Outpatient Psychotherapy Research Articles

Is reflective functioning associated with clinical symptoms and long-term course in patients with personality disorders?

ObjectiveMentalization is the capacity to understand behavior as the expression of various mental states and is assumed to be important in a range of psychopathologies, especially personality disorders (PDs). The first aim of the present study was to investigate the relationship between mentalization capacity, operationalized as reflective functioning (RF), and clinical manifestations before entering study treatment. The second aim was to investigate the relationship between baseline RF and long-term clinical outcome both independent of treatment (predictor analyses) and dependent on treatment (moderator analyses). MethodsSeventy-nine patients from a randomized clinical trial (Ullevål Personality Project) who had borderline and/or avoidant PD were randomly assigned to either a step-down treatment program, comprising short-term day-hospital treatment followed by outpatient combined group and individual psychotherapy, or to outpatient individual psychotherapy. Patients were evaluated on variables including symptomatic distress, psychosocial functioning, personality functioning, and self-esteem at baseline, 8 and 18months, and 3 and 6years. ResultsRF was significantly associated with a wide range of variables at baseline. In longitudinal analyses RF was not found to be a predictor of long-term clinical outcome. However, when considering treatment type, there were significant moderator effects of RF. Patients with low RF had better outcomes in outpatient individual therapy compared to the step-down program. In contrast, patients in the medium RF group achieved better results in the step-down program. ConclusionThese findings indicate that RF is associated with core aspects of personality pathology and capture clinically relevant phenomena in adult patients with PDs. Moreover, patients with different capacities for mentalization may need different kinds of therapeutic approaches.

Typical patterns of depressive disorders during outpatient psychotherapy and their prediction

Are there typical patterns of outpatient psychotherapy among depressed patients? What characterizes patients with different patterns? We examined N= 548 patients with primary depressive disorders using a naturalistic design. Using a latent-state-mixture model and depression measures at baseline, therapy end and 1-year follow-up we found a total of five patterns. Subgroups were compared with respect to sociodemographic and treatment-related variables. Responders with moderate depressive symptoms at baseline and responders with severe symptoms at baseline were most common (54% and 25% of the sample, respectively) compared to late responders (9 %), small-response patients (9 %) and recidivists (4 %). Patterns of change were related to symptom intensity at baseline and ratings of perceived helpfulness at the end of treatment. Since psychometric scales better predicted change pattern than sociodemographic characteristics, primary and secondary diagnoses, psychometric assessments and feedback systems could be a useful supplement to traditional quality assurance procedures.

Pretreatment and process predictors of nonresponse at different stages of inpatient psychotherapy

Objective: Up to 50% of psychotherapeutic treatments end without significant improvements. While there is first evidence about predictors of nonresponse in outpatient psychotherapy, there are currently no studies investigating predictors of nonresponse in inpatient settings. Based upon a previous systematic literature review, we analyzed the predictive value of initial patient characteristics on nonresponse in symptom distress. Methods: Treatment episodes from 546 patients, treated for at least 4 weeks, were assessed under naturalistic conditions. Nonresponse status (i.e., lack of a reliable improvement in symptom distress) was investigated at four different time points: at week 4, at discharge, and at a two follow-ups (3 and 12 months after discharge). Hierarchical binary logistic regression models were used to predict nonresponse. Sociodemographic data, clinical variables, and the previous response status were entered subsequently in the model. Results: A moderate or functional level of initial symptom distress, a comorbid personality disorder, and previous nonresponse were the most consistent predictors of nonresponse. Conclusions: The results point to the importance of early outcome assessment and suggest the implementation of more symptom-specific treatments.

Effectiveness of case management-based aftercare coordination by phone for patients with depressive and anxiety disorders: study protocol for a randomized controlled trial.

