Psychotherapies are efficacious in the treatment of depression, albeit only with a moderate effect size. It is hoped that personalization of treatment can lead to better outcomes. The network theory of psychopathology offers a novel approach suggesting that symptom interactions as displayed in person-specific symptom networks could guide treatment planning for an individual patient. In a sample of 254 patients with chronic depression treated with either disorder-specific or non-specific psychotherapy for 48 weeks, we investigated if person-specific symptom networks predicted observer-rated depression severity at the end of treatment and one and two years after treatment termination. Person-specific symptom networks were constructed based on a time-varying multilevel vector autoregressive model of patient-rated symptom data. We used statistical parameters that describe the structure of these person-specific networks to predict therapy outcome. First, we used symptom centrality measures as predictors. Second, we used a machine learning approach to select parameters that describe the strength of pairwise symptom associations. We found that information on person-specific symptom networks strongly improved the accuracy of the prediction of observer-rated depression severity at treatment termination compared to common covariates recorded at baseline. This was also shown for predicting observer-rated depression severity at one- and two-year follow-up. Pairwise symptom associations were better predictors than symptom centrality parameters for depression severity at the end of therapy and one year later. Replication and external validation of our findings, methodological developments, and work on possible ways of implementation are needed before person-specific networks can be reliably used in clinical practice. Nevertheless, our results indicate that the structure of person-specific symptom networks can provide valuable information for the personalization of treatment for chronic depression.

Early change in specific depression symptoms and later outcome in internet-delivered psychotherapy for depression: A cohort study and cross-lagged network analysis

BackgroundSymptom reduction occurring early in depression treatment is associated with favourable post-treatment outcome, but it is not known how early reduction in specific depression symptoms affect treatment outcome. We aimed to determine the impact of symptom-specific change from pre-treatment to week four during internet-delivered CBT (ICBT) on overall and symptom-specific depression severity at post-treatment. We hypothesized that change in mood and emotional involvement would be most strongly associated with later overall depression severity. Methods1300 participants with Major Depressive Disorder were followed over 12 weeks of ICBT using the self-report Montgomery-Åsberg Depression Rating Scale gauging nine symptoms. Linear models, informed by causal inference and cross-lagged network analysis methods, were used to estimate associations between early symptom-specific change and post-treatment depression severity, controlling for register-based and self-reported pre-treatment confounders. ResultsEarly reduction in all symptoms was associated with lower overall and symptom-specific depression severity post-ICBT. Seven symptoms showed similar associations between early change and overall depression severity post-treatment: mood (standardized beta [β] = 0.44), feelings of unease (β = 0.39), ability to concentrate (β = 0.46), initiative (β = 0.43), emotional involvement (β = 0.42), pessimism (β = 0.44), and zest for life (β = 0.42). Change in sleep (β = 0.27) and appetite (β = 0.27) had weaker associations with overall depression severity at post-treatment and were the only symptoms showing the hypothesized difference compared with mood and emotional involvement. ConclusionsThe impact of early symptom-specific reduction on post-treatment depression severity in ICBT for MDD may be similar across most symptoms, but less for the sleep and appetite symptoms, although causal interpretations rests on several assumptions.

The alliance–outcome relationship in individual psychotherapy for early psychosis: a secondary analysis of a randomized clinical trial

ABSTRACT Background Studies of the alliance–outcome relationship in psychosocial treatments for early psychosis are limited both in number and design, with few utilizing subjective measures as outcomes, multiple alliance timepoints or existing benchmarks to distinguish high or low levels of the alliance. We addressed these gaps in the context of a pilot randomized controlled psychotherapy trial for early psychosis. Methods Twenty-eight clients with early psychosis completed alliance ratings at mid-treatment (4.5 months) and post-treatment (9 months). We tested the alliance–outcome relationship through change scores between mid- and post-treatment and the use of a pre-defined benchmark to distinguish high versus low mid-treatment alliance. We also examined baseline differences between levels of the alliance. Outcomes included objective and subjective targets. Results Change in the alliance did not predict any outcomes at post-treatment. Clients with high mid-treatment alliance had lower perceived stress and higher psychological well-being at post-treatment. At baseline, clients with high alliance had lower negative symptoms and loneliness as well as higher community functioning and well-being. Discussion Use of an empirical alliance benchmark may help identify early psychosis clients who need additional support in alliance formation as well as facilitate positive psychotherapy outcomes

Emotional changes and outcomes in psychotherapy: A systematic review and meta-analysis.

