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Previous research suggests that common relationship factors are composed of two overarching factors, "Confidence in the therapist" and "Confidence in the treatment." The aim of this naturalistic process-outcome study was to investigate the reciprocal relationships between these two constructs and patients' symptom level across treatment. The sample consisted of 587 patients who were admitted to an inpatient program and treated with psychotherapy for a range of mental health disorders, such as chronic depression, anxiety disorders, and eating disorders. Our data consisted of weekly measures of symptomatic distress (Patient Health Questionnaire) and the common relationship factors were measured weekly using a newly developed scale. Latent curve modeling with structured residuals was used to investigate the between- and within effects of week-to-week changes in the two components as predictors of subsequent symptom level. An increase in both relationship factors predicted a decrease in subsequent levels of symptoms at the within-patient level, and the other way around, but the two relationship factors did not systematically relate to one another at the within-patient level over the course of treatment. Our findings indicate that patients' perceptions of the therapist as a person and their appraisal of the treatment, are important, different predictors of therapeutic change. Furthermore, they support prior research demonstrating a reciprocal relationship between common relationship factors and symptomatic distress and add to existing common factor theory by exploring the role of two central relationship dimensions and using a method which examines reciprocal relationships and within-patient effects simultaneously. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Patients seeking psychotherapy may progress through treatment in varying ways. Modeling multiple treatment trajectories through growth mixture modeling provides a comprehensive way of understanding a patient population. Multiple trajectories may additionally help researchers describe complexities within a patient population, such as those with severe and persistent disorders and comorbid symptoms, to understand characteristics of patients that may be struggling during treatment. We analyzed the depression symptom outcome measures (PHQ-9) for 246 patients receiving inpatient depression treatment. We constructed a growth mixture model of depression symptom changes, allowing the number of treatment trajectories to emerge through the data, and utilized goodness-of-fit indices to select the superior model. Results indicated three classes was the best fitting model, with patients either (a) patients started above the clinical cutoff score for depression and had significant linear change over time, ending therapy just above the clinical cutoff-"Improvement-leveling off-improvement"; (b) patients started therapy well above the clinical cutoff, showed symptom alleviation at the beginning of therapy before the trajectory started to level off-"High symptom pressure"; or (c) patients started therapy just below the clinical cutoff, had steady change throughout therapy, ending well below the clinical cutoff-"continuous improvement." Implications of the study may include altering the length of treatment based on patient presenting symptoms in order to best serve patients and utilize hospital resources. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Meta-analyses have established the alliance as the most robust predictor of outcome in psychotherapy. A growing number of studies have evaluated potential threats to the conclusion that alliance is a

Objective: Prior research has established that common therapeutic relationship factors are potent predictors of change in psychotherapy, but such factors are typically studied one at a time and their underlying structure when studied simultaneously is not clear. We assembled empirically validated relationship factors (e.g., therapist empathy; patient expectations; agreement about goals) into a single instrument and subjected it to factor analysis. Method: The instrument was applied to patients (N = 332) undergoing intensive psychotherapy of different types for depressive disorders, anxiety disorders, eating disorders, and childhood trauma in an inpatient specialized mental health setting. In order to examine the psychometric properties of the scale, we used half the sample (N=164) to conduct exploratory factor analysis (EFA) and parallel analysis before we tested the solution using exploratory structural equation modeling (ESEM) on the second half of the sample (N=168). Measurement invariance analysis was conducted to examine the stability of the factor structure. Results: The analysis yielded two factors, which were termed 1. "Confidence in the therapist" and 2. "Confidence in the treatment." Discussion: When assessed simultaneously, patients differentiate between their evaluation of the therapist and of the treatment. The results indicate that there is substantial overlap among previously established relationship factors.Trial registration: ClinicalTrials.gov identifier: NCT03503981.

