Psychotherapy Research Research Articles

An in-Vivo Daily Self-Report Approach to the Assessment of Outcomes of Two Psychotherapies for Women With Posttraumatic Stress Disorder

Emotion regulation and interpersonal psychotherapies that do not require trauma memory processing have been shown to be effective in treating posttraumatic stress disorder (PTSD). This study used a novel method to assess in vivo outcomes in a randomized clinical trial with women (N = 147; ages 18–54; 61% of color; 94% low income) with full (79%) or partial (21%) PTSD. Participants were assigned to affect regulation or interpersonal therapy, or wait-list, and completed daily self-reports for 2 to 4 weeks at baseline and up to 30 days at posttest. Mixed model regression analyses tested pre-post change on five factor analytically derived aggregated daily self-report scores. Emotion regulation-focused therapy was associated with reduced PTSD symptoms, dysregulation, and negative affect, and improvement in adaptive self-regulation and positive affect. Interpersonal-focused therapy was associated with reduced PTSD symptoms and dysregulation. Although both therapies were associated with reduced PTSD symptoms, whether this was due to nonspecific factors rather than the treatments per se could not be determined. Daily self-report data warrant further investigation in psychotherapy research with disorders such as PTSD, in order to assess affective and interpersonal dysregulation and adaptive regulation as they occur in daily life.

Competence and Adherence Scale for Cognitive Behavioural Therapy (CAS-CBT) for anxiety disorders in youth: reliability and factor structure.

There has been increased research interest into the concept of treatment integrity within psychotherapy research. The Competence and Adherence Scale for Cognitive Behavioural Therapy (CAS-CBT) was developed to measure therapists' competence and adherence in cognitive behavioural therapy (CBT), when delivered to children and youth with anxiety disorders. The aim of this study was to evaluate the psychometric properties of the CAS-CBT in a naturalistic treatment setting. Ratings of 212 randomly selected sessions from a clinical effectiveness trial for children with anxiety disorders (n = 165, mean age = 10.46 years, SD = 1.49) were analysed to assess the psychometric properties of CAS-CBT. Therapy format included both individual sessions and group sessions. Internal consistency for the CAS-CBT was excellent (Cronbach's alpha = .88). Factor analysis suggested a two-factor solution for the total sample, where the first factor was related to CBT structure and session goals, and the second factor was associated with process and relational skills. The individual CBT treatment condition (ICBT) and group CBT treatment condition (GCBT) showed the same factor solution. The CAS-CBT is a feasible and reliable measure for assessing competence and adherence to CBT in the treatment of anxious children. Future research is needed to further assess the generalizability of this scale, its psychometric properties in different treatment populations and with other treatment approaches, and ideally with larger sample sizes.

Person-centred experiential therapy versus cognitive behavioural therapy delivered in the English Improving Access to Psychological Therapies service for the treatment of moderate or severe depression (PRaCTICED): a pragmatic, randomised, non-inferiority trial

Person-centred experiential therapy versus cognitive behavioural therapy delivered in the English Improving Access to Psychological Therapies service for the treatment of moderate or severe depression (PRaCTICED): a pragmatic, randomised, non-inferiority trial

Hand movements that change during psychotherapy and their relation to therapeutic outcome: An analysis of individual and simultaneous movements

Hands are, compared to other body parts, the body parts that display the most gestural movements during an interaction and their movement is sensitive to reveal anxiety states. However, psychotherapy research focuses on movement synchrony of different body parts to be an indicator of improved symptoms. The present study investigates symptoms in social anxiety disorder and considers both, individual and simultaneous hand movements. 56 video recordings of 28 patient-therapist dyads with patients with social anxiety at the beginning and in the end of psychotherapy were analyzed. Two independent blind certified raters analyzed the hand movement behavior using the NEUROGES® analysis system for nonverbal behavior concerning individual movement units and the simultaneous overlaps between the patients’ and therapists’ movement units. Simultaneous overlap change negatively correlated with symptoms (LSAS week eight-measurement, r = −.52; and week 15-measurement, r = −.52; BDI pre-measurement, r = −.54). The patients’ right hand movement at the end of the psychotherapy correlated significantly with therapeutic alliance (HAQ post-measurement; r = .55). Hand movement behavior analysis should be considered in psychotherapy research in combination with movement synchrony as a measurement parameter related to therapeutic process and outcome. Enriching previous findings, this study indicates that simultaneous movement change is related to symptoms and therefore a process-sensitive parameter in psychotherapy.

Operationalizing alliance rupture-repair events using control chart methods.

