Psychotherapy Outcome Research Articles

Development and Preliminary Analysis of a Scale to Assess Client Characteristics that Influence Clinical Decision-Making

Understanding client variables relevant to clinical decision-making is a core feature of psychotherapy. The previous meta-analysis emphasized variables related to stages of psychotherapy, motivational stages of change, alliance, reactance, coping, attachment styles, and emotional stability in psychotherapy outcomes. However, a clinical measure that captures these empirically based clinical variances is missing. The present study describes the development and preliminary analysis of the Clinical Decision-Making Inventory (CDMI) in a sample of individuals engaged in a psychotherapeutic process. One hundred and twenty-three participants (M = 20.28, SD = 5.80) engaged in a psychotherapy process, were assessed in a cross-sectional design. On one hand, the stages of psychotherapy, motivational stages of change, reactance, coping, attachment styles, and emotional stability were negatively correlated with symptomatology, cognitive fusion, interpersonal problems, coping mechanisms, and expressive suppression. On the other hand, correlated positively with metacognition and cognitive reappraisal. Attachment style and emotional stability predicted symptomatology. The CDMI showed promising results; however, more research is required to deepen the psychometric analysis.

Learning from other patients – A feasibility study to establish an ecologically valid paradigm to modify negative expectations in depression through authentic psychotherapeutic treatment reports

BackgroundPatients’ expectations about psychotherapy are of great importance, since they can influence the outcome of psychotherapy. Thus, it is important to ensure that patients have positive expectations about the outcomes of psychotherapy. This is particularly relevant in patients with major depression, since they often hold (unrealistically) negative expectations and tend to maintain these expectations despite novel positive information. Here, we test the feasibility of a novel, ecologically valid experimental paradigm to investigate how depressed patients learn from other patients’ experiences with psychotherapy, and which cognitive mechanisms hinder the integration of novel positive information. MethodN = 17 outpatients diagnosed with a major depressive disorder watched videotaped experience reports of five acting patients. Each acting patient was shown twice: first, before receiving psychotherapeutic treatment, where they reported on feeling depressed and pessimistic about their future; second, at the end of psychotherapy, where they reported on feeling better and having overcome the challenges they used to struggle with. Before and after watching the videos, participants rated their expectations for positive and negative future life events. ResultsResults indicate that the paradigm is well applicable and the videos were perceived as credible, interesting and helpful. Descriptive results show that the video reports led to a slight modification of expectations. ConclusionThe results indicate that our new paradigm is a suitable tool to investigate expectation change in response to other patients’ experiences with psychotherapy. Furthermore, our paradigm is suitable to investigate potential cognitive mechanisms involved in expectation change in depression.

Baseline depression severity as moderator on depression outcomes in psychotherapy and pharmacotherapy

BackgroundEvidence-based treatments for adult depression include psychotherapy and pharmacotherapy, yet little is known about how baseline depression severity moderates treatment outcome. ObjectivesWe aimed to compare the effects of psychotherapy and pharmacotherapy for adult depression and to examine the association between baseline depression severity and treatment outcome, converting multiple baseline depression measures into the scores of the Beck Depression Inventory, second edition (BDI-II). MethodsWe conducted systematic searches in bibliographical databases up to September 2022 to identify randomized controlled trials (RCTs) in which psychotherapy was compared with pharmacotherapy in the treatment of adult depression. Various meta-regressions using the baseline depression severity as predictor of the relative effects of psychotherapy and pharmacotherapy were performed. ResultsWe identified 65 RCTs including 7250 participants for the meta-analyses and 56 RCTs including 5548 participants for the meta-regression. We found no significant difference between psychotherapy and pharmacotherapy (g = −0.08, 95 % CI: −0.2 to 0.04, p = 0.193) and baseline depression severity was not significantly associated with the relative effects of psychotherapy and pharmacotherapy (B = 0.0032, SE = 0.0096, p = 0.74). Results were similar in several sensitivity analyses. LimitationsLimitations included the low quality of the included studies, and the omission of long-term effects and within-study variability. ConclusionsWe found no indication for a moderation effect of baseline depression severity on the relative effects of psychotherapy and pharmacotherapy. Thus, other factors such as availability and patients' preference must be considered when deciding for treatment options.