This systematic review and meta-analysis summarize current knowledge on emotional change processes and mechanisms and their relationship with outcomes in psychotherapy. We reviewed the main change processes and mechanisms in the literature and conducted meta-analyses of process/mechanism-outcome associations whenever methodologically feasible. A total of 121 studies, based on 92 unique samples, met criteria for inclusion. Of these, 85 studies could be subjected to meta-analysis. The emotional change processes and mechanisms most robustly related to improvement were fear habituation across sessions in exposure-based treatment of anxiety disorders (r = .38), experiencing in psychotherapy for depression (r = .44), and emotion regulation in psychotherapies for patients with various anxiety disorders (r = .37). Common methodological problems were that studies often did not ascertain representative estimates of the processes under investigation, determine if changes in processes and mechanisms temporally preceded outcomes, disentangle effects at the within- and between-client levels, or assess contributions of therapists and clients to a given process. The present study has identified a number of emotional processes and mechanisms associated with outcome in psychotherapy, most notably fear habituation, emotion regulation, and experiencing. A common denominator between these appears to be the habitual reorganization of maladaptive emotional perception. We view this as a central pan-theoretical change mechanism, the essence of which appears to be increased differentiation between external triggers and one's own affective responses, which facilitates tolerance for affective arousals and leads to improved capacity for adaptive meaning-making in emotion-eliciting situations. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Multimodal analysis of temporal affective variability within treatment for depression.

Affective flexibility, the capacity to respond to life's varying environmental changes in a dynamic and adaptive manner, is considered a central aspect of psychological health in many psychotherapeutic approaches. The present study examined whether affective two-dimensional (i.e., arousal and valence) temporal variability extracted from voice and facial expressions would be associated with positive changes over the course of psychotherapy, at the session, client, and treatment levels. A total of 22,741 mean vocal arousal and facial expression valence observations were extracted from 137 therapy sessions in a sample of 30 clients treated for major depressive disorder by nine therapists. Before and after each session, the clients self-reported their level of well-being on the outcome rating scale. Session-level affective temporal variability was assessed as the mean square of successive differences between consecutive two-dimensional affective measures. Session outcome was positively associated with temporal variability at the session level (i.e., within clients, between sessions) and at the client level (i.e., between clients). Importantly, these associations held when controlling for average session- and client-level valence scores. In addition, the expansion of temporal variability throughout treatment was associated with steeper positive session outcome trajectories over the course of treatment. The continuous assessment of both vocal and facial affective expressions and the ability to extract measures of affective temporal variability from within-session data may enable therapists to better respond and modulate clients' affective flexibility; however, further research is necessary to determine whether there is a causal link between affective temporal variability and psychotherapy outcomes. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Disentangling between- and within-patients effects of emotion regulation on outcome in naturalistic psychotherapy.

The aim of this study was to disaggregate the between-patient and within-patient effects of emotion regulation (ER) on treatment outcome and explore relevant trait-like moderators of the within-patient effects. Three hundred thirty-nine patients with heterogenous clinical conditions were admitted to psychotherapy at a clinical center. During the intake evaluation, patients completed the Inventory of Interpersonal Problems, the Outcome Questionnaire 30, and the State Difficulties of Emotion Regulation Scale. Subsequently, patients responded to the Outcome Questionnaire 30 and State Difficulties of Emotion Regulation Scale every session for the initial five sessions, followed by assessments every two sessions until the 15th session and then every four sessions until the end of treatment. Multilevel models revealed significant between- and within-patient effects of ER on clinical distress. That is, patients with lower average levels of ER difficulties showed greater benefit from treatment, and lower ER difficulties over the course of treatment were associated with lower clinical distress. Furthermore, interactive models demonstrated that lower average levels of ER throughout treatment and fewer interpersonal problems at the beginning of treatment were associated with better treatment outcome. These findings provide evidence supporting the role of ER as a mechanism of change. The interaction between trait-like components and state-like fluctuations of ER suggests a capitalization model for the role of ER in psychotherapy. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Prediction of adolescent psychotherapy outcomes using youth- and caregiver-reported symptoms data