Objective The relationship between the therapeutic alliance and outcome has been supported consistently over time. More recently, studies have examined therapist effects in the alliance-outcome relationship and came up with somewhat mixed findings. The purpose of this study was to replicate and extend previous meta-analytic work using a much larger data set, permitting not only the verification of the overall impact of the therapists' contribution but, at the same time, controlling for several potential covariates effecting this relationship. Method We conducted two- and three-level mixed-effects meta-analyses (k = 152; 827 total effect sizes) to examine the significance of several potential moderators of the alliance-outcome correlation. These moderators included (a) Patient-Therapist Ratio (PTR; Patient N divided by therapist N to test therapist effects), (b) Alliance and Outcome Rater's contribution (patient, therapist, observer, and other), (c) Alliance Measures, (d) Research Design (RCT, Other) and (e) Personality Disorder. Results The PTR, an index of the therapist's contribution to the alliance, was a significant moderator of the alliance-outcome correlation in both the two- and three-level models. When several potential confounds were simultaneously tested in a three-level multipredictor metaregression, including rater of alliance and outcome, research design, alliance measure, and personality disorder, PTR remained a significant moderator of the alliance-outcome correlation. Conclusion Replicating and extending previous research, this study supported the significance of therapists' impact in the alliance-outcome relationship. These results remained significant even when, using three-level metaregressions, several potential covariates were simultaneously controlled. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The alliance is widely recognized as a robust predictor of posttreatment outcomes. However, there is a debate regarding whether the alliance is an epiphenomenon of intake characteristics and/or treatment processes occurring over the course of treatment. This meta-analysis aimed to synthesize the evidence on this issue. We identified 125 effect sizes in 60 independent samples (6,061 participants) of studies that reported alliance-outcome correlations as well as parallel intake or process characteristics. We examined the impact of these potential confounds on the alliance-outcome correlations. We meta-analyzed the studies estimates by computing omnibus effects models as well as multivariate models. We identified 3 variable types that were used to adjust the alliance-outcome correlations: (a) intake characteristics (k = 35); (b) simultaneous processes, such as adherence or competence (k = 13); and (c) both intake and simultaneous processes (k = 24). We found moderate alliance-outcome correlations with or without adjustments for intake and simultaneous processes (range from r = .23 to r = .31). Our results provide robust empirical evidence for the assertion that the alliance-outcome association is an independent process-based factor. Findings suggest that alliance is positively related to outcome above and beyond the studied patient intake characteristics and treatment processes. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Objective Even though the early alliance has been shown to robustly predict posttreatment outcomes, the question whether alliance leads to symptom reduction or symptom reduction leads to a better alliance remains unresolved. To better understand the relation between alliance and symptoms early in therapy, we meta-analyzed the lagged session-by-session within-patient effects of alliance and symptoms from Sessions 1 to 7. Method We applied a 2-stage individual participant data meta-analytic approach. Based on the data sets of 17 primary studies from 9 countries that comprised 5,350 participants, we first calculated standardized session-by-session within-patient coefficients. Second, we meta-analyzed these coefficients by using random-effects models to calculate omnibus effects across the studies. Results In line with previous meta-analyses, we found that early alliance predicted posttreatment outcome. We identified significant reciprocal within-patient effects between alliance and symptoms within the first 7 sessions. Cross-level interactions indicated that higher alliances and lower symptoms positively impacted the relation between alliance and symptoms in the subsequent session. Conclusion The findings provide empirical evidence that in the early phase of therapy, symptoms and alliance were reciprocally related to one other, often resulting in a positive upward spiral of higher alliance/lower symptoms that predicted higher alliances/lower symptoms in the subsequent sessions. Two-stage individual participant data meta-analyses have the potential to move the field forward by generating and interlinking well-replicable process-based knowledge. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The aim of this naturalistic process study was to investigate the relationship between emotional clarity and tolerance of emotional distress and depressive symptoms over the course of short-term psychodynamic psychotherapy for chronically depressed patients.Weekly self-reports of emotional clarity, tolerance of emotional distress, and depressive symptoms (PHQ-9) were provided by 252 patients with chronic depression who were admitted to a 13-week inpatient treatment program. Latent curve modeling with structured residuals (LCM-SR) was applied to investigate the between- and within-person effects of week-to-week change in emotional clarity and tolerance of emotional distress as predictors of subsequent depression. The relationship between emotional clarity and tolerance of emotional distress was also investigated.At the within-person level, higher level of emotional clarity and tolerance of emotional distress predicted subsequent lower level of depression. A reciprocal relationship was found for tolerance of emotional distress (lower level of depression predicted subsequent level of tolerance emotional distress) but not for emotional clarity. No within-person effect between emotional clarity and tolerance of emotional distress was found.The results indicate that emotional clarity and tolerance of emotional distress may be mechanisms of change in short-term psychodynamic psychotherapy for chronic depression. The results are consistent with previous findings of the importance of emotional clarity and tolerance of emotional distress in psychotherapy. This study demonstrated the utility of LCM-SR as a method to identity mechanisms of change in psychotherapy. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Psychotherapy as it is implemented today, can be seen as the composition of unconnected groups of practitioners and scientists pursuing different theories. The idea of finding a common “umbrella” for all evidence-based treatments in the field of psychotherapy is gaining more interest. Based on this background, experts in clinical psychology from various backgrounds led a fundamental discussion about modern psychotherapy and its basic mechanisms. Process-Based Therapy (PBT) was presented by Stefan Hofmann as a possible novel approach to clinical research and practice. In this article we present the different perspectives of the four panelists on PBT and in how far the model builds a common ground for different treatment approaches. Learning mechanisms and the therapeutic alliance were almost unanimously considered as indispensable factors in a global model of psychotherapy. In conclusion, the panelists emphasized a much-needed focus on characteristics and competencies of therapists themselves e.g., in communication, listening and empathy. These core competencies should be trained and promoted independently of the therapeutic approach.

