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Purpose of Review Individuals with personality disorders are frequently seen in mental health settings. Their symptoms typically reflect a high level of suffering and burden of disease, with potentially harmful societal consequences, including costs related to absenteeism at work, high use of health services, ineffective or harmful parenting, substance use, suicidal and non-suicidal self-harming behavior, and aggressiveness with legal consequences. Psychotherapy is currently the first-line treatment for patients with personality disorders, but the study of psychotherapy in the domain of personality disorders faces specific challenges. Recent Findings Challenges include knowing what works for whom, identifying which putative mechanisms of change explain therapeutic effects, and including the social interaction context of patients with a personality disorder. By following a dimensional approach, psychotherapy research on personality disorders may serve as a model for the development and study of innovative psychotherapeutic interventions. Summary We recommend developing the following: (a) an evidence base to make treatment decisions based on individual features; (b) a data-driven approach to predictors, moderators, and mechanisms of change in psychotherapy; (c) methods for studying the interaction between social context and psychotherapy.

Meaningful Measurement and Validation in the action of mental health measurement: A mixed methods research program on how people understand and score self-report measures in mental health research and practice, and how resulting data can be validly interpreted by the users of the measure (researchers/clinicians). Utilizing qualitative research methods to explore meaning-making in scoring, change of meaning (response shifts) following treatment, and validation in the action of mental health measurement.

The objective of our study is to assess the frequency, type and way of using multi-person settings – e.g. including close others into individual psychotherapy for adults and for children/adolescents - in Germany. A large body of literature indicates that including the social context directly into psychotherapy is of benefit not only for the patient him-/herself, but also for the close other and their relationship.

Quantified symptom measurement by self-report questionnaires is part of the ‘gold standard’ of assessing psychotherapeutic efficacy. In this paper, we report a qualitative case comparison to explore how June and Amy, two patient-participants in a gold standard psychotherapy study, experienced the process of quantitative data collection. The study resembles cognitive interviewing studies conducted in the development of measures, yet advances them by investigating patients’ experiences of questionnaire administration in actual psychotherapy. Both cases reported known issues in interpretation of pre-structured item- and response formats, communicative administrator-respondent dynamics, and response shifts. Beyond known scoring problems, the act of questionnaire administration changed their interpretation of experienced symptoms, which facilitated clinical change beyond therapeutic effects. For Amy, this change was associated with improvement, but for June, questionnaire administration facilitated deterioration in experienced symptoms. These findings emphasize that it is both epistemically and ethically vital to consider measurement effects in clinical practice. This study demonstrates the importance of taking a qualitative stance in psychotherapy research, as qualitative research can elaborate the contextual and idiosyncratic nature of questionnaire scores, and highlights that both researchers and clinicians have to be attentive to the meaning of scores as words in participants’ clinical stories.

Resumen Introducción: En los últimos años se ha reconocido la importancia de evaluar la supervisión clínica y su rol en el proceso psicoterapéutico. No obstante, son escasos los instrumentos que cumplen con este propósito, particularmente en Latinoamérica. En este estudio, se buscó adaptar al castellano la versión breve del Cuestionario de relación de supervisión (S-SRQ, por sus siglas en inglés de: Short Supervisory Relationship Questionnaire), compuesto de tres dimensiones: base segura, educación reflexiva y estructura; y aportar evidencias sobre su desempeño psicométrico. Método: El S-SRQ fue traducido y retraducido a su idioma original. Posteriormente, fue administrado a 374 psicoterapeutas argentinos (muestra no probabilística). Se realizaron análisis de consistencia interna (alfa de Cronbach), dimensionales (análisis paralelo y factorial confirmatorio), y a nivel del ítem (coeficientes estandarizados y correlación ítem-escala). Resultados: Los coeficientes de consistencia interna fueron adecuados para la escala total y, en general, para cada dimensión. Los análisis dimensionales se ajustaron a un modelo de tres dimensiones, base segura, educación reflexiva y estructura. El desempeño de los ítems fue bueno con relación a la escala total y cada dimensión. Discusión: El desempeño psicométrico del S-SRQ en castellano fue similar al de la escala original, con algunas diferencias. La escala presenta potencial para ser aplicada en el contexto argentino, tanto en el ámbito científico como en la práctica. Abstract Introduction: In recent years the significance of evaluating clinical supervision and its role in the psychotherapeutic process has been recognized. However, there are few instruments for such evaluation, particularly in Latin América. This study aimed to adapt the three-dimensional (reliable basis, reflexive education and structure) Short Version of the Supervisory Relationship Questionnaire (S-SRQ) to Spanish. Method: The questionnaire was administered to 374 Argentine psychotherapists (non-probabilistic sample). The S-SRQ was translated and retranslated to its original language. It was performed internal onsistency (Cronbach's alpha), dimensional (parallel and confirmatory factor analysis), and item analyzes (standardized coefficients and item-scale correlation). Results: The internal consistency coefficients were adequate for the total scale and, in general, for each dimension. The dimensional analyses were adjusted to a three-dimensional model, reliable basis, reflective education and structure. Item performance was good in relation to the total scale and each dimension. Discussion: The psychometric performance of the S-SRQ in Spanish was like the original scale, with some exceptions. The scale has potential to be implemented in our context, both at a practical and scientific level.