ABSTRACT Objective We used longitudinal youth- and caregiver-reports of adolescent psychological symptoms from three samples of youth receiving mental health services in routine treatment settings to derive expected change trajectories and identify cases at risk for treatment failure. Method Participants were 1906 youth (1053 caregivers) receiving treatment in community mental health settings, merged across three samples. The Symptoms and Functioning Severity Scale (SFSS) was used as an indicator of weekly clinical change. Multilevel modeling methods were used to develop expected change trajectories and identify cases at risk for treatment failure (not on track; NOT). Logistic regression was used to predict client improvement as a function of NOT status. Results The SFSS was a reliable indicator of therapeutic change according to youth-reported symptoms. Caregiver reports were not as robust. Whereas predictive accuracy of NOT status yielded moderately high sensitivity in detecting improvement according to youth report, caregiver reports were not as predictive. Conclusions The youth-reported version of the SFSS-based algorithm seems appropriate for implementation in clinical care. Future studies should search for similarly predictive measures for caregivers.

Client resources and the prediction of therapeutic change using an interview: An exploratory study

Objectives Although psychotherapy research suggests that clients’ resources are related to positive outcomes, there is a lack of clinical tools available to consider their integration into psychotherapy. In this exploratory research, we studied the feasibility of a semi-structured interview to identify resources reported by clients at the onset of therapy and the relationship between resources and therapy outcomes. Methods Data consisted of interviews with 30 clients from a clinical trial, in which elicitation of resources and their relationship with the outcomes were the main study objectives. Results This interview was content analyzed and both adaptative resources and maladaptive resources (dysfunctional coping strategies) were identified. The association between the adaptive resources and the evolution of outcomes throughout treatment was analyzed. Time (i.e. sessions) and resources were negatively correlated with psychological distress. Moreover, resources positively influenced the impact of time on distress. Conclusions Clinicians should not take at face value resources that are self-reported, as they may reflect the maladaptive functioning of the client. The finding that clients with higher resources at onset have better outcomes points to the need to study how resources may be elicited effectively during therapy, and if this improves psychotherapy outcomes.

Retraction Note: Long-term follow-up outcomes of MDMA-assisted psychotherapy for treatment of PTSD: a longitudinal pooled analysis of six phase 2 trials.

Retraction Note: Long-term follow-up outcomes of MDMA-assisted psychotherapy for treatment of PTSD: a longitudinal pooled analysis of six phase 2 trials.

Childhood Trauma and Panic Disorder: The Impact of History of Child Abuse on Illness Severity and Treatment Response.

Patients who have experienced child abuse often have complex clinical presentations; whether a history of child abuse (HCA) affects psychotherapy outcomes is unclear. The authors examined relationships between HCA, clinical baseline variables, and change in these variables after three different psychotherapies for panic disorder (PD). Two hundred adults with PD (with or without agoraphobia) were randomly assigned to one of three treatments across two sites: panic-focused psychodynamic psychotherapy (PFPP), cognitive-behavioral therapy (CBT), or applied relaxation training (ART). Differences in demographic and clinical variables between those with and without HCA were compared. The primary analysis addressed odds of meeting clinical response criteria on the Panic Disorder Severity Scale (PDSS) between treatments, as moderated by HCA. This effect was examined via continuous outcomes on the PDSS and psychosocial functioning (Sheehan Disability Scale). Compared with patients without HCA (N=154), patients with HCA (N=46) experienced significantly more severe symptoms of PD (d=0.60), agoraphobia (d=0.47), and comorbid depression (d=0.46); significantly worse psychosocial impairment (d=0.63) and anxiety sensitivity (d=0.75); greater personality disorder burden (d=0.45)-particularly with cluster C disorders (d=0.47)-and more severe interpersonal problems (d=0.54). HCA significantly moderated the likelihood of clinical response, predicting nonresponse to ART (B=-2.05, 95% CI=-4.17 to -0.30, OR=0.13, z=-2.14, p=0.032) but not CBT or PFPP. HCA did not interact with treatment condition to predict slopes of PDSS change. The results of this study highlight the importance of HCA in formulating treatment recommendations. Increased awareness of HCA's effects on severity of PD and treatment responsiveness among patients with PD may improve outcomes.

