Psychotherapy Outcome Research Articles

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.

Consensus on Alliance Quality in the Psychotherapeutic Dyad and Its Differentiating Effect on Treatment Outcomes in Patients with Adjustment Disorders

The study aimed to analyze patient–therapist convergence in therapeutic alliance ratings. The author also tested if increasing patient–therapist consensus on alliance quality during psychotherapy was related to better treatment outcomes. The study included 20 patients and one psychotherapist, who was a person other than the researcher in this study. The patients, suffering from adjustment disorders, were undergoing individual outpatient treatment in private practice. Three estimations of alliance and two estimations of treatment outcomes were performed. Psychotherapeutic processes, lasting nearly a year and a half, were examined from their commencement to their natural completion. The hypotheses were verified using difference tests. Two-dimensional correlations were computed, and the outcomes of psychotherapy were estimated using a clinical significance index. The results revealed systematic patient–therapist discrepancies in alliance quality ratings at specific time points and the psychotherapist’s tendency to underrate alliance quality. Patient–therapist convergence in therapeutic alliance perceptions increased over the course of psychotherapy. The expected differences in treatment outcomes depending on convergence in alliance quality ratings were not found. Analysis results indicate that, in psychotherapy for patients with adjustment disorders, patient and therapist evaluations of alliance diverge, particularly in the early phases of treatment. Increasing consensus on alliance quality is observed. Similar convergence in alliance ratings was found in adjustment disorder patients with better and worse treatment outcomes.

Changes in dreams - the development of a dream-transformation scale in psychoanalyses with chronically depressed, early traumatized patients

ABSTRACT As is well known, dreams are still seen as via regia to the unconscious by many psychodynamic and psychoanalytic clinicians and researchers. Therefore, this article reports on decades of efforts to understand changes in manifest dreams in psychodynamic therapies as indicators for relevant, sustaining transformations in the inner object world of patients and to use them in comparative psychotherapy outcome studies. An empirical psychotherapy study by Leuzinger-Bohleber has described the following changes in manifest dream during successful psychoanalyses: reduction of nightmares, widening of the affective spectrum, increase of successful problemsolving, fewer observer dreams and more mature object relations. These transformations are illustrated in a detailed case report of a chronically depressed, early traumatized patient of the LAC Depression Study. In the next section the results of a systematic focused literature review aiming to identify suitable instruments for the study of dreams are presented. Finally, we discuss which conclusions can be drawn for the development of a dream transformation scale capturing changes in manifest dreams in psychodynamic therapies with depressive patients. Such a scale would be an important methodological addition for future comparative psychotherapy outcome studies, since it takes into account dreams, as a genuinely psychoanalytic criterion for psychic transformations.

Therapeutic alliance is calming and curing-The interplay between alliance and emotion regulation as predictors of outcome in Internet-based treatments for adolescent depression.

Therapeutic alliance is one of the most stable predictors of outcome in psychotherapy, regardless of theoretical orientation. The alliance-outcome relationship in internet-based treatments has been investigated with mixed results. There is preliminary evidence that emotion regulation can work as a mediator for the alliance-outcome relationship. The present study aimed to investigate whether alliance predicted outcome session by session in two internet-based treatments for adolescent depression, and whether this relationship was mediated by emotion regulation. Two hundred and seventy-two participants aged 15-19 years and diagnosed with depression were randomized to 10 weeks of internet-based psychodynamic or cognitive behavioral treatment. Both therapists and patients rated the alliance weekly. Patients also rated depressive symptoms and emotion regulation weekly. Analyses were made using cross-lagged panel modeling. Alliance, as rated by both therapist and patient, predicted depression scores the following week. Emotion regulation rated by the patient also predicted depression scores the following week. Furthermore, alliance scores predicted emotion regulation scores the following week, which in turn predicted depression scores the week after, supporting the hypothesis that alliance influences outcome partly through emotion regulation. There were no group differences in any of these relationships. Alliance seems to play an important role in internet-based treatments, partly through emotion regulation. Clinicians working with text-based treatments should pay attention to the working alliance. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Psychotherapy outcomes with Latinx clients attending Hispanic-serving institutions and predominantly White institutions.