Recognition: A Key for Understanding a Necessary Role of the Psychotherapist for the Successful Outcome of Psychotherapy

The purpose of this paper is to focus on an aspect of psychodynamic psychotherapy that includes psychoanalysis to illustrate the important element in the psychotherapeutic relationship called recognition. This involves an emotional sharing with the patient of the importance of particular life experiences that he has had and as such this not only cements the relationship but becomes the substrate of change and an internalization of the therapist that persists after the end of treatment. This interaction parallels the experience with a responsive mother able to echo the infant's experience. The experience of recognition is illustrated with 10 case presentations that demonstrate the power of this factor in a variety of patients ranging from brief consultations to psychoanalysis.

Interpersonal problems as a predictor of outcome in psychotherapy for depressive and anxiety disorders: A multilevel meta-analysis.

Although interpersonal problems are assumed to play an important role in the treatment of depression and anxiety, meta-analytic attempts to explore the association between interpersonal problems and outcome in psychotherapy for these patients are missing. This study aims to conduct a systematic review and meta-analytic synthesis of the association between patients' baseline interpersonal problems and outcome in psychotherapy for depressive and anxiety disorders. We conducted a three-level meta-analysis (i.e., disaggregating sampling variance, within-study variance, and between-study variance) of the interpersonal problems-outcome prediction (IPOP; as measured by the total distress factor of Inventory of Interpersonal Problems). We found 40 effect sizes (ESs) nested within 21 primary studies. The three-level model showed a significant aggregated effect size of IPOP, r = -.13, SE = 0.02, 95% CI [-.18, -.09]; t(39) = -5.71, p < .001; d = -0.27, with greater interpersonal distress being associated with worse psychotherapy outcome. Results showed significant heterogeneity across effect sizes with considerable variability across studies (I² = .39) and to a lower extent across reported outcomes (I² = .19). Graphical measures did not show evidence of a substantial publication bias. This meta-analysis showed that baseline overall interpersonal problems are a small but robust negative predictor of psychotherapy outcome. Therapists might benefit from exploring patients' interpersonal problems at the beginning of therapy to enhance their prognostic inferences. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Identity salience: An intersectional approach to understanding multicultural processes and outcomes in psychotherapy.

A growing body of research has demonstrated the importance of therapists' multicultural orientation (MCO), namely, their cultural humility (CH), cultural comfort, and cultural missed opportunities, on treatment processes and outcomes (Davis et al., 2018). However, to date, few research has attempted to identify client factors that may moderate the relationship between therapists' MCO and therapeutic processes and outcomes. Informed by Yakushko et al.'s (2009) identity salience model, this study seeks to advance the MCO literature by examining the saliency of clients' cultural identities, therapists' MCO, and improvement in therapy. Data for this study consisted of 193 individuals who had received at least five sessions of psychotherapy in the last 6 months and responded to an online survey about their experience in therapy. Moderated polynomial regression and response surface analysis was used to examine if the relationship between therapists' MCO and clients' perceived improvement in psychotherapy differed as a function of the salience of clients' first and second most important cultural identities. The results indicated that when clients report only one highly salient cultural identity and perceive their therapist high in cultural humility, they report high levels of improvement. In contrast, when clients reported two highly salient identities, cultural humility and improvement in therapy were not significantly related. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Early distress score instability predicts outcome in brief psychotherapy.

Among psychotherapy patients, unstable early distress scores are known to predict substantial intersession improvement later in treatment. The evidence has been ambiguous as to whether early distress instability also predicts outcome. We investigated the links among early distress instability, later intersession improvement, and outcome. In a sample of 1,796 students treated with brief psychotherapy at university counseling centers, we sought to predict intersession improvement and treatment outcome from an index of distress instability, as assessed during the first four treatment sessions. Large intersession shifts late in treatment appeared to mediate the link between early distress instability and outcome. These relationships were limited to participants who demonstrated early score shifts larger than measurement error. As hypothesized by dynamic systems theory, some psychotherapy patients experience stepwise improvement that is preceded by early instability in distress scores. However, the effect size linking early instability to outcome is small. Sudden gains may not be the optimal measure to elucidate these relationships. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Retraction of Kivlighan et al. (2016).