This study aimed to determine how control charts-a form of time-series line graphs-can be implemented in psychotherapy research to indirectly identify probable rupture-repair episodes that are associated with psychotherapy outcome. There is no current standard in psychotherapy research with regard to how to use control charts to identify rupture-repair events. Control charts were generated for each patient (N = 73) using patient-rated Working Alliance Inventory (WAI) scores obtained at the end of every session in a 30-session therapy protocol of either brief relational therapy (BRT) or cognitive behavioural therapy (CBT). Empirically derived cut-off points were used to identify rupture and repair based on each dyad's control chart. Coded rupture-repair episodes were correlated with outcome measures to assess for their relationships. The results of these analyses provide preliminary support for the utility of control charts in psychotherapy research for the indirect identification of probable rupture repair events that are associated with psychotherapy outcome.

Views on psychotherapy research among members of the Medical Psychotherapy Faculty of the Royal College of Psychiatrists.

Research drives innovation and improved practice in psychotherapy. We describe views of members of the Faculty of Medical Psychotherapy of the Royal College of Psychiatrists (RCPsych) regarding their knowledge, experience and perspectives on psychotherapy research. We sent questionnaires to the Faculty membership emailing list. In total, 172 psychiatrists from all levels of training returned fully complete responses. Respondents considered knowledge of psychotherapy research to be important to clinical work. Many have qualifications and experience in research but lack current opportunities for research involvement and would welcome the Faculty doing more to promote psychotherapy research. Perceived obstacles to research involvement included lack of competence, competing demands and wider organisational factors. The lack of research opportunities for medical psychotherapists may lead to their underrepresentation in psychotherapy research and a less medically informed research agenda. Providing support at academic, RCPsych and National Health Service organisational levels will allow more clinically relevant research not only in psychotherapy but in other psychiatric disciplines as well.

A national evaluation of the Irish public health counselling in primary care service\u2013 examination of initial effectiveness data

BackgroundThe Counselling in Primary Care service (CIPC) is the first and only nationally available public counselling service in the Republic of Ireland. This study provides initial data for the effectiveness of short-term psychotherapy delivered in a primary care setting in Ireland for the first time.MethodA practice-based observational research approach was employed to examine outcome data from 2806 clients receiving therapy from 130 therapists spread over 150 primary care locations throughout Ireland. Pre-post outcomes were assessed using the CORE-OM and reliable and clinically significant change proportions. Binary logistic regression examined the effect of pre therapy symptom severity on the log odds of recovering. Six and 12 month follow up data from a subsample of 276 clients were also analysed using growth curve analysis.ResultsOf 14,156 referred clients, 5356 presented for assessment and 52.3% (N = 2806) consented to participate. Between assessment and post-therapy a large reduction in severity of symptoms was observed- Cohen’s d = 0.98. Furthermore, 47% of clients achieved recovery,a further 15.5% reliably improved, 2.7% reliably deteriorated and34.7% showed no reliable improvement. Higher initial severity was associated with less chance of recovering at post-therapy. Significant gains were maintained between assessment and12 months after therapy- Cohen’s d = 0.50.ConclusionsOutcomes for clients in the CIPC service compared favourably with large scale counselling and psychotherapy services in jurisdictions in the U.K., the U.S.A., Norway and Sweden. This study expands the international primary care psychotherapy research base to include the entire Republic of Ireland jurisdiction.

Developing a manual for identifying interventions in psychotherapy to measure treatment adherence in research

Abstract: This article describes the process of developing a manual of therapeutic interventions of ten different modalities. With this manual, independent raters can identify the therapeutic interventions occurring in a therapy session. In research, this is called the control of treatment adherence. The article also presents some results shown by using this manual. A surprising finding was that treatment fidelity was rather low in all treatment modalities. Therapists in all modalities were identified as using between 4.7% and 32.5% of interventions specific to their school of psychotherapy. Nonspecific interventions ranged between 51.4% and 73.2% of all interventions identified. Between 14.8% and 24.8% were identified as interventions from other treatment modalities. Keywords: psychotherapy research, naturalistic design, treatment adherence, Manual of therapeutic interventions, Gestalt therapy, specific and non-specific interventions

The adaptive unconscious in psychoanalysis

This paper aims to emphasize the fundamental role of unconscious processes in our adaptation. We will point out how we are able to unconsciously perform higher mental functions such as setting goals and planning how to pursue them, dealing with complex data, and making choices and judgments. In the first part of this paper, we will describe the main features of conscious and unconscious processes as pointed out by recent empirical research studies, and we will see how safety is essential in pursuing our fundamental goals, and how unconscious mental processes are strongly oriented towards preserving our safety and pursuing these goals. Finally, we will discuss control-mastery theory (CMT), an integrative, relational, cognitive-dynamic theory of mental functioning, psychopathology, and psychotherapy processes developed by Joseph Weiss and empirically validated by Weiss, Harold Sampson, and the San Francisco Psychotherapy Research Group over the last 50 years. This conceptualizes unconscious processes starting from this “higher unconscious mental functioning” paradigm and, in accordance with research data, stresses that our main goal is to adapt to reality and pursue adaptive developmental goals while preserving our safety. Three clinical vignettes will help show how the concepts proposed by CMT have important implications for therapeutic process.