The overall aim of the thesis was to enhance and revive the practical understanding of the active ingredients in Transactional Analysis Psychotherapy (TA) and to define and lay down elements of TA that make it a distinct and replicable method of treatment. The thesis includes three empirical studies of a videotaped one-year long TA Group Therapy with 10 clients. Three different key areas of Transactional Analysis have been investigated with support of three different approaches. The first study (Johnsson, 2011 a) was a diagnostic client assessment with TA Script Analysis made as a reliability study. The second study (Johnsson, 2011 b) dealt with identification of different components in TA psychotherapy method with the use of Discourse Analysis and the third study (Johnsson & Stenlund, 2010) investigated the Therapeutic Alliance with a psychodynamic approach, using the CCRT method (the CORE Conflictual Relationship method) by Luborsky & Crits-Christoph (1990, 1998) and the Plan – Diagnosis method by Weiss & Sampson (1986). Study I: A script questionnaire and associated checklist developed by Ohlsson, Johnsson & Björk (1992) was used by the author and two professional colleagues to independently assess ten clients of a year-long transactional analysis therapy group conducted by the author. Ratings based on written responses at start of therapy were compared to ratings based on videotape interviews conducted by the author six years after termination of therapy. Moderately high inter-assessor reliability was found but intra-assessor reliability was low for the independent assessors; agreement increased for script components ‘primary injunction from father,’ ‘racket feeling’, ‘escape hatch’, ‘driver from father’ and ‘driver from mother’. Study II: Operational definitions of categorisations by McNeel (1975) were developed and applied by the author and an independent assessor to complete discourse analysis of 72 hours of transactional analysis group therapy in the style of Goulding & Goulding (1976, 1979) conducted during 1984/85. Results showed that the therapist used an average of 42% of the discourse space and that the therapy did indeed contain TA components, with the two main categories being ‘Feeling Contact’ and ‘Contracts’, and with particular use of TA techniques of ‘talking to Parent projections’, ‘make feeling statement’, ‘mutual negotiation’ and ‘specificity/clarity’. Inter-rater reliability was 46.2% (Araujo & Born 1985), Cohen’s (1960) kappa coefficient shows a spread from slight to moderate agreement, and the Odds Ratio (Viera, 2008) is above 1.0 for most categories. One intervention, "mutual negotiation", with moderate reliability could be identified as “TA typical". Study III: The study describes an investigation of the significance of the affective dimension of the therapeutic alliance (Bordin 1979), in a psychodynamic form of transactional analysis therapy after the style of “Redecision therapy” (Goulding & Goulding, 1979). We explored the client’s pattern of affective relationships by use of CCRT by Luborsky & Crits-Christoph (1990, 1998) and examined how the therapist responds to the client’s affective messages (“tests”) by use of the Plan-Diagnosis method (Weiss & Sampson, 1986). We found that “emotional” aspects play a more decisive role than has been envisioned in the TA redecision method and similar approaches of TA psychotherapy that emphasise contracts, tasks of therapy and a rational approach.

The introduction of novel methodologies in the past decade has advanced research on mechanisms of change in observational studies. Time-lagged panel models allow us to track session-by-session changes and focus on within-patient associations between predictors and outcomes. This shift is crucial as change in mechanisms inherently takes place at a within-patient level. These models also enable preliminary casual inferences, which can guide the development of effective personalised interventions that target mechanisms of change, used at specific treatment phases for optimal effect. Given their complexity, panel models need to be implemented with caution, as different modelling choices can significantly affect results and reduce replicability. We outline three central methodological recommendations for use of time-lagged panel analysis to study mechanisms of change: (a) taking patient-specific effects into account, separating out stable between-person differences from within-person fluctuations over time; (b) properly controlling for autoregressive effects; and (c) considering long-term time trends. We demonstrate these recommendations in an applied example examining the session-by-session alliance-outcome association in a naturalistic psychotherapy study. We present limitations of time-lagged panel analysis and future directions. Funding Agencies|NIMHUnited States Department of Health & Human ServicesNational Institutes of Health (NIH) - USANIH National Institute of Mental Health (NIMH) [T32 MH019132]

The adoption of a pluralistic perspective on research design, processes of data collection and \ud analysis and dissemination of findings, has the potential to enable psychotherapy research to \ud make a more effective contribution to building a just society. A review of the key features of the \ud concept of pluralism is followed by a historical analysis of the ways in which research in \ud counselling, psychotherapy and related disciplines has moved in the direction of a pluralistic \ud position around knowledge creation. Core principles of a pluralistic approach to research are \ud identified and explored in the context of a critical case study of contemporary research into \ud psychotherapy for depression, examples of pluralistically oriented research practices, and \ud analysis of a pluralistic conceptualisation of the nature of evidence. Implications of a pluralistic \ud perspective for research training and practice are discussed. Pluralistic inquiry that emphasises \ud dialogue, collaboration, epistemic justice and the co-existence of multiple truths, creates \ud opportunities for individuals, families and communities from a wide range of backgrounds to \ud co-produce knowledge in ways that support their capacities for active citizenship and \ud involvement in open democratic decision-making. To fulfil these possibilities, it is necessary for \ud psychotherapy research to be oriented towards social goals that are sufficiently relevant to both \ud researchers and co-participants to harness their passion and work together for a common good.\ud Keywords: dialogue, epistemic (in)justice, pluralism, psychotherapy research, social relevance