In the present study, we used a large, national data set to examine psychotherapy outcomes from 9,515 Latinx clients seeking treatment in 71 college or university counseling centers in the United States, 13 of which were in Hispanic-serving institutions (HSIs) and 58 in predominantly White institutions (PWIs). We examined the hypothesis that Latinx clients in HSIs, compared to Latinx clients in PWIs, would experience greater relief in symptoms of depression, generalized anxiety, and academic distress over the course of psychotherapy. Results of multilevel modeling offered partial support for our hypothesis. Compared to their counterparts in PWIs, Latinx clients in HSIs were found to experience significantly greater relief in academic distress over the course of psychotherapy, but there were no significant differences between Latinx clients in HSIs and PWIs in terms of changes in depression or generalized anxiety over time. We offer recommendations for future research and discuss the practical implications of these findings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Therapists' oxytocin response mediates the association between patients' negative emotions and psychotherapy outcomes

BackgroundExisting literature suggests that patients' experiences of emotions, especially negative emotions, predict outcomes in psychotherapies for major depressive disorder. However, the specific mechanisms underlying this effect remain unclear. Based on studies pointing to the role of oxytocin (OT) in attachment relationships, we proposed and tested a mediation model where the therapists' hormonal responses, as represented by increases in their OT levels, mediates the association between negative emotions and symptomatic change. MethodOT saliva samples (pre- and post-session, N = 435) were collected on a fixed schedule over 16 sessions from the therapists of 62 patients receiving psychotherapy for major depression. The Hamilton Rating Scale for Depression was administered to the patients before the sessions, and the patients reported their in-session emotions after the sessions. ResultsThe findings support the proposed within-person mediation model: (a) higher levels of negative emotions in patients predicted greater increases in therapist OT levels pre- to post-session throughout treatment; (b) greater OT levels in therapists, in turn, predicted reduction in patients' depressive symptoms on the subsequent assessment; and (c) the therapists' OT levels significantly mediated the association between patients' negative emotions and reduction in their depressive symptoms. LimitationsThis design precluded establishing a time sequence between patients' negative emotions and therapists' OT; thus, causality could not be inferred. ConclusionThese findings point to a possible biological mechanism underlying the effects of patients' experiences of negative emotions on treatment outcomes. The findings suggest that therapists' OT responses could potentially serve as a biomarker of an effective therapeutic processes.

Common factors, Responsiveness and Outcome in Psychotherapy (CROP): study protocol for a naturalistic prospective cohort study of psychotherapy in Denmark

IntroductionThe aim of the Common factors, Responsiveness and Outcome in Psychotherapy (CROP) study is to identify client and psychologist characteristics and therapeutic processes associated with the outcome of psychotherapy delivered...

Research Review: The internalizing paradox - youth anxiety and depression symptoms, psychotherapy outcomes, and implications for research and practice.

Youth anxiety and depression have long been combined within the empirically derived internalizing syndrome. The two conditions show substantial comorbidity, symptom co-occurrence, and overlap in treatment procedures, but paradoxically diverge in psychotherapy outcomes: strong, positive effects for anxiety and weak effects for depression. Drawing on recent research, we examine candidate explanations for this paradox to help identify strategies for addressing it by improving outcomes for youth depression. Candidate explanations include that youth depression, compared with youth anxiety, has more varied comorbidities and more heterogeneous symptom combinations, has greater uncertainty regarding mediators and mechanisms of change, is treated with more complex and potentially confusing protocols, and has characteristics that may impede client engagement. Candidate strategies for shrinking the psychotherapy effectiveness gap include personalizing through transdiagnostic modular treatment, simplifying therapy by focusing on empirically supported principles of change, developing effective strategies for engaging family members as intervention allies, using shared decision-making to inform clinical decisions and boost client engagement, capitalizing on youth-friendly technological advances, and shortening and digitizing treatments to enhance their accessibility and appeal. Recent advances suggest explanations for the internalizing paradox, which in turn suggest strategies for shrinking the youth anxiety-depression psychotherapy outcome gap; these form an agenda for a promising new era of research.