The present study tested the efficacy of an unguided internet-based Acceptance and Commitment Therapy (iACT) program for depression, and identified the psychological characteristics of participants who benefitted the most from the program.Undergraduate students with mild to severe symptoms of depression were randomized to the iACT group (n = 95) or the waiting-list group (WLC group; n = 87). Depressive symptoms and positive mental health were assessed at baseline (TCompared with the WLC group, the iACT group showed significantly more improvement in depressive symptoms (d = 1.27) and positive mental health (d = 0.59), both at TThe iACT was effective in treating the depressive symptoms of undergraduates, especially suitable for the clients with high baseline depression, high externality, high resistance, and high sensitivity to relationships.

The therapeutic relationship and responsiveness/treatment adaptations rightfully occupy a prominent, evidence-based place in any guidelines for the psychological treatment of trauma. In this light, we critique the misguided efforts of the American Psychological Association's (APA, 2017) Clinical Practice Guideline on Posttraumatic Stress Disorder in Adults to advance a biomedical model for psychotherapy and thus focus almost exclusively on treatment methods for particular disorders. Instead, the research evidence, clinical expertise, and patient preferences and culture (the necessary triumvirate of evidence-based practice) should converge on distinctive psychological guidelines that emphasize the therapy relationship, treatment adaptations, and individual therapist effects, all of which independently account for patient improvement more than the particular treatment method. Meta-analytic findings and several trauma-specific studies illustrate the thesis. Efforts to promulgate guidelines without including the relationship and responsiveness are seriously incomplete and potentially misleading. The net result is an APA Guideline that proves empirically dubious, clinically suspect, and marginally useful; moreover, it squanders a vital opportunity to identify what actually heals the scourge of trauma. We conclude with recommendations for moving forward with future APA practice guidelines. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

This replication study examined the change over time and the relationship between depressive symptoms and dyadic adjustment during residential couple therapy and at one- and three-year follow-up. Mixed models were used in the analyses, and a disaggregation procedure was applied to examine the results on a between-person as well as on a within-person level. Overall, the results of the previous study were replicated. Significant improvement (

Different forms of psychotherapy are effective for cluster C personality disorders, but we know less about what in-session processes promote change. Contrasting successful and unsuccessful cases may elucidate processes that facilitate or impede outcome and offer suggestions for clinical practice and future research. In this exploratory outcome-process study, 10 successful and 10 unsuccessful cases were selected from a randomized trial comparing cognitive therapy and short-term psychodynamic psychotherapy for cluster C personality disorders. Videotaped sessions were rated with the Psychotherapy Process Q-Set (PQS). The treatments were compared in terms of which PQS items differentiated successful and unsuccessful cases, as well as their resemblance with PQS prototypes of "ideal treatments." Therapists' behavior in early sessions was also explored. Results indicate that successful cases in our sample were characterized by a more active and engaged patient. In contrast, unsuccessful cases were characterized by a more directive or "controlling" therapist stance. Correlations with PQS prototypes were moderate to strong in both successful and unsuccessful cases, suggesting that optimal and suboptimal interpersonal processes may be independent of adherence to particular treatments. Exploration of therapist behaviors in early sessions indicated that therapists were more likely to adjust their way of working in the successful cases. Our result suggests that patient engagement and therapists' early efforts to improve the therapy relationship may be pivotal for successful outcome, whereas therapist controlling behavior may obstruct the treatment process, regardless of therapy model used. The impact of these in-session processes should be examined more closely in larger samples in future studies. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The present study aimed to explore the relationship between changes in depressive symptoms and the capacity to mentalize over the course of a 3-month inpatient psychodynamic therapy in a sample of 56 patients with depression. Depressive symptoms and mentalizing were assessed weekly during treatment and at 1-year follow-up with the Beck Depression Inventory and the Reflective Functioning Questionnaire (RFQ). Data were analyzed using Latent Growth Curve (LGC) modeling with structured residuals. In the total sample, depressive symptoms improved on average from baseline to the end of treatment, while mentalizing skills did not. However, individual variations were observed in mentalizing skills, with some patients improving while others did not. Within-patient residual changes in mentalizing skills did not predict residual changes in depressive symptoms. Accordingly, the results did not support mentalizing as a mechanism of change at this level. Nonetheless, between-patient effects were found, showing that patients with higher levels of mentalizing at baseline and patients whose mentalizing skills improved over the course of therapy also had greater reductions in depressive symptoms. We suggest that the presence of relatively higher mentalizing skills might be a factor contributing to moderately depressed individuals' ability to benefit from treatment, while relatively poor or absent mentalizing capacity might be part of the dynamics underlying treatment resistance in individuals with severe depression. (PsycInfo Database Record (c) 2021 APA, all rights reserved). ispartof: JOURNAL OF COUNSELING PSYCHOLOGY vol:68 issue:6 pages:705-718 ispartof: location:United States status: published