Client agency is considered a crucial contributor to good treatment outcome. Recent studies, however, differ strongly in how they conceptualise and investigate agency. The current study explores the nature of client agency in ten clients’ pre-treatment interviews. Applying Consensual Qualitative Research, we constructed three overarching categories, subdivided into 14 sub-categories capturing both between- and within-person differences in agency before therapy. We found that all participants oscillated between the experience of a lack of grip on problems on the one hand and noticing their involvement in the problem and taking action on the other. These results present a dynamic conceptualisation of client agency. This allows us to ask pertinent questions for both future research and clinical practice.

Background The 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. Method A 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. Results Of 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. Conclusions Outcomes 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.

Common conclusions from traditional psychotherapy research are that we still do not know how or why even our most well-studied interventions produce change, and that there is little evidence that any form of psychotherapy is generally more effective than any other. This has led some researchers to the so-called Dodo Bird Verdict, that all forms of psychotherapy are equally effective, and to the conclusion that what is at work are “common factors” that have little to do with treatment method. An alternative explanation, however, is that the traditional research paradigm is insufficiently sensitive to provide us with the required kind of knowledge. First, the outcome in typical RCTs is averaged across individuals, and at best complemented by a search for predictors in the form of stable individual differences. This means that this research stays at a group level of analysis and is insensitive to variation and change in individual patients. Second, the independent variable in RCTs does not consist in any well-controlled psychological intervention, but in large-scale treatment packages that contain a large number of interventions over a considerable time period. In other words, this research is insensitive to the effects of specific treatment interventions. Third, traditional psychotherapy research is insensitive to the therapist and patient as individual persons, and their specific interaction. It is argued that a person-oriented approach to psychotherapy, which is idiographic, holistic and interactional, may be able to overcome some of these problems by being more sensitive to (1) the treatment course of individual patients, and patterns during that course; (2) the effects of the specific interventions that are implemented over time, and (3) the personal characteristics of patient and therapist, and nuances of their interaction.

Scientific evidence leaves no doubt about the active role that individuals play in managing their adverse life events and their ability to recover. Similarly, each person takes a leading role in psychotherapy, where all research identifies the so-called «patient» as the true agent of change; the role of the therapist is to tailor treatment to the needs and characteristics of his/her clients, as well as to create the right climate to mobilize their skills and resources, facilitating change. Evidence supports a vision of psychotherapy more suited to a collaborative relational model. Las evidencias científicas no dejan lugar a dudas sobre el papel activo que las personas tienen en la gestión de sus acontecimientos vitales adversos y su capacidad de recuperación. Ocurre lo mismo con su papel protagonista en psicoterapia, donde todas las investigaciones sitúan al mal llamado «paciente» como el verdadero agente de cambio; el papel del terapeuta consiste en adaptar el tratamiento a las necesidades y características de sus clientes, así como crear el clima adecuado para movilizar sus competencias y recursos facilitando el cambio. La evidencia apoya una visión de la psicoterapia más ajustada a un modelo relacional colaborativo.

This article discusses how the Generic Model of Psychotherapy (Orlinsky and Howard, 1987) can help to organize the psychotherapy research and the knowledge in the field of psychotherapy for sexual and gender minority patients. The structure that this traditional model provides is a good foundation for research in this field, inasmuch as it stresses macrosocial aspects that determine the provision of psychotherapy and contextualize its outcomes. Each one of the main components offered by the Generic Model of Psychotherapy – Determinants, Processes, and Consequences – are specified for psychotherapy with LGBT patients and are illustrated with a selection of already existing research in the field of sexual minorities; they are also stress areas marked by knowledge gaps that require future developments. In addition, a set of questions are proposed to contribute to new studies, including the clinical implications that can be derived from this model.

Background Psychology is at the beginning of a cooperative revolution. Traditionally, psychological research has been conducted by individual labs, limiting its scope in clinical samples and promoting replication problems. Large-scale collaborations create new opportunities for highly powered studies in this resource-intensive research area. To present the current state of a Germany-wide platform for coordinating research across university outpatient clinics for psychotherapy. Method Since 1999, over 50 such clinics were created in Germany. They represent a unique infrastructure for research, training, and clinical care. In 2013, a steering committee initiated a nationwide research platform for systematic coordination of research in these clinics (German abbreviation “KODAP”). Its main goal is to aggregate and analyze longitudinal treatment data – including patient, therapist, and treatment characteristics – across all participating clinics. Results An initial survey (100% response rate) yielded recommendations for improved integration of data collection. Pilot data from 4,504 adult (16 clinics) and 568 child and adolescent patients (7 clinics) proved feasibility of data transfer and aggregation despite different data formats. Affective, neurotic, stress, and somatoform (adults) and anxiety and behavioral (children and adolescents) disorders were most frequent; comorbidity was high. Overcoming legal, methodological, and technical challenges, a common core assessment battery was developed, and data collection started in 2018. To date, 42 clinics have joined. Conclusions KODAP shows that research collaboration across university outpatient clinics is feasible. Fulfilling the need for stronger cumulative and cooperative research in Clinical Psychology will contribute to better knowledge about mental health, a core challenge to modern societies.