Therapist Adherence to Two Treatments for Adolescent Suicide Risk: Association to Outcomes and Role of Therapeutic Alliance.

In psychotherapy research, adherence refers to the extent to which therapists deliver a treatment as intended. This study examined whether therapist adherence to two different manualized treatments was associated with improved client outcomes and whether the association was moderated by therapeutic alliance. The study sample included 320 video recordings of therapy sessions from 118 cases in a randomized controlled trial (RCT) comparing attachment-based family therapy (ABFT) with family-enhanced nondirective supportive therapy (FE-NST). Recordings were selected from early, middle, and late stages of treatment. The adherence measure consisted of 24 items representing essential therapist interventions from both treatments. Trained raters coded tapes from both therapies. Adolescent self-report of alliance was measured at session 4. Adherence to ABFT was associated with a significant increase in family cohesion at mid-treatment but not at posttreatment. Adherence to FE-NST was significantly associated with an increase in suicide ideation posttreatment. Using therapeutic alliance as a moderator, adherence to ABFT was significantly associated with a reduction in suicide ideation, family conflict, and higher client satisfaction posttreatment. Alliance did not positively affect the association of FE-NST adherence to outcomes. Findings suggest that adherence to ABFT interventions may be better linked to treatment outcomes when adolescents feel a strong alliance with their therapist. Implications for future research and therapist training are explored.

A not-knowing, values-based and relational approach to counselling education

ABSTRACT In this paper, we present our development of a previously articulated approach to counselling education of transformational learning through a relational dynamic approach (Macaskie et al., 2013). We replace the idea of integration with a values-based approach and supplement the notion of transformational relational learning with a not-knowing attitude. This perspective on education and learning in counselling parallels the attitude within psychotherapy that we teach our students. We argue that this unites relational approaches to learning and psychotherapy across modalities and offers a trans-theoretical approach that could explain the common factors research in psychotherapy.

Psychedelic-Assisted Psychotherapy Practices and Human Caring Science: Toward a Care-Informed Model of Treatment

Psychedelic therapies intentionally combine a caring/healing environment, psychotherapy, and psychedelic medicine as a powerful means of treating intractable conditions of depression and posttraumatic stress disorder. This article utilizes the nursing theory of human caring science, as articulated by Jean Watson, to describe the essential and fundamental human caring qualities in psychedelic therapy. By mapping these qualities onto the traits of a psychedelic therapist, articulated by Janis Phelps and illustrating them with qualitative, exemplar data from a psilocybin assisted therapy study, we have created a nursing-informed philosophical theoretical framework with which to begin to examine questions related to trust enhancement between patient and therapist, therapeutic communication of openness to patient experiences, mutual learning between therapist and patient, the influence spiritual or psychedelic practices of the therapist on outcomes, optimizing therapeutic healing environments, and care of the physical body during psychedelic therapy sessions. This article is intended to identify themes and generate hypotheses for future nursing-informed psychedelic psychotherapy research.

Altered resting-state functional connectivity of the default mode and central executive networks following cognitive processing therapy for PTSD

Psychotherapy research is increasingly targeting both psychological and neurobiological mechanisms of therapeutic change. This trend is evident in and applicable to post-traumatic stress disorder (PTSD) treatment research given the high nonresponse rate of individuals with PTSD who undergo cognitive-behavioral therapy (CBT). Functional connectivity analyses investigating disrupted brain networks across mental disorders have been employed to understand both mental disorder symptoms and therapeutic mechanisms. However, few studies have examined pre-post CBT brain changes in PTSD using functional connectivity analyses. The current study investigated a) whether brain networks commonly implicated in psychopathology (e.g., default mode network [DMN], central executive network [CEN], and salience network [SN]) changed following Cognitive Processing Therapy (CPT) for PTSD and b) whether change in these networks was associated with PTSD and/or transdiagnostic symptom change. Independent components analysis was implemented to investigate resting-state functional connectivity in DMN, CEN, and SN in 42 women with PTSD and 18 trauma-exposed controls (TEC). Results indicated decreased CEN-cerebellum connectivity in PTSD participants versus TEC prior to CPT and decreased DMN connectivity in PTSD participants after CPT. Additionally, DMN and SN connectivity was related to change in positive and negative affectivity, while exploratory analyses at a cluster threshold of pFDR < .10 indicated DMN and SN connectivity was also related to change in PTSD symptoms and rumination. These findings provide evidence for normalization of CEN connectivity with treatment and implicate the DMN and SN in clinical symptom change following CPT.