Supplemental Material for Emotional Changes and Outcomes in Psychotherapy: A Systematic Review and Meta-Analysis

Supplemental Material for Emotional Changes and Outcomes in Psychotherapy: A Systematic Review and Meta-Analysis

Fostering practice-based evidence through routine outcome monitoring in a university psychotherapy service for common mental health problems: a protocol for a naturalistic, observational study

IntroductionData-informed psychotherapy and routine outcome monitoring are growing as referents in psychotherapy research and practice. In Ecuador, standardised web-based routine outcome monitoring systems have not been used yet, precluding data-driven...

Enhancing mental health and well‐being outcomes for psychotherapy and counselling through idiographic analysis: A four‐quadrant approach

AbstractMental health and well‐being outcomes in psychotherapy and counselling have largely been studied through the use of standardised nomothetic measurement. A key limitation is that nomothetic measurement and current statistical analyses do not necessarily capture the outcomes of the complicated and individual psychotherapy processes. There is an increased interest in the use of idiographic patient‐reported outcome measures (I‐PROMs), which are uniquely useful because they may explore areas of importance that are unexplored by nomothetic outcome measures. We argue that to optimise the value of I‐PROMs, it is necessary to consider their contribution alongside standardised nomothetic measures. However, there are important considerations with respect to whether or not I‐PROMs from different clients, or indeed from the same client, can be meaningfully explored at a team/service level, and alongside standardised nomothetic outcomes. We provide worked examples on real client data to show that delineating four quadrants of analysis is important to explore the breadth of information: (a) individual progress on single items, (b) individual progress by aggregated scores, (c) team/service‐level progress by goal item/theme and (d) team/service‐level progress by aggregated scores.

The variability of client, therapist and clinic in psychotherapy outcomes: A three‐level hierarchical model

AbstractThis article investigates the percentage of variance in psychotherapy outcomes explained by the case‐mix variables for individual cases, by the therapist (therapist effects), and what additional variance is explained by the clinic with which the therapist is affiliated. While there has been substantial recent research regarding therapist effects, very little has been published regarding clinic‐level effects after controlling for therapist effects. The study utilised the largest sample reported to date, using data from 28 clinics with a minimum of 2,000 cases in a clinical range of severity of symptoms with pre‐post change scores on an outcome questionnaire. Only cases treated by a therapist with at least 30 cases were included. These selection criteria resulted in a case count of 156,258 clients treated by 874 therapists located at 28 clinics. After controlling for differences in case mix using diagnosis and intake score (severity of symptoms), the resulting analyses indicated that 5.21% of the variance in treatment outcome was explained by the therapist, while another 1.13% of the variance was associated with the clinic. Findings are discussed with implications for practice and policy.

Could negative outcomes of psychotherapies be contributing to the lack of an overall population effect from the Australian Better Access initiative?

We examine deterioration in psychotherapies, as reported in the recent evaluation of the Australian Medicare Better Access initiative. A focus on patients who experience poor clinical outcomes helps programs minimise harm and improve quality of care. The Better Access evaluation found the mental health of 20-40% of patients deteriorated. This may partly explain why population distress and suicide rates were not reduced by the introduction of the Better Access initiative. Deterioration was more likely for milder conditions, and less likely for severe conditions, which also improved the most. Using severity as a criterion for priority setting and resource allocation may minimise patient risk and maximise benefits. Patients with severe conditions may require considerably more sessions than the current average for Better Access psychotherapies.

The sister concepts of working alliance and real relationship: A meta-analysis

ABSTRACT The real relationship and working alliance are considered sister concepts, because, even though they are distinct elements of the therapeutic relationship, they seem to be highly interrelated, especially regarding the bond element of the relationship. Both concepts are considered to contribute significantly to the therapy outcomes, but some questions remain regarding their relationship, similarities, and conceptual differences. The present study aimed to examine the association of real relationship and working alliance across studies and analyze their contribution to treatment success. For this purpose, we conducted a meta-analysis on these two constructs and performed a quantitative analysis to differentiate the contribution of real relationship and working alliance for psychotherapy outcomes. Results from the meta-analysis confirmed the theorized association between real relationship and working alliance, revealing an overall correlation of r = .66. Based on our quantitative analysis, real relationship seems to be as good a predictor as the working alliance, although both benefit from each other. The research findings underline the importance of considering the contribution of these two concepts for therapeutic outcomes. Therapists should pay attention to both real relationship and the working alliance as key factors that improve therapy success.