BackgroundDepressive and anxiety disorders are highly prevalent, but only a small percentage (approximately 50%) of patients receive appropriate treatment. Relevant barriers include communication and coordination gaps between different providers that result from the lack of integration between different care-giving systems. Aftercare following inpatient treatment represents one of these gaps because systematic follow-up care does not exist. Case management-based aftercare coordination by phone might be a promising approach to overcoming this gap and improving long-term treatment outcomes. Case management is a patient-centered and situation-based approach comprising systematic tracking and support of patients by a case manager.The aim of this study is to evaluate the effectiveness of aftercare coordination by phone for patients with depressive and anxiety disorders.Methods/designThe effectiveness of aftercare coordination will be investigated in a prospective randomized controlled trial in four psychotherapeutic inpatient routine care units (St. Franziska-Stift Bad Kreuznach, MediClin Seepark Klinik Bad Bodenteich, Segeberger Kliniken Gruppe Bad Segeberg and Luisenklinik Bad Dürrheim). The patients receiving aftercare coordination (intervention group; IG) will be compared with those who receive treatment as usual (TAU control group; CG). Eligible patients will be required to have a diagnosis of an anxiety and/or depressive disorder and a recommendation for follow-up outpatient psychotherapy.The aftercare coordination consists of six phone contacts at intervals of two weeks that are performed by therapists in the inpatient units. The patients will complete questionnaires at discharge (t1), 3 months after discharge (i.e., at the end of the intervention (t2)) and 9 months after discharge (t3). The primary outcome will be change in symptom severity from t1 to t3, the secondary outcomes will be health-related quality of life and the proportion of patients who manage to begin outpatient psychotherapy by t3.DiscussionThis study will determine whether case management-based aftercare coordination by phone is an adequate approach for overcoming treatment barriers in the clinical pathways of patients with depressive and anxiety disorders. If proven effective, an accessible supplementary treatment approach that will help to maintain and even improve long-term treatment outcomes will be made available for patients following inpatient treatment.Trial registrationClinicalTrials.gov: (NCT02044913).

Client concealment and disclosure of secrets in outpatient psychotherapy

We investigated client motivations for concealing vs. disclosing secrets and how concealment and disclosure relate to therapeutic process and outcome. Of 115 participants who were currently in psychotherapy, most had revealed a secret and about half were concealing a secret in psychotherapy. Concealed secrets were most likely to be sexual in nature and were concealed due to shame or embarrassment. Disclosed secrets were most likely to be related to relationships and were disclosed because clients felt they could trust their therapists and because they thought they could benefit from sharing the secret. Clients were most likely to report that they would choose to share their concealed secret if keeping it prevented them from making progress in therapy, and about half of the clients keeping a secret thought they would eventually disclose it. Reflecting back, clients thought they experienced equal levels of negative and positive emotion when they first disclosed their secret, but currently felt more positive and less negative about disclosing. Concealment was negatively related to the real relationship. Implications for research and practice are discussed.

Can MBTI Dimensions Predict Therapy Outcome: Differences in the Thinking-Feeling Function Pair in CBT

The Myers-Briggs Type Indicator (MBTI) is often used in psychotherapy for multiple purposes, including outcome prediction. However, the empirical basis for the MBTI’s prediction of outcome is minimal. In the current study, psychological type (assessed via the MBTI), current Global Assessment of Functioning (GAF), and cognitive-behavioral therapy were used to predict psychotherapy outcome as measured by change in GAF within a sample of outpatient psychotherapy clients (N = 525). Linear regression analyses were used to identify whether the 16 MBTI psychological types and/or which dichotomous attitude and function pairs best predicted psychotherapy outcome. The Thinking-Feeling function was found to be a significant predictor of psychotherapy outcome, such that individuals who prefer Thinking demonstrated greater improvement in GAF than did individuals who preferred Feeling. However, four-letter personality type was not a significant predictor of psychotherapy outcome. Overall, the results indicated that individuals preferring the Thinking function showed greater benefit from cognitive-based CBT than individuals preferring Feeling.

Application of psychological diagnosis in the process of establishing criteria for psychodynamic therapy designed for patients with personality disorders.