Objective Depression is typically seen as composed of several factors (i.e., cognitive, affective, somatic) which may be targeted by different interventions (i.e., pharmacotherapy, psychotherapy, or combination treatment). Successfully targeting these factors may contribute to improved treatment response in depression. A previous study identified two subfactors on Beck Depression Inventory-II (BDI-II) in a sample of chronically depressed patients: (a) self-criticism and (b) somatic symptoms (sleep disturbance, fatigue, changes in appetite). Prior research indicates that these symptoms may respond differently to psychotherapy and pharmacotherapy. In this study, we examined whether patients who were on antidepressant medication (ADM) had different outcomes on these factors than patients not using medication while undergoing intensive inpatient psychotherapeutic treatment. Method After adjusting for baseline difference with propensity score matching, a total of 238 patients with chronic depression were included in the analysis of which 119 patients were using ADM during treatment while 119 were not. We analyzed whether the two groups had different trajectories of change on the factors "self-criticism" and "somatic symptoms" using multilevel growth curve modeling. Results Patients not using medication during treatment had significantly larger symptom reduction than ADM users on the self-criticism factor, while there was no difference between groups on the somatic factor. Conclusion There seems to be a difference in outcomes on self-criticism depending on the use of ADM for this patient group. This may suggest that the simultaneous use of ADM while in psychotherapy could make patients less accessible to the effects of psychotherapeutic interventions on this factor. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Overview In the current work, we build upon a small body of literature that delineates cross-cutting factors, or processes, of evidence-based alcohol or other drug (AOD) therapies. Here, we discuss Psychoeducation. We define psychoeducation as a brief process of therapy focused on the communication of varied aspects of disease- and/or treatment-related information. Method The authors conducted a literature review and qualitative content analysis to derive a set of principles and practices of psychoeducation. The review used source documents (i.e., literature reviews, therapy manuals, and government-issued practice guidelines) and videos (i.e., therapy demonstration videos), and we performed analyses in NVIVO. Results The review identified nine principles and 21 practices. Together, the principles suggest that psychoeducation in evidence-based addictions therapies can be characterized as a collaborative approach to teaching, education, or other provision of information. The term collaborative denotes a shift in emphasis from compliance to a more egalitarian partnership focused on meeting individual health needs. Specific practices included ways to transition to psychoeducation (e.g., provide rationale and promote expectancy), teaching methods in psychoeducation (e.g., use plain language), tailoring content in psychoeducation (e.g., to learning style, to cultural worldview), and methods for facilitating a dialogue about the information (i.e., five question types), for facilitating understanding and retention of the information (e.g., tailor to individual needs, use of varied teaching modalities), and how to end psychoeducation and engage in related goal-setting, where applicable. Conclusions We frame psychoeducation as a collaborative approach to teaching where client engagement, understanding, and utilization of the information provided is the central goal. We offer a novel resource with pragmatic value to trainees, providers, and clinical supervisors who do not consider themselves aligned with a single evidence-based modality but who may benefit from training and proficiency assessment in core, behavioral health counseling competencies.

Objective Mental health disparities between racial/ethnic minorities (REM) and White individuals are well documented. These disparities extend into psychotherapy and have been observed among clients receiving care at university/college counseling centers. However, less is known about if campus RE composition affects outcomes from psychotherapy for REM and White clients. Method This study examined psychotherapy outcomes from 16,011 clients who engaged in services at 33 university/college counseling centers. Each of these clients completed the Behavioral Health Measure as a of part routine practice. Campus RE composition was coded from publicly available data. Results The results demonstrated that White clients had better therapy outcomes than REM clients when they were at campuses where there were more White students. For universities 1 SD below the mean percentage of White students, the average difference in therapy outcomes for White and REM clients was Cohen's d = .21 (with White students experiencing more improvement); however, for universities 1 SD above the mean, the between group outcome disparity was greater (Cohen's d = .38). Conclusion Therapists and higher education professionals should consider environmental impacts on counseling services. Implications for higher education, counseling centers, and mental health disparities are provided. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The therapeutic alliance has gained status as a common factor in psychotherapy due to its robust predictive relationship with outcome. The current challenge in our field is to gain a more nuanced understanding of alliance's impact on the progress of treatment over the course of therapy. In the current study, alliance was measured on 3 dimensions: (a) the individual's as well as the couple's joint perception of alliance with the therapist ("self/group-therapist"), (b) each partner's perception of the alliance between the spouse and the therapist ("other-therapist"), and (c) the couple's assessment of alliance with each other ("within-system"). Based on self-reported data from 165 adult clients, we analyzed whether scores on these alliance dimensions at the beginning of therapy predicted the frequently measured outcomes on individual symptoms and relationship distress during treatment. We found that 2 of the alliance dimensions, the "self/group-therapist" and the "other-therapist," at the start of treatment predicted the slopes of the outcome measures. These findings add to established research suggesting that early establishment of alliance is an important predictor for progress during treatment. Variations in the results among the 3 alliance dimensions suggest the usefulness of the clinician assessing different aspects of alliance in couple therapy. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Objective In couple therapy clients often suffer from a blend of individual psychiatric symptoms as well as severe relational distress. However, research is inconclusive on whether relational change predicts symptom change or vice versa. Because answers to this question could have important clinical implications on what to focus on in couple therapy at which time in treatment, more research is recommended. Method In this study, data collected before every therapy session were used to test whether changes in relational functioning predicted symptom functioning or vice versa. The study used a multilevel modeling approach, and the variables of interest were disaggregated into within- and between-person effects. Results The results indicated that if an individual improved more than expected on relational functioning, this predicted more improvement than expected on individual symptoms. No significant reciprocal relationship was found between these variables. Conclusions The clinical implication is discussed, suggesting that an emphasis on relational improvement seems to be an important mechanism during couple therapy that may facilitate the change on individual symptoms in the long run.