Background: Ethical informed consent to psychotherapy has recently been the subject of in-depth analysis among healthcare ethicists. Objective: This study aimed to explore counseling and psychotherapy students' views and understanding about informed consent to psychological treatments. Methods: Two focus groups were conducted with a total of 10 students enrolled in a Masters course in counseling and psychotherapy at a British university. Questions concerned participants' understanding of informed consent including judgments about client capacity; the kinds of information that should be disclosed; how consent might be obtained; and their experiences of informed consent, both as a client and as a therapist. Focus groups were audio-recorded, transcribed, and analyzed using qualitative content analysis. Coding was conducted independently by three authors. Results: Comments were classified into three main themes: (1) the reasons and justifications for informed consent; (2) informed consent processes; and (3) the hidden ethics curriculum. Some trainees expressed significant doubts about the importance of informed consent. However, participants also identified the need to establish the clients' voluntariness and their right to be informed about confidentiality issues. In general, the format and processes pertaining to informed consent raised considerable questions and uncertainties. Participants were unsure about rules surrounding client capacity; expressed misgivings about describing treatment techniques; and strikingly, most trainees were skeptical about the clinical relevance of the evidence-base in psychotherapy. Finally, trainees' experiences as clients within obligatory psychotherapy sessions were suggestive of a “hidden ethics curriculum”—referring to the unintended transmission of norms and practices within training that undermine the explicit guidance expressed in formal professional ethics codes. Some students felt coerced into therapy, and some reported not undergoing informed consent processes. Reflecting on work placements, trainees expressed mixed views, with some unclear about who was responsible for informed consent. Conclusions: This qualitative study presents timely information on psychotherapy students' views about informed consent to psychotherapy. Major gaps in students' ethical, conceptual, and procedural knowledge were identified, and comments suggested the influence of a hidden curriculum in shaping norms of practice. Implications: This exploratory study raises important questions about the preparedness of psychotherapy students to fulfill their ethical obligations.

To define boundaries and links between research and training in psychotherapy we have to establish what kind of research is needed for this purpose. For defining psychotherapy as a science some basic epistemological premises should be affirmed and specific methods have to be devised, using both quantitative and qualitative approaches, diachronic and longitudinal perspectives, cumulative and meta-analytic strategies, focusing both the techniques used in the therapies and the relationship between the therapist subject and the client subject as a core mean for produce change. What should be evaluated in this research process, what methods and techniques of assessment should be preferred, what analyses of data are suitable: these are the main issues addressed in the article, as they are useful for planning the training of a therapist as a researcher, regardless of the privileged theoretical and technical approach. Science and practice have to be connected, since they both allow the monitoring of what occurs within the confines of the therapy and favor exchange among psychotherapists from differing theoretical approaches, which also increases their external visibility in the scientific community and in a wider social context. The goal of fostering scientific attitudes in the psychotherapists needs a specific training, to acquire a research mindedness also out of the academic laboratories. A cooperation among scientific associations and institutions is proposed to reach these objectives necessary for psychotherapists’ trainings including competencies in evaluating and sharing the scientific aspects of their work.

Objective: Borderline personality disorder (BPD) is characterized by immature defense mechanisms. Dialectical behavior therapy (DBT) is an effective treatment for BPD. However, understanding the underlying mechanisms of change is still limited. Using a transtheoretical framework, we investigated the effect of DBT skills training on defense mechanisms. Method: In this randomized controlled trial, 16 of 31 BPD outpatients received DBT skills training adjunctive to individual treatment as usual (TAU), while the remaining 15 received only individual TAU. Pre-post changes of defense mechanisms, assessed with the Defense Mechanism Rating Scale, were compared between treatment conditions using ANCOVAs. Partial correlations and linear regressions were conducted to explore associations between defenses and symptom outcome. Results: Overall defense function improved significantly more in the skills training condition (F(1, 28) = 4.57, p = .041). Borderline defenses decreased throughout skills training, but not throughout TAU only (F(1, 28) = 5.09, p = .032). In the skills training condition, an increase in narcissistic defenses was associated with higher symptom scores at discharge (β = 0.58, p = .02). Conclusions: Although DBT does not explicitly target defense mechanisms, skills training may have favorable effects on defense function in BPD. Our findings contribute to an integrative understanding of mechanisms of change in BPD psychotherapy.

This study examines client utterances that can be understood as ambivalent in violence-focused therapy. The purpose is to enrich our scientific understanding of client contributions to therapy when they appear ambivalent to the therapeutic project and develop clinically relevant perspectives that enable us to help this and other client groups. Using constructivist grounded theory analysis of five completed therapies, we describe three categories of client ambivalence present throughout all five therapies: I am bad, but I am not that bad; I have tried and tried in vain; and I know it is wrong, but I have to, I have no choice. The categories are described and understood from a clinical perspective. They are developed on the basis of an interpretation of what seems to be at stake for the client in the here-and-now of therapy. Clinical implications are discussed.