Aim of the studyThe main purpose of this paper was to present a model of psychological diagnosis, aimed at establishing the fundamental criteria for qualifying patients with symptoms of various mental disorders (including neurotic and personality disorders) for outpatient psychodynamic therapy.Subject or material and methodsRorschach Inkblot Test, clinical interviewResultsThe research was conducted in the years 2010-2013 in the Neurosis Treatment Centre and in the Mental Health Outpatient Clinic A study population comprised 38 males and 42 females.DiscussionThe structure of personality characteristics and their impact on a patient’s eligibility to participate in a particular type of psychotherapy was assessed based on the major assumptions of psychodynamic approach, with special focus on the criteria put forward by Gabbard; the Big Five personality dimensions; as well as on the diagnostic criteria for personality disorders, developed by the American Psychiatric Association.ConclusionsAnalysis of the result of this research allowed to develop a model of fundamental criteria for selecting an appropriate form of psychotherapy designed for patients with various types of personality disorders. Eight criteria were found to be significant in the process of qualifying the aforementioned individuals for outpatient psychotherapy. They included two psychological dimensions: intrapsychic (describing psychological indicators of the self-structure and maturity level of the patient's identity) and interpersonal (describing indicators of the person’s capacity for establishing emotional relations with others). Diagnosis of the aforementioned indicators proves to contribute significantly to the process of selecting effective therapeutic methods for neurotic patients as well as individuals who exhibit symptoms of more severe destabilization of personality organization.

On Becoming a Teacher: Reflections on Teaching and Learning in Psychiatry Residency and Beyond.

Although over a decade has passed since my postgraduate year (PGY) 2 in psychiatry residency, it was a formative year for me as a psychiatrist and teacher. It felt, in many ways, like another PGY-1 year in terms of the transitions I faced. Although I was relieved and excited to (finally) be a full-fledged psychiatry resident rather than the “psych” resident passing through various rotations—internal medicine, emergency, and palliative care—I also felt the weight of expectation on my shoulders. This is the true test now—core inpatient and outpatient psychiatry, psychotherapy, and psychopharmacology—the heart of psychiatric practice. What if I didn’t like it? What if I wasn’t any good at it? And now they’re asking me to teach clinical clerks? Wasn’t I one just recently? Fast-forward 6 years from my PGY-2 year. I am sitting in a class of 14 other “scholars” in the Education Scholars Program (ESP) as a newly minted attending physician. I’ve been supported to attend by the chief of my department and I feel as nervous as I did inmy PGY-1 and 2 years of residency. Do you ever shake this feeling? Didn’t I just pass the requisite licensing exams and complete a fellowship? Haven’t I “arrived”? We were asked on the first day of class in the ESP to communicate our metaphors for teachers and teaching. The answers are both expected and unexpected—a chameleon, constantly adjusting to learners and the context, a guide on a journey, and an orchestra conductor. One answer from a thoughtful surgeon resonates with me. He speaks of his experience in Japanese martial arts and the term senseiwhich means “teacher” in Japanese. The surgeon says sensei’s literal translation is something like “the one who came before.” This term honors the perspective that teachers have in terms of imparting wisdom and perspective and I realize, in reflecting on this, that this is what I lacked as a PGY-2: bright eyed and bushy tailed; I had no idea how formative and meaningful teaching and being taught by talented and dedicated teachers would be inmy career development. I also had no sense of how impactful my contribution to teaching medical students could be. As doctors, I think we implicitly value teaching and learning. We are, after all, supposed to be “lifelong learners” and we’ve invested a lot in becoming doctors, but that’s just it, isn’t it, the essence of being a lifelong learner: Each of us is always in the process of becoming, learning, and growing. It’s never done. However, in those first months in PGY-2 and the years that followed it was the wisdom and guidance from the “ones who came before,”my/our teachers who provided time, guidance, safety, wisdom, knowledge, a sympathetic ear, perspective, inspiration...and so much more that helped to provide the “secure base,” to borrow a term from Bowlby [3], from which I could explore and become the clinician and educator I am today. Another flash forward and backwards. It’s 3 years into my being an attending physician and I am sitting in a faculty development program called “Train the Trainer” that is meant to teach faculty how to deliver a teaching skills program. I’m Acad Psychiatry (2016) 40:380–381 DOI 10.1007/s40596-014-0260-2

Depleted Resources and Chronic Stress

There is a well-established relationship between number and severity of stressful life events and the onset of depression. Cognitive-behavioral therapy (CBT) for depression should include relevant evaluation of chronic stressors and skill building related to garnering available resources. This clinical case study illustrates the use of a CBT approach to treating depression in an individual with a complicated history of life stressors. An adult woman with recurrent major depressive disorder sought treatment at a university-based psychology training clinic and received outpatient individual psychotherapy on a weekly basis. Therapeutic progress was evaluated through self-reported depression and anxiety symptom change, therapist observation of affect, and client and therapist assessment of progress toward therapeutic goals. This case highlights several key factors to consider when providing outpatient psychotherapy to address symptoms of depression in adults with severely depleted resources, particularly bolstering the utilization of social support.