The development of the Moments of Flourishing Experience Scale: a new scale to measure positive, affect-based flourishing state experiences

ABSTRACT Flourishing has been a focus of positive psychology, with increased attention to its translation into psychotherapy practice. Flourishing is an emergent process manifested in momentary experiential states characterized by positive emotions. A conceptualization of flourishing as an innate potential that psychotherapeutic interventions can help cultivate informs the development of this scale. The current study details the development of the Moments of Flourishing Experience Scale (MFES), a 23-item scale. The data were obtained from four different studies involving a total of 1472 adults (normative sample n = 1312; clinical sample n = 160). A bifactor model with four distinct positive affective experience subscales, yielded by factor analysis and then supported by a confirmatory factor analysis, was as follows: Calm & Self-Acceptance; Vitality; Generosity of Spirit & Gratitude; and Connection & Purpose. Across studies, the MFES showed discriminant validity from psychopathology measures and convergent validity with positive psychological functioning measures. The overall scale, as well as each of four subscales, also demonstrated strong reliability in both general and clinical populations. The MFES has initial psychometric support for the study of flourishing and shows promise as a tool to study flourishing as both outcome and process in psychotherapy.

Intake Characteristics as Predictors of Psychotherapy Outcome in a Practice Research Network in Argentina

There are few studies exploring intake diagnostic characteristics as predictors of change in integrative naturalistic settings. The aim of this study is to explore baseline variables at the intake process and establish the predictive value of the individual trajectories of the patients. We recruited 259 patients undergoing an integrative psychotherapy network of psychotherapists from Buenos Aires, Argentina. Every therapist completed the intake form of each patient involved in the routine outcome monitoring. Thereafter step-wise regressions based on forward selection strategies were used, in order to identify meaningful baseline predictors of patients’ clinical evolution, derived from the intake process. The selected predictors were social support network, subjective distress, the initial measure of clinical distress, unemployment, sociocultural status and reactance. When including those six variables in a multilevel model, the results indicate that social support network, subjective distress, and the initial measure of clinical distress were significant predictors of the trajectories of OQ-30, whereas unemployment, sociocultural status and reactance were not significant. The results regarding social support network are in line with the literature, while results of socioeconomic status (unemployment and sociocultural level) move in an opposite direction in comparison to the available evidence. Moreover, the mental health findings (initial OQ-30 and subjective distress) confirm the contradictory body of literature produced in this domain. Finally, reactance seems to be a significant predictor in previous study in contradiction of our results. Overall, this endeavor constitutes important but preliminary evidence to enhance the production of bottom-up science within practice research networks in the global south.

Psychotherapists' outcome expectations: How are they established?

Therapists' outcome expectations influence the psychotherapy process and outcomes, but little is known about the factors influencing their development. This study explored therapists' experiences with establishing outcome expectations for their patients. The participants were 35 therapists from a public mental health setting, who were interviewed in five different focus groups. Interviews were transcribed and analyzed using thematic analysis. Three themes and 10 subthemes were identified. In Theme 1 (understanding the problem), participants' expectations were influenced by (a) their patients' diagnoses and the diagnostic process, (b) their perceptions of the complexity of the presenting problem, (c) how stable the patients' symptoms and situations were, and (d) whether they experienced familiarity with the patient or the patients' situation. In Theme 2 (the patient's openness to change), participants' expectations were influenced by (a) the patient's stated reason for seeking treatment, (b) the patient's conceptualization of their problem/situation, and (c) their perception of the patient's willingness to invest in the treatment. In Theme 3 (the fit between the therapist and patient), the participants discussed the factors that influenced whether they felt they were a good fit for working with an individual patient and how this perception of personal and professional fit influenced their expectations. We identify several ways that therapists' situational factors and their recognition of the patient through their own past experiences can influence their expectations. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

A systematic review on the role of therapist characteristics in the treatment of eating disorders.