Mindfulness has without doubt been the fastest spreading and most popular concept in psychotherapy in the last two decades. Its influence exceeds that of any other individual concept or approach in modern psychotherapy. However, there are many dilemmas, open questions and controversies related to this rapid, almost fanatic spread, which obviously compensates for a certain lack in modern Euro- and Americo-centric societies. Similarly, we are witnessing in the West a lack of reflection, a process of limitless idealization, and the search for a panacea. This all flows with a tint of colonialism, presumptuously taking over ideas, concepts and techniques without a proper study of the primary sources, and with all the accompanying negative side-effects: profiteering, self-promotion, unethical conduct, empty promises of instant rewards, and so on. In the present paper, the development of interest in mindfulness in psychotherapy, as well as the research findings and dilemmas, and concepts and mechanisms of applying mindfulness in psychotherapy, will be reviewed. The main purpose of the paper is to contribute to the critical reflection in studying and applying mindfulness in psychotherapy.

Highlights • This is the first study that assessed cortical hemodynamic reactions during exposure therapy in situ. • During exposure patients showed increased activity in the cognitive control network (CCN) compared to a control condition. • CCN activity deceased during the session. • Further, CCN activity was associated with fear ratings at the beginning of the session and this relationship decreased from session to session., Exposure therapy is a well-studied and highly efficacious treatment for phobic disorders. Although the neurobiological model of fear is well underpinned by various studies, the mechanisms of exposure therapy are still under discussion. Partly, this is due to the fact that most neurophysiological methods like fMRI are not able to be used in the natural therapeutic settings. The current study used in situ measurements of cortical blood oxygenation (O2Hb) during exposure therapy by means of functional near-infrared spectroscopy. 37 subjects (N = 30 completers) underwent exposure therapy during 5 adapted sessions in which subjects were exposed to Tegenaria Domestica (domestic house spider – experimental condition) and Dendrobaena Veneta/ Eisenaia hortensis (red earthworm – control condition). Compared to the control condition, patients showed higher O2Hb levels in the anticipation and exposure phase of spider exposure in areas of the cognitive control network (CCN). Further, significant decreases in O2Hb were observed during the session accompanied by reductions in fear related symptoms. However, while symptoms decreased in a linear quadratic manner, with higher reductions in the beginning of the session, CCN activity decreased linearly. Further, higher anxiety at the beginning of session one was associated with increased O2Hb in the CCN. This association decreased within the following sessions. The current study sheds light on the neuronal mechanisms of exposure therapy. The results are discussed in light of a phase model of exposure therapy that posits a role of cognitive control in the beginning and routine learning at the end of the therapy session.

There is currently little empirical evidence regarding how patients' attachment patterns manifest in individual psychotherapy. This study compared the in-session discourse of patients classified secure, dismissing, and preoccupied on the Adult Attachment Interview (AAI). Rather than focusing on content or form alone, this study analyzed how patients' discourse elicits and maintains emotional proximity with the therapist. The AAI was administered to 56 patients prior to treatment and one session for each patient was rated with the Patient Attachment Coding System (PACS) by four independent raters, blind to patients' AAI classification. Significant differences were found in the discourse of patients with different attachment patterns. Namely, secure and preoccupied patients showed more contact-seeking behavior than dismissing patients, who avoided emotional proximity more, while preoccupied patients resisted therapists' help more than did secure and dismissing patients. These results suggest that the different attachment patterns may have distinctive manifestations in the psychotherapy process that can be tracked by external observers.

While many adolescent patients resistantly engage in psychotherapy, they are attracted by new technologies and video games. A development and research project was implemented to design an online adventure video game as a psychotherapeutic tool for depressed adolescents and to evaluate its acceptability. The game design followed the narrative structure of the hero’s journey and ideas from the cognitive behavioral and interpersonal psychotherapy models for depression. Five psychotherapists and fifteen of their female adolescent patients with symptoms of depression tested the game. Some patients valued the video game in terms of learning helpful social and mental health-related behaviors. Therapists manifested that a video game like Maya could be a useful complementary tool for psychotherapy of adolescent girls. The study suggests that future developments of video games for mental health are worthwhile and it provides some ideas on how to incorporate psychotherapeutic notions in ludic environments.

This paper provides an analysis of a basic assumption grounding the clinical research: the ontological autonomy of psychotherapy-based on the idea that the clinical exchange is sufficiently distinguished from other social objects (i.e. exchange between teacher and pupils, or between buyer and seller, or interaction during dinner, and so forth). A criticism of such an assumption is discussed together with the proposal of a different epistemological interpretation, based on the distinction between communicative dynamics and the process of psychotherapy-psychotherapy is a goal-oriented process based on the general dynamics of human communication. Theoretical and methodological implications are drawn from such a view: It allows further sources of knowledge to be integrated within clinical research (i.e. those coming from other domains of analysis of human communication); it also enables a more abstract definition of the psychotherapy process to be developed, leading to innovative views of classical critical issues, like the specific-nonspecific debate. The final part of the paper is devoted to presenting a model of human communication--the Semiotic Dialogical Dialectic Theory--which is meant as the framework for the analysis of psychotherapy.