Time-series panel analysis (TSPA): Multivariate modeling of temporal associations in psychotherapy process.

Processes occurring in the course of psychotherapy are characterized by the simple fact that they unfold in time and that the multiple factors engaged in change processes vary highly between individuals (idiographic phenomena). Previous research, however, has neglected the temporal perspective by its traditional focus on static phenomena, which were mainly assessed at the group level (nomothetic phenomena). To support a temporal approach, the authors introduce time-series panel analysis (TSPA), a statistical methodology explicitly focusing on the quantification of temporal, session-to-session aspects of change in psychotherapy. TSPA-models are initially built at the level of individuals and are subsequently aggregated at the group level, thus allowing the exploration of prototypical models. TSPA is based on vector auto-regression (VAR), an extension of univariate auto-regression models to multivariate time-series data. The application of TSPA is demonstrated in a sample of 87 outpatient psychotherapy patients who were monitored by postsession questionnaires. Prototypical mechanisms of change were derived from the aggregation of individual multivariate models of psychotherapy process. In a 2nd step, the associations between mechanisms of change (TSPA) and pre- to postsymptom change were explored. TSPA allowed a prototypical process pattern to be identified, where patient's alliance and self-efficacy were linked by a temporal feedback-loop. Furthermore, therapist's stability over time in both mastery and clarification interventions was positively associated with better outcomes. TSPA is a statistical tool that sheds new light on temporal mechanisms of change. Through this approach, clinicians may gain insight into prototypical patterns of change in psychotherapy.

Evaluating Statistical and Clinical Significance of Intervention Effects in Single-Case Experimental Designs: An SPSS Method to Analyze Univariate Data

Single-case experimental designs are useful methods in clinical research practice to investigate individual client progress. Their proliferation might have been hampered by methodological challenges such as the difficulty applying existing statistical procedures. In this article, we describe a data-analytic method to analyze univariate (i.e., one symptom) single-case data using the common package SPSS. This method can help the clinical researcher to investigate whether an intervention works as compared with a baseline period or another intervention type, and to determine whether symptom improvement is clinically significant. First, we describe the statistical method in a conceptual way and show how it can be implemented in SPSS. Simulation studies were performed to determine the number of observation points required per intervention phase. Second, to illustrate this method and its implications, we present a case study of an adolescent with anxiety disorders treated with cognitive-behavioral therapy techniques in an outpatient psychotherapy clinic, whose symptoms were regularly assessed before each session. We provide a description of the data analyses and results of this case study. Finally, we discuss the advantages and shortcomings of the proposed method.

Nonverbal synchrony of head- and body-movement in psychotherapy: different signals have different associations with outcome.

Objective: The coordination of patient’s and therapist’s bodily movement – nonverbal synchrony – has been empirically shown to be associated with psychotherapy outcome. This finding was based on dynamic movement patterns of the whole body. The present paper is a new analysis of an existing dataset (Ramseyer and Tschacher, 2011), which extends previous findings by differentiating movements pertaining to head and upper-body regions.Method: In a sample of 70 patients (37 female, 33 male) treated at an outpatient psychotherapy clinic, we quantified nonverbal synchrony with an automated objective video-analysis algorithm (motion energy analysis). Head- and body-synchrony was quantified during the initial 15 min of video-recorded therapy sessions. Micro-outcome was assessed with self-report post-session questionnaires provided by patients and their therapists. Macro-outcome was measured with questionnaires that quantified attainment of treatment goals and changes in experiencing and behavior at the end of therapy.Results: The differentiation of head- and body-synchrony showed that these two facets of motor coordination were differentially associated with outcome. Head-synchrony predicted global outcome of therapy, while body-synchrony did not, and body-synchrony predicted session outcome, while head-synchrony did not.Conclusion: The results pose an important amendment to previous findings, which showed that nonverbal synchrony embodied both outcome and interpersonal variables of psychotherapy dyads. The separation of head- and body-synchrony suggested that distinct mechanisms may operate in these two regions: Head-synchrony embodied phenomena with a long temporal extension (overall therapy success), while body-synchrony embodied phenomena of a more immediate nature (session-level success). More explorations with fine-grained analyses of synchronized phenomena in nonverbal behavior may shed additional light on the embodiment of psychotherapy process.