Research indicates that combination of psychotherapy and antidepressant medication (ADM) provides cumulative effects and thus outperforms monotherapy in treating chronic depression. In this quasi-experimental study, we explored symptom change for patients with chronic depression treated with ADM when presenting for a 12-week psychotherapeutic inpatient treatment programme. We compared outcomes through treatment and follow-up of patients who continued medication with those who discontinued. We also tested possible moderator effects of initial depression severity on change between the groups. Based on prior research, we hypothesized that combination treatment would yield better results (i.e., more reduction in depression). Patients (N = 112) were referred from general practitioners or local secondary health care. Outcome was measured by Beck Depression Inventory-II (BDI-II), and comparisons were carried out using multilevel modelling. Although 35 patients discontinued ADM during treatment, 77 continued. Both continuers and discontinuers had a significant treatment effect that was maintained at 1-year follow-up. There was no difference in outcome between continuers and discontinuers of ADM. Patients with severe depression had significantly more symptom improvement than patients with moderate depression, but depression severity did not affect outcomes across continuers and discontinuers of ADM differently. The results could indicate that patients had developed resistance and/or tolerance to the prophylactic effects of medication and that ADM did not contribute to the reduction of depressive symptoms. The findings may also indicate that psychotherapy alone in some instances can be a viable alternative to continued combined treatment. Clinicians should carefully assess benefits of patients' ongoing use of antidepressant medication when entering psychotherapy.

Objective: Both good therapeutic bond as well as extra-therapeutic social support seem to enhance treatment outcomes. Some features of the therapeutic bond are similar to experiences in extra-therapeutic relationships (e.g., feelings of trust or belongingness). Patients with a lack of social support might benefit particularly from a good therapeutic bond, because a well-formed bond can partly substitute relationship needs. This study replicates former research (main effects of bond and social support) and investigates the hypothesized interaction between both constructs. Method: Data from 1206 adult patients receiving cognitive-behavioral outpatient therapy were analyzed. Patients rated early therapeutic bond, their impairment, as well as their social support. Multilevel regression analyses were applied to test for main effects and interactions between bond and social support predicting therapy outcome post treatment. Results: Consistent with prior research, both therapeutic bond and social support predicted therapy outcome. Among patients with high social support, the impact of the therapeutic bond was minimal, while patients with low social support benefited most from a good therapeutic bond. Conclusions: Results suggest that both the therapeutic bond and social support play a role in therapy outcomes and that good therapeutic bond quality might be especially important if a patient lacks social support.

Background: The factor structure of depression differs for different sub-samples. The purpose of this study was to explore the factor structure of Beck Depression Inventory-II in patients with chronic depression presenting for inpatient treatment. Methods: Using exploratory structural equation modeling (ESEM), we explored whether a two-factor solution or a bifactor solution provided best model fit for a sample of 377 patients. For the best fitting model stability was assessed with tests for invariance across primary diagnosis (persistent depressive disorder v. recurrent major depressive disorder), and presence of comorbidity. Results: A bifactor solution with one general factor and two specific factors provided best model fit. Invariance analyses provided support for measurement invariance and stability of the factor solution. Limitations: The naturalistic study design implies some uncertainty regarding possible systematic differences between the patients on demographic and clinical characteristics. Conclusion: The factor structure in our sample was best explained by a general depression factor, one specific factor pertaining to self-criticism, and one consisting of the somatic items fatigue, disturbance of sleep, and appetite. Clinicians could benefit from paying special attention to the subfactors identified, as these findings may have implications for treatment choice for patients with chronic depression.

Deciding on the number of psychotherapy sessions to satisfactorily treat a patient is a vital clinical as well as economic issue in most mental health systems worldwide. The length of outpatient psychotherapy in naturalistic conditions ranges from a single session to hundreds of sessions [1]. In randomized clinical trials, the number of sessions is typically fixed to deliver manualized treatments and to control for dosage effects (e.g., in a 16-session format [2]). Using data from Routine Outcome Monitoring studies [3, 4], we investigated whether the treatments under naturalistic conditions were fixed to a particular number of sessions or not (H1), whether naturalistic conditions tended to include unusually long treatments (e.g., >100 sessions) (H2), and how the observed number of sessions was distributed across countries (H3).

In this study, we introduce the journal issue devoted to evidence-based responsiveness and frame it within the work of the third interdivisional APA Task Force on Evidence-Based Relationships and Responsiveness. We summarize the meta-analytic results and clinical practices on the adaptations of psychotherapy to multiple transdiagnostic characteristics of the patient, including attachment style, culture (race/ethnicity), gender identity, coping style, therapy preferences, reactance level, religion and spirituality, sexual orientation, and stages of change. We then discuss the clinical and research process of determining what works, and what does not work, for whom. The limitations of the Task Force's work are outlined and frequently asked questions are addressed. The article closes with the Task Force's formal conclusions and 28 recommendations and with some reflections on fitting psychotherapy to the individual client.