Reports the retraction of "Working alliance, real relationship, session quality, and client improvement in psychodynamic psychotherapy: A longitudinal actor partner interdependence model" by Dennis M. Kivlighan Jr., Clara E. Hill, Charles J. Gelso and Ellen Baumann (Journal of Counseling Psychology, 2016[Mar], Vol 63[2], 149-161). The following article is being retracted (https://doi.org/10.1037/cou0000134). This retraction is at the request of coauthors Kivlighan, Hill, and Gelso after the results of an investigation by the University of Maryland Institutional Review Board (IRB). The IRB found that the study included data from between one and four therapy clients of the Maryland Psychotherapy Clinic and Research Laboratory (MPCRL) who either had not been asked to provide consent or had withdrawn consent for their data to be included in the research. Baumann was not responsible for obtaining and verifying participant consent but agreed to the retraction of this article. (The following abstract of the original article appeared in record 2015-57048-001.) We used the Actor Partner Interdependence Model (APIM; Kashy & Kenny, 2000) to examine the dyadic associations of 74 clients and 23 therapists in their evaluations of working alliance, real relationship, session quality, and client improvement over time in ongoing psychodynamic or interpersonal psychotherapy. There were significant actor effects for both therapists and clients, with the participant's own ratings of working alliance and real relationship independently predicting their own evaluations of session quality. There were significant client partner effects, with clients' working alliance and real relationship independently predicting their therapists' evaluations of session quality. The client partner real relationship effect was stronger in later sessions than in earlier sessions. Therapists' real relationship ratings (partner effect) were a stronger predictor of clients' session quality ratings in later sessions than in earlier sessions. Therapists' working alliance ratings (partner effect) were a stronger predictor of clients' session quality ratings when clients made greater improvement than when clients made lesser improvement. For clients' session outcome ratings, there were complex three-way interactions, such that both Client real relationship and working alliance interacted with client improvement and time in treatment to predict clients' session quality. These findings strongly suggest both individual and partner effects when clients and therapists evaluate psychotherapy process and outcome. Implications for research and practice are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Effects of religious and spiritual struggles on psychotherapy process and outcome.

Effects of religious and spiritual struggles on psychotherapy process and outcome.

Effectiveness of a Multicomponent Group-Based Treatment in Patients with Medically Unexplained Physical Symptoms: A Multisite Naturalistic Study

Psychotherapy is expected to be effective in the treatment of patients with medically unexplained physical symptoms (MUPS). However, evidence is scarce. The aim of this study was to examine the effectiveness of a multicomponent treatment based on group therapy in patients with MUPS in a naturalistic setting and to explore potential predictors of the outcomes. A multisite naturalistic uncontrolled effectiveness study. A total of 290 patients with MUPS participated in group psychotherapy across seven clinical sites. Somatic symptoms, depression, anxiety, general psychotherapy outcomes operationalized as the Outcome Rating Scale (ORS) score, well-being, role functioning interference, as well as a number of pretreatment predictors were measured using a battery of self-report measures. Multilevel modeling and lasso regression with bootstrapping were used for the analysis. Medium to large pre-post effects were found for somatic symptoms, ORS, depression, anxiety, well-being, role functioning interference found in completers after controlling for site and group effects, pretreatment outcome values, and treatment length. Changes reported at 6- and 12-month follow-up were higher for most variables. No substantial pretreatment predictors of the patients’ posttreatment status were found in addition to the pretreatment level of outcome variables. Somatic symptoms seem to be less malleable in psychotherapy than psychological outcome variables. However, there was a trend of further improvement after treatment completion.RegistrationThis study was retrospectively registered with ISRCTN (Identifier 13532466).

Cognitive restructuring and psychotherapy outcome: A meta-analytic review.