Long-term course in female survivors of childhood abuse after psychodynamically oriented, trauma-specific inpatient treatment: a naturalistic two-year follow-up.

This study examined the long-term course of 43 female survivors of childhood abuse after receiving inpatient treatment based on psychodynamic-orientated trauma therapy. Data on symptom load was assessed at admission, discharge and two-year follow-up. Further information on post-discharge treatment and life events in the follow-up period was collected. At two-year follow-up global symptom load (GSI), PTSD, depression (d = 0.43-0.57) and self-soothing ability (d = 0.72) were significantly improved compared to the admission status with no change in dissociative symptoms. 40% of the sample showed good long-term outcome (clinical significant change, GSI) with a significant reduction in depressive, dissociative and by trend in PTSD symptoms. There were no group differences in the amount of stressful life-events and treatment in the follow-up period. Patients with good outcome showed more previous inpatient treatment. Inpatient treatment leads to a significant symptom reduction in women with severe childhood abuse. The treatment effects remain stable for two years under further outpatient psychotherapy.

Psychotherapy participants show increased physiological responsiveness to a lab stressor relative to matched controls.

Accumulating evidence indicates that psychotherapy participants show increased physiological responsiveness to stress. The purpose of the present study was to examine differences between individuals participating in outpatient psychotherapy and matched controls using an experimental design. Forty-two psychotherapy participants and 48 matched controls were assessed on cardiovascular and cortisol functioning at baseline, during the Trier Social Stress Test (TSST), and during a 20-min recovery period. Psychotherapy participants and matched controls did not differ at baseline or during the TSST on the physiological measures but psychotherapy participants had higher cortisol and heart rate (HR) during the recovery period. In regards to reactivity, cortisol increased during the recovery period for the psychotherapy participants but decreased for those in the matched control group. Psychotherapy participants experiencing clinically significant levels of distress displayed elevated systolic and diastolic blood pressure and HR during the TSST when compared to psychotherapy participants not experiencing clinically significant levels of distress. Overall, physiological reactivity to stress appears to be an important issue for those in psychotherapy and directly addressing this issue may help improve psychotherapy outcomes.

Mental distress and wish for psychosomatic treatment of patients with pulmonary hypertension

The study investigated the level of mental distress in patients with pulmonary hypertension (PH) and assessed the use of and the wish for psychosomatic treatment. A total sample of n=187 outpatients participated in the cross-sectional survey. The short form of the Patient Health Questionnaire (PHQ-D), the EuroQol (EQ-5D) and a questionnaire assessing the wish for psychosomatic treatment were applied. 50.6% of the patients exhibited depressive symptoms of varying degrees, 19.2% showed symptoms of major depression. 14.8% of the pa-tients reported panic attacks, and 7.1% demonstrated symptoms of a panic syndrome. Quality of life was low (EQ-5D VAS M=60). Experience with outpatient or inpatient psychotherapy was reported by 23.4% and 8.6% of the patients, respectively. 56.5% reported a wish for psychosomatic treatment. PH-Patients are more likely to suffer from mild or subthreshold depressive syndromes, but are very interested in psychosomatic treatment. The implementation of psychosomatic interventions into clinical practice would be desirable.

Clinical characteristics associated with premature termination from outpatient psychotherapy for anorexia nervosa.

The literature on clinical characteristics associated with premature termination of treatment (PTT) is beset with conflicting and non-replicated findings. This study explores clinical characteristics potentially associated with PTT in a randomised controlled outpatient psychotherapy trial for anorexia nervosa (AN). Participants were 56 women aged 17-40 years with spectrum AN. The completer group (n = 35) included those completing at least 15/20 planned sessions with the remainder of the sample comprising the PTT group (n = 21). Variables examined included demographic factors, psychosocial functioning, psychiatric history, lifetime comorbidity, temperament and eating disorder characteristics. Logistic regression was used to examine significant variables. A Kaplan-Meier survival curve was used to illustrate time taken to PTT. The mean number of sessions in the PTT group was 8.1. Lower self-transcendence scores on the Temperament and Character Inventory were associated with PTT. Recognising and addressing personality factors have the potential to enhance retention in treatment.