Extended validation of the Relational Depth Frequency Scale: Retest reliability, divergent and criterion validity, and measurement invariance in UK- and US-stratified samples.

The Relational Depth Frequency Scale (RDFS) assesses moments of profound connection in psychotherapy, associated with therapeutic benefit. To date, the RDFS has not been tested for its retest reliability, divergent and criterion validity, and measurement invariance, nor has it been tested in stratified samples of psychotherapy patients. Two stratified online samples of United Kingdom (n = 514) and United States (n = 402) psychotherapy patients filled out the RDFS, the Brief Social Desirability Scale (BSDS); and the Satisfaction with Therapy and Therapist Scale-revised (STTS-R). Two subsamples of patients (United Kingdom: n = 50 and United States: n = 203) filled out the RDFS again after 1 month. Reliability for the six-item RDFS were excellent in United Kingdom and United States samples (Cronbach's α = 0.91 and 0.92; retest r = 0.73 and r = 0.76). Divergent (r = 0.10 and r = 0.12) and criterion validity (r = 0.69; and r = 0.70) were good. Full scalar invariance was established across countries, genders, and time. This contributes important evidence to the validity of the RDFS. Future research should assess predictive validity against psychotherapy outcomes and replicate these analyses in diverse samples.

Participant factors as correlates of patients’ psychotherapy outcome expectation: A meta-analytic and box-count review

ABSTRACT Objective More positive pre- or early therapy patient outcome expectation (OE) has consistently correlated with better treatment outcomes. Thus, it is important to identify factors that contribute to patients’ OE, which can inform therapist responsivity to such risk or facilitative markers. With growing research on OE correlates—centered primarily on patient characteristics/treatment factors and, to a lesser extent, therapist factors—a comprehensive synthesis is warranted to elucidate replicated and mixed associations and stimulate further research. Accordingly, we set a pragmatic cutoff of k ≥ 5 for meaningful empirical aggregation of participant factor-OE associations; otherwise, we conducted box counts. Method We searched for articles published through March 2022 that included a clinical sample, a measure of patient’s pre- or early treatment OE, and an explicit test of the factor-OE association. Results Patient problem severity, problem chronicity, education, age, and quality of life were meta-analyzed. Greater severity correlated with lower/less optimistic OE (r = −0.13, p < .001) and higher QOL correlated with higher/more optimistic OE (r = 0.18, p < .001). Box counts revealed that few variables had consistent associations with OE. Conclusions Some factors can help forecast patient OE, though additional research is needed to enhance confidence and clinical meaning.

Machine learning-based identification of a psychotherapy-predictive electroencephalographic signature in PTSD

Although psychotherapy is at present the most effective treatment for posttraumatic stress disorder (PTSD), its efficacy is still limited for many patients, due mainly to the substantial clinical and neurobiological heterogeneity in the disease. Development of treatment-predictive algorithms by leveraging machine learning on brain connectivity data can advance our understanding of the neurobiological mechanisms underlying the disease and its treatment. Doing so with low-cost and easy-to-gather electroencephalogram (EEG) data may furthermore facilitate clinical translation of such algorithms for patients with PTSD. This study investigates whether individual patient-level resting-state EEG connectivity can predict psychotherapy outcomes in PTSD. We developed a treatment-predictive EEG signature using machine learning applied to high-density resting-state EEG collected from military veterans with PTSD. The predictive signature was dominated by theta frequency EEG connectivity differences and was able to generalize across two types of psychotherapy—prolonged exposure and cognitive processing therapy. Our results also advance a biological definition of a PTSD patient subgroup who is resistant to psychotherapy, which is currently the most evidence-based treatment for the condition. The findings support a path towards clinically translatable and scalable biomarkers that could be used to tailor interventions for each individual or drive the development of novel treatments (ClinicalTrials.gov registration: NCT03343028 ). Using machine learning, Zhang et al. identify EEG signature to predict psychotherapy outcomes in PTSD, paving the way towards the development of scalable biomarkers.

Psychological therapies for depression and cardiovascular risk: evidence from national healthcare records in England.