Cognitive restructuring (CR) is one method that is hypothesized to play a role in the process of change across many psychotherapies and for a variety of clinical presentations. In this article, we define and illustrate CR. We then present a meta-analysis of four studies (including a total of 353 clients) examining the effect of CR measured within session on psychotherapy outcomes. The overall CR-outcome association was r = .35 (95% CI [.24, .44]; equivalent of d = 0.85). While more research on CR and immediate psychotherapy outcomes is needed, there is accumulating encouraging evidence regarding the therapeutic effect of CR. We conclude by advancing implications for clinical training and therapeutic practices. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Self-compassion and fear of compassion in the treatment of chronic depression: Mechanisms of change?

The aim of this naturalistic process study was to investigate the relationship between self-compassion, fear of compassion from others, and depressive symptoms over the course of psychotherapy in patients with chronic depression. A sample of 226 patients with chronic depression who received inpatient short-term psychodynamic psychotherapy (STPP) provided weekly self-report measures of self-compassion, fear of compassion, and depressive symptoms (Patient Health Questionnaire-9). Trivariate latent curve modeling with structured residuals was applied to investigate the between- and within-patient relationships among the variables. At the between-patient level, a significant positive correlation was found between slope of depression and the slope of fear of compassion. At the within-patient level, a lower than expected level of fear of compassion predicted a subsequent lower than expected level of depression (mean weekly effect size = 0.12), with a smaller reciprocal relationship (mean weekly effect size = 0.08). There was no significant within-patient effect of self-compassion predicting subsequent depression, but a significant effect of a lower than expected level of depression predicting a subsequent higher than expected level of self-compassion (mean weekly effect size = -0.13). No within-patient effect between self-compassion and fear of compassion was found. In the context of this study, it appears that fear of compassion may be a putative mechanism of change involved in alleviating depressive symptoms in patients with chronic depression treated with STPP. On the other hand, self-compassion appears to be an outcome of psychotherapy. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Individual-Level Prediction of Exposure Therapy Outcome Using Structural and Functional MRI Data in Spider Phobia: A Machine-Learning Study

Machine-learning prediction studies have shown potential to inform treatment stratification, but recent efforts to predict psychotherapy outcomes with clinical routine data have only resulted in moderate prediction accuracies. Neuroimaging data showed promise to predict treatment outcome, but previous prediction attempts have been exploratory and reported small clinical sample sizes. Herein, we aimed to examine the incremental predictive value of neuroimaging data in contrast to clinical and demographic data alone (for which results were previously published), using a two-level multimodal ensemble machine-learning strategy. We used pretreatment structural and task-based fMRI data to predict virtual reality exposure therapy outcome in a bicentric sample of N = 190 patients with spider phobia. First, eight 1st-level random forest classifications were conducted using separate data modalities (clinical questionnaire scores and sociodemographic data, cortical thickness and gray matter volumes, functional activation, connectivity, connectivity-derived graph metrics, and BOLD signal variance). Then, the resulting predictions were used to train a 2nd-level classifier that produced a final prediction. No 1st-level or 2nd-level classifier performed above chance level except BOLD signal variance, which showed potential as a contributor to higher-level prediction from multiple regions across the brain (1st-level balanced accuracy = 0.63 ). Overall, neuroimaging data did not provide any incremental accuracy for treatment outcome prediction in patients with spider phobia with respect to clinical and sociodemographic data alone. Thus, we advise caution in the interpretation of prediction performances from small-scale, single-site patient samples. Larger multimodal datasets are needed to further investigate individual-level neuroimaging predictors of therapy response in anxiety disorders.

Genetic Influences on Outcomes of Psychotherapy in Borderline Personality Disorder: A Narrative Review of Implications for Personalized Treatment.

Borderline personality disorder (BPD) manifests as instability in mood, relationships, self-image, and behavior, representing a challenging mental health issue. This review scrutinizes genetic factors influencing BPD and the corresponding treatment outcomes. The primary objective of this narrative review is to illuminate the association between genetic factors and BPD treatment outcomes, discussing the potential of genetic testing for personalized therapy. The review is derived from observational and experimental studies on BPD, genetic factors, and psychotherapy from 2000 to 2023, sourced primarily through PubMed. Reviews and meta-analyses were excluded. Our review suggests that genetic factors account for 40-60% of BPD variation, with significant roles played by epigenetic alterations like DNA methylation and microRNAs, particularly in the context of childhood trauma. Gene-environment interactions are also vital for BPD's development. Treatments such as dialectical behavior therapy, mentalization-based therapy, and schema therapyhave shown efficacy, with success variability possibly linked to genetic factors. However, existing research is constrained by recall bias, diverse methodologies, and limited sample sizes. Future research necessitates long-term follow-up, diverse populations, and controlled variables to enhance our comprehension of BPD treatment outcomes' genetic foundations. The review underlines the promise of personalized medicine in BPD treatment, driven by genetic insights.