Integrating theory-based and data-driven methods to case conceptualization: A functional analysis approach with ecological momentary assessment

Objective Ecological momentary assessment (EMA) and network analysis are promising empirical developments for psychotherapy research and practice, but they lack a therapeutic rationale that could guide case conceptualization and treatment planning. We developed an assessment strategy that aims to assess functional analysis with EMA. Method: The assessment strategy was applied to a series of three N-of-1 assessments in a proof-of-concept study. After selecting a personalized set of items, EMA was implemented with three measurement time points per day for a period of 30 days. The participants evaluated feasibility and acceptance. Practicing psychotherapists discussed clinical implications in a focus group. Results: The implementation of the assessment strategy seemed feasible and accepted; participants did not report any side effects. Principal component and network analyses indicated interpretable components (e.g., participant 1: hopelessness, procrastination, coping, avoidance). The focus group pointed out potentials (e.g., efficient profit of the waiting time, empowering patients) and challenges (e.g., prioritize and interpret all the information). Conclusion: The presented assessment strategy may enhance the scientific quality of case conceptualization empowering therapists’ decision-making regarding treatment planning. At the same time, it is a concrete demonstration of the challenges that need to be addressed in future research.

Shift in representation and symbolisation of affective experience: A paradoxical outcome in therapy

Shift in representation and symbolisation of affective experience: A paradoxical outcome in therapy: Defining outcome represents a key challenge for psychotherapy theory, research and practice. The present paper uses a case study of a client with anorexia nervosa to contribute to the development of conceptual understanding of the nature of paradoxical outcome. In this case, different sources of outcome data offered different answers to the question of whether or not the therapy had been successful. Qualitative thematic analysis of therapy transcriptions was carried out, using Interpretative Phenomenological Analysis (IPA). Both the process of change that occurred in this case, and the conflicting outcome indicators, could be explained in terms of a model of affect elaboration. These findings are discussed in terms of the need for caution when interpreting results from outcome measures in psychotherapy research and practice.

Paradoxical outcomes in psychotherapy: Theoretical perspectives, research agenda and practice implications

ABSTRACT Client self-report symptom measures are widely used in counselling and psychotherapy research and practice to track client progress and evaluate outcome. A growing body of evidence indicates differences between self-report assessments and information collected through other sources. This paper considers a range of theoretical and empirical perspectives on this issue, including the concept of illusory mental health. Particular emphasis is given to the relevance of single-case research as a means of identifying different patterns of paradoxical outcome. Implications for practice and research are discussed.

Is divergence in outcome evaluation paradoxical? Towards validating multiple perspectives on psychotherapy practice

ABSTRACT The concept of ‘paradoxical outcome’ refers to instances of differences in evaluation of the outcome of psychotherapy when taken from different sources and/or by different modes of evaluation. Paradoxical outcome has become a central issue in psychotherapy practice and research because of its prevalence as well as its implications for the aims and process of therapy. The concept of paradoxical outcome treats discrepancies in the evaluation of psychotherapy as problematic, indicating that the underlying expectation is that the outcome of psychotherapy should be consistent. In this commentary to the special issue, I propose that this assumption that the outcome of psychotherapy is a unified construct that is agreed among interested parties, that underlies the concept of paradoxical outcome, is a fundamental fallacy. Moreover, I argue that it is important to recognize that the outcome of psychotherapy is a complex notion that has different meanings for the various agents implicated in it. This recognition may in turn open the way to exploring the function and goal of psychotherapy for each of the different agents involved in it, and this will highlight its central role as a social and institutional practice that regulates contemporary subjectivities and practices.