This study investigated the effects of the Partners for Change Outcome Management System (PCOMS) in adult outpatient treatment at a hospital-based mental health clinic. It also investigated whether the effects differed with the timing of the treatment within a 4-year implementation period, with clients' initial distress levels, and between therapists. Adult clients (N = 170) were randomized to treatment as usual (TAU) or routine outcome monitoring (ROM). Twenty therapists provided therapy in both conditions. Therapy outcome was measured by the Behavior and Symptoms Identification Scale (BASIS-32). Data were analyzed in a series of multilevel models (MLMs). Clients in the ROM condition were 2.5 times more likely to demonstrate improvement than those in the TAU condition. Controlling for therapist variability, the overall effect size (ES) in favor of ROM was small (d = 0.26, p = .037). The superiority for ROM over TAU increased significantly over the duration of the study. ROM effects were not moderated by clients' initial distress levels. Differences between therapists accounted for 9%-10% of the variability in outcomes, and there were no significant differences in ROM effects between therapists. ROM was associated with better treatment outcomes independent of clients' initial distress levels. Clients treated later in the study benefitted more from ROM than those treated earlier. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Introduction This work builds on a small body of literature that explores core processes in psychotherapy, behavior change, and evidence-based alcohol or other drug (AOD) therapies. Here, this paper discusses two separate but dependent processes. The research team defines goal setting and goal monitoring as collaborative processes where clinicians and clients identify and formulate therapeutic goals; actionable objectives; and revisit, measure, and renegotiate these plans via a standardized procedure over time. Method Study methods included a literature review and qualitative content analysis to derive a set of principles and practices of goal setting and monitoring. The research team used source documents (i.e., literature reviews, therapy manuals, and government-issued practice guidelines) and videos (i.e., therapy demonstration videos), and we performed analyses in NVIVO. Results The study identified ten principles and 32 practices. The principles suggest that goal setting and monitoring can be characterized as a collaborative, explicit, and standardized approach to engaging in goal-directed therapeutic work. The term goal-directed therapeutic work connotes a shift toward a more accountable frame for care than has been previously emphasized in the literature. The identified practices were organized into five sub-themes related to goal setting (10 practices), goal monitoring (10 practices), as well as practices specific to mechanisms of goal pursuit and behavior change. These practices involved ways to attend to client self-determination (4 practices), motivation (4 practices), and self-efficacy (4 practices). Conclusions Goal setting and monitoring are a collaborative means of mapping and tracking a course of mutually accountable treatment. The current work is a novel resource for trainees, clinicians, and clinical supervisors interested in care based on evidence-based principles and practices of AOD and other behavior change therapies.

Despite widespread scientific and popular interest in mindfulness-based interventions, questions regarding the empirical status of these treatments remain. We sought to examine the efficacy of mindfulness-based interventions for clinical populations on disorder-specific symptoms. To address the question of relative efficacy, we coded the strength of the comparison group into five categories: no treatment, minimal treatment, non-specific active control, specific active control, and evidence-based treatment. A total of 142 non-overlapping samples and 12,005 participants were included. At post-treatment, mindfulness-based interventions were superior to no treatment (d = 0.55), minimal treatment (d = 0.37), non-specific active controls (d = 0.35), and specific active controls (d = 0.23). Mindfulness conditions did not differ from evidence-based treatments (d = −0.004). At follow-up, mindfulness-based interventions were superior to no treatment conditions (d = 0.50), non-specific active controls (d = 0.52), and specific active controls (d = 0.29). Mindfulness conditions did not differ from minimal treatment conditions (d = 0.38) and evidence-based treatments (d = 0.09). Effects on specific disorder subgroups showed the most consistent evidence in support of mindfulness for depression, pain conditions, smoking, and addictive disorders. Results support the notion that mindfulness-based interventions hold promise as evidence-based treatments.

Clinical or methodological significance of this article: Meta-analysis is a powerful tool for resolving conflicting conjectures or findings while also providing a critical overview of a scientific area.

Psychotherapists have long questioned what mediating processes are linked to outcome of psychotherapy. Few studies examining this question have assessed within-person changes in the process outcome relationship over time. The present study examined changes in cognition and metacognition over the course of therapy using a dataset from a randomized controlled trial comparing Metacognitive therapy (MCT) and Cognitive-behavioral therapy (CBT). The sample included 74 patients measured on process and symptom instruments weekly throughout therapy. Multilevel longitudinal models (sessions nested within patients) were used to examine the relationship between metacognition, cognition, and anxiety. Main effects of metacognition and cognition on anxiety and the interaction with treatment, as well as the reciprocal relationships, were investigated. The results indicate a main effect of both cognitions and metacognitions on predicting anxiety. However, there was no interaction with treatment condition. The reciprocal relationship of anxiety on metacognitions was larger in MCT compared with CBT. This is the first study documenting within-person effects of both cognitions and metacognitions on anxiety over the course of therapy. Implications for therapy are discussed. (PsycINFO Database Record