Does deliberate practice surpass didactic training in learning empathy skills? – A randomized controlled study

A large body of research identifies therapist expressed empathy as one of the most important predictors of psychotherapy outcome. Deliberate practice (DP) is an effective method to improve skills in many fields. We asked if DP also can be used to enhance the skill of expressing empathy. Objective: The aim was to compare the efficacy of DP to didactical learning methods (DLM) in enhancing the skill of empathic expression in students. Method: A repeated measures randomized controlled group design was used. Novice students (N = 36) from psychologist-, medicine-, social work-, and nursing programs received two training sessions of either DP (n = 21) or DLM (n = 15). Participants’ skills in empathic expression were assessed with the Measure of Expressed Empathy (MEE) on three occasions: before the first, between, and after the last training session. Results: Participants in the DP-group showed improved empathic expression, whereas participants in the DLM-group did not. Conclusions: These findings suggest that DP is an effective training method for therapeutic skills such as empathic expression and holds implications for the future development of educational practices to incorporate active skill training methods.

Systemic Individual Therapy: Therapeutic Change from the Perspective of Clients and Therapists

ABSTRACT Therapeutic change is a well-studied construct in psychotherapy process and outcome studies, providing the basis for how psychotherapy practices are effective in individuals wellbeing. The current study explores the experiences of therapists and clients regarding how therapeutic change is experienced in systemic individual therapy. 12 therapists (1 men, 11 women) and 12 clients (2 men, 10 women) were recruited as participants from two training centers. Both therapists’ and clients’ experiences are investigated with semi-structured interviews using thematic analysis (TA). Results revealed three main themes for clients: “Sense-making the Problems Through Relational Awareness”, “Acceptance in Relationships”, and “Manifesting the Differentiated Self in Relationship.” Regarding therapists’ perspective, the results yielded three main themes: “Going Beyond One-to-one Relationship in Therapy”, “Increasing Relational Awareness”, “Shift in Clients’ Attitudes Towards Boundaries with Significant Others.”. The themes were discussed in the context of the systems theory literature, limitations, strengths, future research directions, and clinical implications.

Validation of the client satisfaction questionnaire: a pilot psychometric analysis in Portuguese routine practice.

Treatment satisfaction has been found to have good therapeu- tic results in psychotherapy, and the 18-item version of the client satisfaction questionnaire (CSQ-18) is one of the most widely used measures to evaluate it. This study sought to carry out a pilot analysis of the psychometric's properties and factorial structure, as well as validate the CSQ-18's applicability to the Portuguese population within the context of routine clinical practice. It also sought to explore the association that treatment satisfaction has with general symptoms, therapeutic alliance, and expectations at an early stage of psychotherapy. The sample comprised 98 clients who were undergoing psychotherapy in a routine practice context. All these clients completed self-reported measures for symptom assessment and therapeutic relationship, namely the clinical out- come routine evaluation-outcome measure, working alliance in- ventory, and credibility/expectancy questionnaire, in addition to the CSQ-18. The semi-confirmatory factorial analysis demon- strated that the CSQ-18 has good psychometric properties and re- vealed an association between treatment satisfaction and therapeutic alliance. The results corroborate the findings of other versions of the measure and present a good adjustment model for the semi-confirmatory factorial analysis.