‘The silent intermediary’: a co-authored exploration of a client’s experience of art psychotherapy for C-PTSD

ABSTRACT Background This article presents a client’s (art therapee’s) conceptualisation of his experience of art psychotherapy for symptoms of complex post-traumatic stress disorder (C-PTSD). Context He was receiving treatment through a community adult mental health team within the UK National Health Service. Approach The art therapee wrote about his art psychotherapy experience, and then he and his art psychotherapist identified key themes. They related his account to art psychotherapy theory and evidence and drew out implications of his experience for art psychotherapy research. Outcomes/Conclusions The art therapee found that an art psychotherapy approach was helpful in these ways: having control; expressing without words; distancing from trauma; being creative and playful. He identified some aspects of the art psychotherapy which seem to be under-represented in art psychotherapy literature: the importance of the therapist’s acceptance of the client’s artwork for building trust; the way in which artmaking bypasses the fear of ‘telling’ about past abuse; and the therapeutic value of creativity and play for accessing positive aspects of the child self. Implications for research It would be valuable to gain information from other clients with C-PTSD about their experiences of art psychotherapy. Research into the identified under-explored aspects of art psychotherapy practice, the use of artmaking for C-PTSD symptom management and how artmaking can be integrated within other approaches to C-PTSD treatment would be useful. Plain-language summary This article describes how a client (art therapee) with symptoms of complex post-traumatic stress disorder (C-PTSD) experienced art psychotherapy. The art therapee received therapy through a UK National Health Service community adult mental health team. The therapy sessions were on a weekly basis over an 18-month period. The art therapee wrote about his art psychotherapy experience, and then he and his art psychotherapist identified some themes. They related his account to art psychotherapy theory and evidence and drew out implications of his experience for art psychotherapy research. The art therapee found that an art psychotherapy approach was helpful in four main ways. It helped him to feel in control of the therapeutic process, and enabled him to express experiences of past abuse without having to use words. It gave him a sense of distance from his traumatic experiences. Finally, it helped him to connect with his creativity. He identified some particular aspects of his experience which seem to be under-represented in art psychotherapy literature: the importance of the therapist’s acceptance of the client’s artwork for building trust; the way in which artmaking bypasses the fear of ‘telling’ about past abuse; and how creativity and playfulness in art psychotherapy sessions can enable a more positive view of oneself as a child. The authors consider that it would be valuable to gain information from other clients with C-PTSD about their experiences of art psychotherapy and to undertake research into those aspects of the client’s experience which appear not to have been explored significantly so far. Research into how artmaking can help relieve C-PTSD symptoms and how artmaking might be used within other approaches to C-PTSD treatment would also be useful.

Separation anxiety in a community sample of Italian emerging adults and its relationship with dimensions of borderline personality.

Research studies focusing on separation anxiety and its relation with other measures of anxiety and personality-relevant variables in community samples are still scarce. This study aimed to describe in a dimensional perspective the relationship between separation anxiety symptoms, anxiety levels, and personality traits in a community sample of Italian emerging adults. A sample of 260 college students [mean age (Mage)=21.22, standard deviation (SD)=1.91, 79.6% females] completed the adult separation anxiety questionnaire-27 (ASA-27), the state and trait anxiety inventory-Y (STAI-Y), and the personality assessment inventory borderline scale (PAI-BOR). ASA-27 was significantly and positively correlated with the PAI borderline scale. The mediation model showed that ASA-27 influenced the PAI-BOR through trait anxiety. Clinical implications of the study for psychotherapy research are discussed.

Psikoterapi Araştırmalarında Konuşma Çözümlemesi: Yöntemsel Bir Gözden Geçirme

Conversation analysis is a qualitative research method developed in social sciences that inspects naturally occurring conversations and reveals the particular characteristics of conversationalists’ interactions. Psychotherapy research aims to understand the features that determine the psychotherapy process and its effectiveness by using many different qualitative and quantitative research methods. The characteristics of interactions between psychotherapists and clients in psychotherapy are one of these features, and conversation analysis has become one of the methods used in psychotherapy research. Although conversation analysis in Turkey is better known as a research method in sociology, educational sciences, and various subfields of psychology, there is a lack of Turkish resources on the kind of questions conversation analysis can answer in psychotherapy research. Hence, the current article provides theoretical and methodological information about how conversation analysis is utilized in psychotherapy research and reviews the literature. Studies examining psychotherapy interactions using this method belong to the psychotherapy research tradition based on hermeneutics. Conversation analysis makes inferences about how therapists and clients jointly construct the psychotherapy process and how changes take place using its unique assumptions and analysis methods. In the psychotherapy research literature, conversation analysis studies have sought answers to many questions. The research hitherto has evolved around three main areas of study: therapeutic interventions, elements of the therapeutic relationship, and the effects of psychotherapy. In this paper, the literature findings are summarized and the implications of these studies for the practice of psychotherapy and recent research trends are touched upon. Furthermore, the analysis of a Turkish psychotherapy extract is illustrated. Finally, the article concludes that conversation analysis in psychotherapy makes noteworthy contributions to individually and culturally tailored psychotherapy practice. Research on psychotherapy outcomes and mixed-method designs are expected to become prominent in the future.