Relapse prevention in drug addiction: addressing a messy problem by IS Action Research

After primarily successful drug-dependency rehabilitation, relapses occur frequently. There is a tremendous lack of drug-specific outpatient psychotherapy and self-help groups especially in rural areas. Therefore, new approaches must be integrated to reduce relapse rates after inpatient addiction treatment, especially in case of drug dependence. The present paper aims to address this complex problem using an Action Research (AR) methodology. In addition to the systematic literature search, we show the results of interviews with patients and therapists as key stakeholders. After that, the iterative cyclical nature of AR reinforced our research, including the role of adequate ripening concerning inpatient care, the macroeconomic perspective on the insurance companies' patient allocation, the importance of external structure and skills in outpatient aftercare and specific impulses for dedicated information systems (ISs). We finally develop the hypothesis that a mobile technology-based IS could (a) be successfully implemented for patients recovering from drug dependence and (b) improve their outcome.

Codetype-Based Interpretation of the MMPI–2 in an Outpatient Psychotherapy Sample

In an evaluation of the codetype-based interpretation of the MMPI–2, 48 doctoral student psychotherapists rated their clients’ (N = 120) standardized interpretations as more accurate when based on the profile's codetype, in comparison with ratings for interpretations based on alternate codetypes. Effect sizes ranged from nonsignificant to large, depending on the degree of proximity between the profile's codetype and the alternate codetype. There was weak evidence to suggest that well-defined profiles yielded more accurate interpretations than undefined profiles. It appears that codetype-based interpretation of the MMPI–2 is generally valid, but there might be little difference in the accuracy of interpretations based on nearby codetypes.

Functions of non-suicidal self-injury in adolescents and young adults with Borderline Personality Disorder symptoms

Rates of deliberate non-suicidal self-injury (NSSI) increase during adolescence and young adulthood, particularly in clinical samples, making these important developmental stages for understanding the functions of NSSI. Borderline Personality Disorder (BPD) symptoms also begin to emerge in adolescence, though little research has examined relationships between BPD symptoms and the functions of NSSI in youth, the primary goal of the present study. Adolescents and young adults recruited from an outpatient psychotherapy clinic (N=36) endorsed a range of NSSI functions on the Inventory of Statements about Self-Injury (Klonsky and Glenn, 2009). Participants engaged in NSSI to serve intrapersonal functions (e.g., regulate affect, punish oneself) more frequently than interpersonal functions (e.g., bond with peers, establish autonomy). As predicted, linear regression analyses indicated that BPD affective dysregulation symptoms were associated with the intrapersonal but not the interpersonal functions of NSSI. In contrast, BPD interpersonal dysfunction symptoms were differentially associated with the interpersonal rather than intrapersonal functions of NSSI. These preliminary data indicate that clusters of BPD symptoms show unique relationships with functions of NSSI in treatment-seeking adolescents and young adults, relationships that can be used to target specific functions of NSSI in treatment planning.

Relevance of therapy goals in outpatient cognitive-behavioral and psychodynamic psychotherapy

Objective: Against a background of sparse research and contradictory findings, the present study investigates determinants of psychotherapy goals and predictive value for therapy success in outpatient psychotherapy. Method: The sample consisted of 473 patients from a university-based polyclinic and their corresponding 103 therapists. Goals were coded with the Bern Inventory of Treatment Goals (BIT-T). Results: The results show that goal congruence between therapists and patients is relatively small. Theoretical orientation had a significant influence on the complexity of goal structure and goal preferences. With regard to the prognostic validity, only patients' problem- and symptom-focused goals enabled the prediction of treatment success independent of basic therapeutic variables. Conclusions: These findings underline the importance of consideration of patients' individual treatment goals in clinical practice and underpin the relevance of therapy goals for future psychotherapy research.