Outcome Expectations in Psychotherapy: Validation of the Therapy Single Category Implicit Association Test (Therapy SC-IAT)

BackgroundFormer studies demonstrated that negative outcome expectations (OE) toward psychotherapy predict unfavorable psychotherapy outcomes. Critically, the measurement of OE is limited to direct measures that could be subject to self-presentational distortions. This study aimed to validate an online single category implicit association test (SC-IAT) to measure OE toward psychotherapy indirectly.MethodsWe conducted three direct measures of OE, the Therapy SC-IAT, and a (control) Flower SC-IAT in a large sample (N = 705).ResultsThe Therapy SC-IAT correlated with most direct measures of OE (convergent validity) but not with measures of flower associations (discriminant validity). In exploratory analyses, we found that direct and indirect measurements of OE were related to prior experiences with psychotherapy.ConclusionWe discuss ways to improve the indirect-direct correlations and suggest that our newly developed indirect measure could complement the assessment of expectations in research and clinical practice.

Trainee psychotherapists' emotion recognition accuracy improves after training: emotion recognition training as a tool for psychotherapy education.

Psychotherapists' emotional and empathic competencies have a positive influence on psychotherapy outcome and alliance. However, it is doubtful whether psychotherapy education in itself leads to improvements in trainee psychotherapists' emotion recognition accuracy (ERA), which is an essential part of these competencies. In a randomized, controlled, double-blind study (N = 68), we trained trainee psychotherapists (57% psychodynamic therapy and 43% cognitive behavioral therapy) to detect non-verbal emotional expressions in others using standardized computerized trainings - one for multimodal emotion recognition accuracy and one for micro expression recognition accuracy - and compared their results to an active control group one week after the training (n = 60) and at the one-year follow up (n = 55). The participants trained once weekly during a three-week period. As outcome measures, we used a multimodal emotion recognition accuracy task, a micro expression recognition accuracy task and an emotion recognition accuracy task for verbal and non-verbal (combined) emotional expressions in medical settings. The results of mixed multilevel analyses suggest that the multimodal emotion recognition accuracy training led to significantly steeper increases than the other two conditions from pretest to the posttest one week after the last training session. When comparing the pretest to follow-up differences in slopes, the superiority of the multimodal training group was still detectable in the unimodal audio modality and the unimodal video modality (in comparison to the control training group), but not when considering the multimodal audio-video modality or the total score of the multimodal emotion recognition accuracy measure. The micro expression training group showed a significantly steeper change trajectory from pretest to posttest compared to the control training group, but not compared to the multimodal training group. However, the effect vanished again until the one-year follow-up. There were no differences in change trajectories for the outcome measure about emotion recognition accuracy in medical settings. We conclude that trainee psychotherapists' emotion recognition accuracy can be effectively trained, especially multimodal emotion recognition accuracy, and suggest that the changes in unimodal emotion recognition accuracy (audio-only and video-only) are long-lasting. Implications of these findings for the psychotherapy education are discussed.

Therapeutic alliance and clinical outcomes in teletherapy and in-person psychotherapy: A noninferiority study during the COVID-19 pandemic

Objective The current study aimed to inform the varied and limited research on clinical variables in the context of teletherapy. Questions remain about the comparative quality of therapeutic alliance and clinical outcome in the context of teletherapy compared to in-person treatment. Methods We utilized a cohort design and a noninferiority statistical approach to study a large, matched sample of clients who reported therapeutic alliance as well as psychological distress before every session as part of routine clinical practice at a university counseling center. A cohort of 479 clients undergoing teletherapy after the emergence of the COVID-19 pandemic was compared to a cohort of 479 clients receiving in-person treatment before the onset of the pandemic. Tests of noninferiority were conducted to investigate the absence of meaningful differences between the two modalities of service delivery. Client characteristics were also examined as moderators of the association between modality and alliance or outcome. Results Clients receiving teletherapy showed noninferior alliance and clinical outcome when compared to clients receiving in-person psychotherapy. A significant main effect on alliance was found with regard to race and ethnicity. A significant main effect on outcome was found with regard to international student status. Significant interactions on alliance were found between cohort and current financial stress. Conclusions Study findings support the continued use of teletherapy by demonstrating commensurate clinical process and outcome. Yet, it will be important for providers to be aware of existing mental health disparities that continue to accompany psychotherapy – in person and via teletherapy. Results and findings are discussed in terms of research and clinical implications. Future directions for researching teletherapy as a viable treatment delivery method are also discussed.