A presente pesquisa, de natureza exploratória, buscou combinar o critério da eficácia adaptativa com os da Lista de Indicadores Genéricos de Mudança (LIGM), para se compreender melhor como as pessoas mudam em psicoterapia. O objetivo mais específico foi avaliar se existe relação entre a evolução na hierarquia dos Indicadores Genéricos de Mudança e a qualidade das respostas adaptativas. Utilizou-se o delineamento de estudo de caso intensivo. A LIGM refere-se a uma sequência ideal do que se espera que ocorra, se a psicoterapia obtiver êxito. Ela é composta por 19 indicadores dispostos de modo hierárquico, que se referem prioritariamente à forma como o paciente encara o seu problema, sua disposição para enfrentá-lo e as expectativas em relação à psicoterapia e ao psicoterapeuta. A eficácia adaptativa engloba as respostas dadas pelo indivíduo frente às dificuldades e vicissitudes da vida. Quanto mais um conjunto de respostas é adequado, mais eficaz será sua adaptação. Para tanto, os vídeos e as transcrições das sessões de um processo de psicoterapia breve psicodinâmica de paciente adulta que foi atendida por psicoterapeuta experiente foram avaliadas com a LIGM e com a Escala Diagnóstica Adaptativa Operacionalizada Redefinida (EDAO-R). De acordo com a LIGM foram encontrados 14 episódios de mudança, distribuídos em 11 sessões. Observou-se evolução dos indicadores de mudança, em que as sessões iniciais englobaram indicadores de menor hierarquia e as sessões finais abarcaram indicadores de maior hierarquia. Os resultados também mostraram que houve evolução na eficácia adaptativa da paciente, de pouquíssimo adequada para adequada, no setor Afetivo-Relacional (A-R, que diz respeito aos relacionamentos intra e interpessoais) e de pouquíssimo adequada para pouco adequada no setor Produtividade (Pr, que envolve trabalho ou principal ocupação que a pessoa exerce). Sugere-se que o progresso na hierarquia dos indicadores demonstrou que a paciente passou a oferecer respostas mais adequadas, que ocasionaram principalmente em mudanças no setor A-R. Alguns fatores provavelmente contribuíram para as mudanças alcançadas e estes dizem respeito à paciente (participou ativamente do processo, tinha consciência de suas dificuldades e apresentou motivação para trabalhar nos problemas), à terapeuta (intervenções utilizadas durante as sessões) e à relação estabelecida entre ambas (aliança terapêutica). Foi possível concluir que neste estudo houve associação entre as duas medidas, que podem ser usadas para auxiliar o terapeuta na avaliação de progresso do paciente e na compreensão das variáveis que podem facilitar ou limitar a mudança do paciente. Sugere-se a realização de novas pesquisas, que compreendam maior número de casos e que contem com processos considerados mal sucedidos e em que houve abandono por parte do paciente. The present exploratory study aimed to combine the adaptive efficacy criterion with the Generic Change Indicators List (GCIL) to better understand how people change in psychotherapy. The specific aim was to evaluate if the evolution in the hierarchy of Generic Change Indicators is associated with the quality of adaptive responses. Methodologically, the research was based on an intensive case study design. The List presents an ideal of what happens when psychotherapy is successful. The List is composed by 19 indicators disposed hierarchically, which relate primarily to how the patient sees his or her problem, his or her willingness to face it and his or her expectations for psychotherapy and psychotherapist. Adaptive efficacy comprises the responses of the individual in the face of difficulties and vicissitudes of life. The more adequate a set of responses is, the more the adaptation of the subject will be considered effective. The videos and the transcriptions of the sessions of a brief psychodynamic psychotherapy process were evaluated with the GCIL and with the Scale of Adaptation (EDAO-R). According to the GCIL 14 episodes of change were identified into the 11 sessions of the psychotherapy. Results pointed to evolution in the hierarchy of indicators of change. The initial sessions comprised indicators of lower hierarchy and final sessions encompassed indicators of higher hierarchy. The results also showed that there was an evolution in the patient s adaptive efficacy, from very slightly adequate to adequate in the A-R area and from very slightly adequate to slightly adequate in the Pr area. We suggest that the progress in the hierarchy of the indicators showed that the patient began to offer more adequate responses, which resulted mainly in changes in the A-R area. It was possible to conclude in this study the association between the two measures. Some common factors to different therapeutic approaches probably contributed to the changes that the patient achieved and these are relate to the patient (she actively participated in the process, was aware of her difficulties and showed motivation to work on the problems), to the therapist (interventions used during the sessions) and to the relationship between therapist and patient (therapeutic alliance). Further researches must be pursued, involving a larger number of psychotherapies, including unsuccessful and dropout processes.