One explanation for differences in treatment effectiveness for targeted symptoms is that more-effective treatments are more focused on patients' problems than are less-effective treatments. This conjecture was examined meta-analytically. Comparisons of two treatments of adults with anxiety disorders were included. Effect sizes for targeted symptoms, nontargeted symptoms, and global outcomes (e.g., quality of life and well-being) as well as the relative focus on patients' problems and researcher allegiance were coded. Metaregressions were conducted to predict effect sizes from (a) variables related to the focus on patients' problems and (b) researcher allegiance. For symptom measures, the relative focus on patients' problems predicted the relative effectiveness of the treatments, with the expectations created by explanation appearing more predictive than specific therapeutic actions focused on patients' problems, although conclusions about relative importance were difficult to determine given collinearity of predictors. Researcher allegiance also predicted the effects of the comparisons. For global outcomes, both the focus on patients' problems and researcher allegiance seemed to have smaller roles. A focus on patients' problems appears to be important for the reductions of symptoms. Clinical trials comparing treatments need to balance the focus on patients' problems and reduce researcher allegiance. (PsycINFO Database Record

Some of the most important decisions that a researcher will make when conducting a meta-analysis are decisions about the search strategies and inclusion/exclusion criteria. Decisions regarding inclusion/exclusion criteria serve to define the scope of a meta-analysis and search strategy decisions can have a large impact on how well the results of a meta-analysis actually represent the existing body of literature. In this article, we provide descriptions and recommendations for performing searches and making inclusion/exclusion decisions. We also provide a review of 65 meta-analyses of psychotherapy versus pharmacotherapy in order to offer frequency data on the use of various search strategies and inclusion/exclusion decisions in the field.

Routine Outcome Monitoring (ROM) is recommended as a psychotherapy procedure to serve as clinical feedback in order to improve client treatment outcomes. ROM can work as a warning signal to the therapist if the client shows signs of no change or deterioration. This study has investigated whether any difference in outcome could be detected between those clients in couple and family therapy who used the Systemic Therapy Inventory of Change (STIC) feedback system (ROM condition) versus those who were offered treatment without the use of STIC ("treatment as usual" or TAU condition). A sample of 328 adults seeking couple and family therapy in Norway was randomly assigned to ROM versus TAU conditions. Outcome measures were The Outcome Questionnaire-45 and The Revised Dyadic Adjustment Scale. The results demonstrated no significant differences in outcomes between the ROM and TAU. Possible explanations of this result related to design and implementation issues are discussed.

Overview This work builds on previous efforts to delineate cross-cutting factors of evidence-based therapies. In this report, we target a single therapeutic factor—skills training for addictive behavior change—and we operationalize this factor in a manner that will aid clinical training and quality control. Specifically, we identify principles, which we defined as broader understandings on the part of the therapist that must be kept in mind when implementing a specific therapeutic practice. We define a practice as discrete action step or specific type of intervention that the therapist uses when addressing skills training content with clients. Method We conducted a literature review and qualitative content analysis of 30 source documents (i.e., therapy manuals, literature reviews, and government issued practice guidelines) and videos (i.e., therapy demonstration videos). We performed analysis of source materials in NVIVO. Results We identified 10 principles and 30 therapeutic practices. Together, the principles suggest that skills training in evidence-based addiction therapies can be characterized as a client-centered approach to teaching and behavioral practice. The identified practices fell into four function themes: 1) client-centered goal-setting, 2) building client self-efficacy, 3) engaging in teaching, and 4) engaging in practice. Conclusions When the identified principles and practices are combined, they can inform a fidelity-based approach to behavioral skills training that is applicable to a wide range of alcohol or other drug (AOD) content topics, therapeutic modalities, and implementation settings. We discuss future implications regarding standardized training and fidelity assessment.