People with depression are up to 72% more at risk to develop cardiovascular disease (CVD) in their lifetime. Evidence-based psychotherapies are first-line interventions for the treatment of depression and are delivered nationally in England through the National Health Service via the Improving Access to Psychological Therapy (IAPT) primary care programme. It is currently unknown whether positive therapy outcomes may be associated with cardiovascular risk reduction. This study aimed to examine the association between psychotherapy outcomes for depression and incident CVD. A cohort of 636 955 individuals who have completed a course of psychotherapy was built from linked electronic healthcare record databases of national coverage in England: the national IAPT database, the Hospital Episode Statistics (HES) database, and the HES-ONS (Office of National Statistics) mortality database. Multivariable Cox models adjusting for clinical and demographic covariates were run to estimate the association between reliable improvement from depression and the risk of subsequent incidence of cardiovascular events. After a median follow-up of 3.1 years, reliable improvement from depression symptoms was associated with a lower risk of new onset of any CVD [hazard ratio (HR): 0.88, 95% confidence interval (CI): 0.86, 0.89], coronary heart disease (HR: 0.89, 95% CI: 0.86, 0.92), stroke (HR: 0.88, 95% CI: 0.83, 0.94), and all-cause mortality (HR: 0.81, 95% CI: 0.78, 0.84). This association was stronger in the under 60 compared with the over 60 for all outcomes. Results were confirmed in sensitivity analyses. Management of depression through psychological interventions may be associated with reduced risk of CVD. More research is needed to understand the causality of these associations.

Skill Improvement Through Learning in Therapy (SKILT): A Study Protocol for a Randomized Trial Testing the Direct Effects of Cognitive Behavioral Therapy Skill Acquisition and Role of Learning Capacity in Depression.

To improve psychological treatments for major depressive disorder (MDD), a better understanding on how symptoms ameliorate during treatment is essential. In cognitive behavioral therapy (CBT), it is unclear whether procedures focused on the acquisition of CBT skills play a causal role in the improvement of CBT skills. In this randomized trial, we isolate a single CBT Skill Acquisition Procedure (CBTSAP) and test its direct effects on CBT skills and related therapy processes (i.e., change in (idiosyncratic) dysfunctional thinking and reward processing). We hypothesize that the CBTSAP causes improvements in CBT skills and related therapy processes compared to an active control condition. In addition, we hypothesize that individual differences in attentional bias and memory functioning (defined as learning capacity) moderate the effects of CBTSAP on outcomes and that using mental imagery as a cognitive support strategy to strengthen the effects of the CBTSAP will be most beneficial for patients with low learning capacity. 150 patients with MDD will be randomized to one of three conditions: 1. an active control condition, 2. CBTSAP, 2. CBTSAP plus mental imagery, all consisting of three sessions. Primary outcomes will be change in CBT skills, changes in (idiosyncratic) dysfunctional thoughts and behaviors, reward processing. Depressive symptoms are a secondary outcome. Measures of learning capacity will be conducted at baseline and tested as a potential moderator. Knowing whether and for whom the acquisition of CBT skills leads to change in therapy processes and a subsequent reduction of depressive symptoms will inform on how to personalize and optimize psychotherapy outcomes for depression. The trial is registered at the German Clinical Trial Register (DKTR; registration number: DRKS00024116).

Facilitating dyadic synchrony in psychotherapy sessions: Systematic review and meta-analysis

Objective: This paper highlights the facilitation of dyadic synchrony as a core psychotherapist skill that occurs at the non-verbal level and underlies many other therapeutic methods. We define dyadic synchrony, differentiate it from similar constructs, and provide an excerpt illustrating dyadic synchrony in a psychotherapy session. Method: We then present a systematic review of 17 studies that have examined the associations between dyadic synchrony and psychotherapy outcomes. We also conduct a meta-analysis of 8 studies that examined whether there is more synchrony between clients and therapists than would be expected by chance. Results: Weighted box score analysis revealed that the overall association of synchrony and proximal as well as distal outcomes was neutral to mildly positive. The results of the meta-analysis indicated that real client-therapist dyad pairs exhibited synchronized behavioral patterns to a much greater extent than a sample of randomly paired people who did not actually speak. Conclusion: Our discussion revolves around how synchrony can be facilitated in a beneficial way, as well as situations in which it may not be beneficial. We conclude with training implications and therapeutic practices.