Aims: The research-practice gap and lack of engagement with research by trainees and qualified therapists is a widely discussed issue amongst psychotherapy researchers. The present study investigates the perceptions of psychotherapy trainees of psychotherapy research and explores what would encourage them to participate in research. Method: Two focus groups of 16 trainees in total were conducted at two separate psychotherapy training institutes to explore trainees’ attitudes and perceptions. Data was analysed using Braun and Clarke's (2006) thematic analysis. Results: Three superordinate themes emerged: negative perception of research; recognition of the importance of research; and what would be needed to facilitate engagement in research. Discussion: The results suggest that interest in and willingness to participate in research exists, however it is necessary for negative perceptions about research to be addressed and for researchers to design projects which are supportive of participants.

Therapeutic alliance is one of the most important and investigated constructs in psychotherapy research. In this chapter we first discuss the historical development of therapeutic alliance, from psychoanalytic theory to empirical research, and then its measurement and the problematic issues related to it. Then we will focus our discussion on the therapeutic alliance ruptures and resolutions construct, which represents one of the most interesting but, at the same time, controversial issues of contemporary therapeutic alliance research. Finally we propose a brief research agenda about therapeutic alliance ruptures and resolutions.

Systemic therapy (ST) is one of the most widely applied psychotherapeutic approaches in the treatment of children and adolescents, yet few systematic reviews exist on the efficacy of ST with this age group. Parallel to a similar study on adults, a systematic review was performed to analyze the efficacy of ST in the treatment of children and adolescents. All randomized or matched controlled trials (RCT) evaluating ST in any setting with child and adolescent index patients were identified by database searches and cross-references, as well as in existing meta-analyses and reviews. Inclusion criteria were: index patient diagnosed with a DSM-IV or ICD-10 listed psychological disorder, or suffering from other clinically relevant conditions, and trial published by December 2011. Studies were analyzed according to their sample, research methodology, interventions applied, and results at end-of-treatment and at follow-up. This article presents findings for internalizing and mixed disorders. Thirty-eight trials were identified, with 33 showing ST to be efficacious for the treatment of internalizing disorders (including mood disorders, eating disorders, and psychological factors in somatic illness). There is some evidence for ST being also efficacious in mixed disorders, anxiety disorders, Asperger disorder, and in cases of child neglect. Results were stable across follow-up periods of up to 5 years. Trials on the efficacy of ST for externalizing disorders are presented in a second article. There is a sound evidence base for the efficacy of ST as a treatment for internalizing disorders of child and adolescent patients.

There is a dearth of measures specifically designed to assess empirically validated mechanisms of therapeutic change. To fill in this research gap, the aim of the current study was to develop a measure that covers a large variety of empirically validated mechanisms of change with corresponding versions for the patient and therapist. To develop an instrument that is based on several important change process frameworks, we combined two established change mechanisms instruments: the Scale for the Multiperspective Assessment of General Change Mechanisms in Psychotherapy (SACiP) and the Scale of the Therapeutic Alliance—Revised (STA-R). In our study, 457 psychosomatic inpatients completed the SACiP and the STA-R and diverse outcome measures in early, middle and late stages of psychotherapy. Data analyses were conducted using factor analyses and multilevel modelling. The psychometric properties of the resulting Individual Therapy Process Questionnaire were generally good to excellent, as demonstrated by (a) exploratory factor analyses on both patient and therapist ratings, (b) CFA on later measuring times, (c) high internal consistencies and (d) significant outcome predictive effects. The parallel forms of the ITPQ deliver opportunities to compare the patient and therapist perspectives for a broader range of facets of change mechanisms than was hitherto possible. Consequently, the measure can be applied in future research to more specifically analyse different change mechanism profiles in session-to-session development and outcome prediction. Copyright © 2014 John Wiley & Sons, Ltd. Key Practitioner Message This article describes the development of an instrument that measures general mechanisms of change in psychotherapy from both the patient and therapist perspectives. Post-session item ratings from both the patient and therapist can be used as feedback to optimize therapeutic processes. We provide a detailed discussion of measures developed to evaluate therapeutic change mechanisms.

The field of research and practice in psychotherapy has been deeply influenced by two different approaches: the empirically supported treatments (ESTs) movement, linked with the evidence-based medicine (EBM) perspective and the “Common Factors” approach, typically connected with the “Dodo Bird Verdict”. About the first perspective, since 1998 a list of ESTs has been established in mental health field. Criterions for “well-established” and “probably efficacious” treatments have arisen. The development of these kinds of paradigms was motivated by the emergence of a “managerial” approach and related systems for remuneration also for mental health providers and for insurance companies. In this article ESTs will be presented underlining also some possible criticisms. Finally complementary approaches, that could add different evidence in the psychotherapy research in comparison with traditional EBM approach, are presented.

D.Litt. et Phil.

The acknowledgement of the dynamicity of psychological phenomena ®has been progressively gaining acceptance in various branches of psychology. In some of these areas (first of all the neurosciences, psycholinguistic, but also cognitive psychology, and social psychology) the theory has greatly benefited from the adoption of conceptual models and methods of investigation provided by the Dynamic Systems theory (inter alia, Salvatore, Tebaldi, & Poti, 2008). However, in other fields of psychology, authors refer to the dynamic systems in metaphorical terms, using it as a striking image to describe the irreversibility and intrinsic creativity/autonomy of the psychological phenomena under investigation. As a result of this rhetorical strategy, in various areas related to the study of intersubjectivity (work psychology, clinical, and psychodynamic psychology as well as cultural psychology and at least partially developmental psychology) there is an evident gap between the conceptualisation of the phenomena as dynamic and the empirical investigation of it as a “static” process (Lauro-Grotto, Salvatore, Gennaro, & Gelo, 2009—Chapter 1 in this book).