Little is known about the mechanisms through which routine outcome monitoring (ROM) influences psychotherapy outcomes. In this secondary analysis of data from a randomized clinical trial (Brattland et al., 2018), we investigated whether the working alliance mediated the effect of the Partners for Change Outcome Monitoring System (PCOMS), a ROM system that provides session-by-session feedback on clients' well-being and the alliance. Adult individuals (N = 170) referred for hospital-based outpatient mental health treatment were randomized to individual psychotherapy either with the PCOMS ROM system, or without (treatment as usual [TAU]). Treatment was provided by the same therapists (N = 20) in both conditions. A multilevel mediation model was developed to test if there was a significant indirect effect of ROM on client impairment at posttreatment through the alliance at 2 months' treatment controlled for first-session alliance. Alliance ratings increased more from session 1 to 2 months' treatment in the ROM than TAU condition, and alliance increase was associated with less posttreatment impairment. A significant indirect effect of ROM on treatment outcomes through alliance increase (p = .043) explained an estimated 23.0% of the effect of ROM on outcomes. The results were consistent with a theory of the alliance as one mechanism through which ROM works. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The alliance continues to be one of the most investigated variables related to success in psychotherapy irrespective of theoretical orientation. We define and illustrate the alliance (also conceptualized as therapeutic alliance, helping alliance, or working alliance) and then present a meta-analysis of 295 independent studies that covered more than 30,000 patients (published between 1978 and 2017) for face-to-face and Internet-based psychotherapy. The relation of the alliance and treatment outcome was investigated using a three-level meta-analysis with random-effects restricted maximum-likelihood estimators. The overall alliance-outcome association for face-to-face psychotherapy was r = .278 (95% confidence intervals [.256, .299], p < .0001; equivalent of d = .579). There was heterogeneity among the effect sizes, and 2% of the 295 effect sizes indicated negative correlations. The correlation for Internet-based psychotherapy was approximately the same (viz., r = .275, k = 23). These results confirm the robustness of the positive relation between the alliance and outcome. This relation remains consistent across assessor perspectives, alliance and outcome measures, treatment approaches, patient characteristics, and countries. The article concludes with causality considerations, research limitations, diversity considerations, and therapeutic practices. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

A fundamental part of professional practice is to monitor case progress to inform basic clinical decisions about when to discontinue interventions, when to adjust interventions, and when to proceed as planned. When interpreting observed change, there are at least five distinct types of clinical difference that can occur independently, and mistaking one for another can lead to misinformed clinical decisions. We introduce a distinction between observed difference, detected difference, predicted difference, attainment difference, and induced difference, and use these to analyze current systems for routine outcome monitoring (ROM) in clinical practice. Contrary to what supporting evidence of current ROM systems suggests, we find that-by design-these systems fail to detect and predict potentially harmful treatment and fail to detect and predict likely treatment responders. We discuss implications of the presented classification for professional practice and further development of ROM systems. We argue that clinical practice would benefit from monitoring difference instead of change, as these are not equivalent. We further argue that future research and development efforts should focus on the development of a working approach to monitoring induced difference, improving how to monitor predicted difference, exploring statistical models that better discriminate between various types of clinical cases, and better communicate what can and cannot be interpreted from the clinical differences that are actually monitored, as guided by the presented classification of clinical differences to monitor in practice. (PsycINFO Database Record

Objective Psychotherapy researchers have long questioned whether increased therapist experience is linked to improved outcomes. Despite numerous cross-sectional studies examining this question, no large-scale longitudinal study has assessed within-therapist changes in outcomes over time. Method The present study examined changes in psychotherapists' outcomes over time using a large, longitudinal, naturalistic psychotherapy data set. The sample included 6,591 patients seen in individual psychotherapy by 170 therapists who had on average 4.73 years of data in the data set (range = 0.44 to 17.93 years). Patient-level outcomes were examined using the Outcome Questionnaire-45 and a standardized metric of change (prepost d). Two-level multilevel models (patients nested within therapist) were used to examine the relationship between therapist experience and patient prepost d and early termination. Experience was examined both as chronological time and cumulative patients seen. Results Therapists achieved outcomes comparable with benchmarks from clinical trials. However, a very small but statistically significant change in outcome was detected indicating that on the whole, therapists' patient prepost d tended to diminish as experience (time or cases) increases. This small reduction remained when controlling for several patient-level, caseload-level, and therapist-level characteristics, as well as when excluding several types of outliers. Further, therapists were shown to vary significantly across time, with some therapists showing improvement despite the overall tendency for outcomes to decline. In contrast, therapists showed lower rates of early termination as experience increased. Conclusions Implications of these findings for the development of expertise in psychotherapy are explored. (PsycINFO Database Record

There is a paucity of empirical studies that demonstrate psychotherapy trainees improve at assisting their clients' therapy outcomes over time. We examined whether trainees (i.e., practicum, predoctoral interns, and postdoctoral fellows) improved in their clients' therapy outcomes over time. We examined 114 trainees (i.e., who were trainees for the first client in the database) and had over 12 months of client outcome data (M = 45.31 months). At the start of their time in our database, about half of the participants (48.2%) were predoctoral interns, 42.1% were practicum students, and 9.6% were postdoctoral fellows. Collectively, they treated 2,991 clients (M = 26 clients per trainee). Clients completed the Behavioral Health Measure, which assesses general psychological functioning (i.e., well-being, symptom distress, and life functioning), as a measure of therapy outcomes. Trainees demonstrated small-sized growth in their clients' outcomes over time (d = 0.04 per year); however, this growth was moderated by client severity. That is, trainees demonstrated growth over time in working with clients who were less distressed (d = -0.13 to 0.10 over time), but there was no change over time for trainees when working with more distressed clients (d = 0.67 to .65 over time). The results were consistent across trainee level (i.e., practicum, predoctoral intern, postdoctoral fellow), yet trainees varied in their patterns of growth. Psychotherapy training has a small, but positive, effect on trainees' ability to foster positive outcomes with their clients over time. (PsycINFO Database Record