Treating patients with eating disorders can be challenging for therapists, as it requires the establishment of a strong therapeutic relationship. According to the literature, therapist characteristics may influence intervention outcomes. The aim of this systematic review was to identify and synthesize existing literature on therapist interpersonal characteristics that could affect psychotherapy relationship or outcomes in the context of eating disorder treatment from both patients' and therapists' perspectives. We conducted a systematic search using electronic databases and included both qualitative and quantitative studies from 1980 until July 2023. Out of the 1230 studies screened, 38 papers met the inclusion criteria and were included in the systematic review. The results indicate that patients reported therapist's warmth, empathic understanding, a supportive attitude, expertise in eating disorders, and self-disclosure as positive characteristics. Conversely, a lack of empathy, a judgmental attitude, and insufficient expertise were reported as therapist negative characteristics, which could have a detrimental impact on treatment outcome. Few studies have reported therapist's perceptions of their own personal characteristics which could have an impact on treatment. Therapists reported that empathy and supportiveness, optimism, and previous eating disorder experience were positive characteristics. Conversely, clinician anxiety, a judgmental attitude, and a lack of objectivity were reported as negative characteristics that therapists felt could hinder treatment. This systematic review offers initial evidence on the personal characteristics of therapists that may affect the treatment process and outcomes when working with patients with eating disorders.

A systematic review and meta-analysis of predictors of response to trauma-focused psychotherapy for posttraumatic stress disorder.

Although trauma-focused psychotherapy (T-F psychotherapy) is the treatment of choice for posttraumatic stress disorder (PTSD), up to one half of patients do not respond to this treatment. Attempts to improve response to T-F psychotherapy have focused on augmenting fear extinction-based factors. Here, a systematic and meta-analytic review of predictors of T-F psychotherapy outcome was conducted with the goal of using an aggregate data-driven approach to elucidate baseline factors associated with treatment outcome. There were 114 studies that met inclusion criteria (N = 61, 970; Mage = 40.1 years; 40.1% female). There were 237 effect sizes across 24 meta-analytic categories. Poorer treatment response is associated with lower pretreatment levels of activation of fear-related brain regions, psychophysiological reactivity to fear provocation, trauma-related cognitions, anger, depression, high-risk alleles of genes linked to fear, lower levels of executive control, and social support. A range of other factors also predicted poorer responses including being male, non-Caucasian, older in age, early trauma occurrence, more trauma experience, history of combat trauma, as well as comorbid sleep, pain, poor quality life, and alcohol abuse difficulties. This review provides one potential explanation for the limited success of T-F psychotherapy augmentation strategies that have focused only on fear circuity mechanisms at the exclusion of other factors. Here, poor response relating to predictors of early trauma onset and comorbidity are consistent with clinical presentations of complex PTSD, which may suggest T-F psychotherapy is less effective for this condition. This collective evidence suggests that clinicians should consider a tailored approach that targets potential barriers to successful treatment response. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The relationship between attachment needs, earned secure therapeutic attachment and outcome in adult psychotherapy.

The aim of this study was to investigate a sequence of associations between clients' pretreatment attachment style, the development of individuated-secure attachment to the therapist (i.e., therapeutic attachment), and the experience of increased comfort with emotional closeness (growing engagement) or independence (growing autonomy) in therapy. Moreover, the study explored whether clients' experience of growing engagement or growing autonomy was associated with a change in interpersonal problems at the end of therapy. Three hundred thirty adult clients (mean age 40.2, 75% female) were seen by 44 therapists in individual psychotherapy. The associations between pretreatment attachment insecurity measured on the Experiences in Close Relationships scale, repeated measures of therapeutic attachment measured on the Client Attachment to Therapist Scale, repeated measures of a growing engagement or growing autonomy measured on the Therapeutic Distance Scale, and pre-post measures of interpersonal problems measured on the Inventory for Interpersonal Problems were analyzed using multilevel modeling. Two types of therapeutic attachment were estimated, one controlling for anxious attachment characteristics and one for avoidant. Significant associations between higher levels of therapeutic attachment controlled for avoidant attachment characteristics and lower levels of growing autonomy in therapy were found. Moreover, higher levels of growing engagement in therapy and higher levels of therapeutic attachment controlled for anxious attachment characteristics were associated with a decrease in interpersonal problems at the end of therapy. Distinct types of therapeutic attachment may exert different influences on the process and outcome of therapy. Furthermore, therapists' attunement to clients' specific attachment needs in therapy may enhance interpersonal outcomes of treatment. (PsycInfo Database Record (c) 2024 APA, all rights reserved).