El Estilo Personal del Terapeuta (EPT) se conceptualiza como un constructo multidimensional que está presente en todo proceso terapéutico. El objetivo principal de este trabajo es presentar una versión abreviada del cuestionario EPT-C y proporcionar nuevas pruebas sobre la validez de este instrumento como herramienta para la evaluación del constructo. Se administró el EPT-C a una muestra de 461 psicoterapeutas argentinos. Se analizó la validez de constructo del cuestionario mediante Análisis Factorial Confirmatorio, se estudió la relación entre la versión breve y la original, y se evaluó la capacidad del instrumento para discriminar a los diferentes grupos de terapeutas en variables de relevancia para el proceso y los resultados de la psicoterapia. Los resultados indicaron un buen ajuste entre el modelo de medida pentafactorial del EPT-C y las dimensiones del constructo teórico. El cuestionario EPT-C aporta una medida sensible para detectar diferencias entre grupos de terapeutas a partir de varias características de los mismos. The PST is conceptualized as a multidimensional construct which is present throughout the therapeutic pro-cess. The aim of this work is to present a brief versión of the PST-Questionnaire and to give new evidence about the validity of the instrument to evalúate it. The PST-Q was administered to a sample of 461 argentine therapists. A confirmatory factor analysis was applied, and it was studied the relationship between the brief and original versión. It was assessed its capacity to discrimínate the differencies between groups of therapists. The results indicated a good fit between the model of pentafactorial measure PST-Q and the dimensions of the theoretical construct. The PST-Q gives a measure to detect differences between groups of therapists.

A pessoa do psicoterapeuta é um dos componentes de grande importância no processo de atendimento psicológico. O objetivo geral desse trabalho foi realizar um levantamento da produção científica, em periódicos brasileiros classificados como Qualis A ou B, no período de 1998 a 2007, com foco na pessoa do terapeuta. Já os objetivos específicos foram vinculados a analisar a produção de artigos no Brasil, procurando identificar: variáveis do psicoterapeuta, a natureza do trabalho e variáveis relacionadas aos autores, filiação institucional e natureza do trabalho. As variáveis do terapeuta estudadas estavam ligadas a traços observáveis, estados observáveis, traços inferidos e estados inferidos. Verificou-se também a contratransferência (em trabalhos de linha psicodinâmica) e o contexto de atendimento (saúde pública ou clinica particular). A amostra constou de 45 artigos, acessados em 22 periódicos nacionais, pelo portal de periódicos da CAPES e bibliotecas nacionais. O grau de acordo entre avaliações independentes realizadas por dois juizes, em amostra de 10 artigos, revelou bons índices de precisão (k entre 0,1578 e 1). Os resultados relativos aos artigos apontaram no sentido da pouca produção de pesquisas empíricas nos periódicos ligada às variáveis do terapeuta, sendo 60% dos trabalhos encontrados de cunho teórico, 29 % empíricos, 9% relatos de experiências e 2 % de revisão de literatura. Mostrando ainda que a maioria das variáveis que são objeto de pesquisa na literatura internacional são ignoradas ou apenas mencionadas nos trabalhos nacionais. As conclusões remetem à necessidade de realização de novas pesquisas por parte dos pesquisadores brasileiros no que diz respeito às variáveis ligadas à pessoa do terapeuta. The psychotherapist person is one of the most important components in the psychological treatment process. The general objective of this work was to achieve a survey of the scientific production respecting the therapist s person, published in the Brazilian Journals, from 1998 to 2007, and classified as Qualis A and B according to the Capes categories of evaluation. The specific objectives aimed to identify the psychotherapist variables, nature of the work, authorship and institutional affiliation. The therapist s variables were categorized as observable traits, observable states, inferred traits and inferred states. It was also verified the countertransference (in psychodynamics works) and the treatment context (public health or private clinic). The sample consisted of 45 articles, of 22 national Journals accessed in the CAPES website and national libraries. The inter-rater reliability of two independent raters, based on a sample of 10 articles, showed good agreement ( k between 0,1578 and 1). Results suggested a poor production of empirical researches, 60% of the works were theoretical, 29 % empirical, 9 % clinical experience reports and 2 % literature review. The majority of the variables researched into the international literature are ignored or just mentioned in national works. Conclusions point to the necessity of more Brazilian researches on the therapist s variables and their relation to the therapy outcome.

A content analysis of the representative Journals in the field of psychothera-py research has been performed. The analysis focused on the articles’ keywords. We ana-lyzed 7,086 works published in 17 Journals, in the period 2005-2011, using a two-step multidimensional procedure. Firstly, a cluster analysis led to the extrapolation of 4 groups of keywords, each of them interpreted as the marker of a topic active within the literature. Secondly, a factorial analysis was carried out in order to picture the thematic orientation of the most representative Journals, namely the main topics they focus on and how they differ from each other in this respect.