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AIM The therapeutic alliance is a robust predictor of treatment outcome. However, little is known about the way alliance negotiation contributes to psychotherapy outcome. The aim of the present study was to analyze the effects of alliance negotiation on treatment outcome in the first four sessions of psychotherapy. METHODS Ninety-six patients diagnosed with emotional disorders received weekly Solution-Focused Brief Therapy. Each patient completed both the Alliance Negotiation Scale (ANS) and the Outcome Questionnaire 45 (OQ.45) after each of the first four sessions. Both between- and within-patients effects of alliance negotiation on symptom severity were analyzed using Hierarchical Linear Models. RESULTS Results showed significant between and within patient effects of alliance negotiation on symptom severity. Patients with higher levels of alliance negotiation across treatment showed lower levels of symptom severity (between-patient effect). Also, in a session with higher alliance negotiation compared to the average session of this patient, symptom severity was lower than in the average session (within-patient effect). DISCUSSION The results indicate that therapies characterized by higher alliance negotiation and sessions with higher alliance negotiation are beneficial for early outcome. CONCLUSION From a clinical point of view, the results suggest that alliance negotiation is a meaningful factor for therapy outcome and that therapists may benefit from training and monitoring alliance negotiation during the early stages of treatment.

El desarrollo de la psicología en Guatemala durante las últimas décadas se ha visto fortalecido por varios hitos en su historia como han sido los congresos, encuentros académicos y profesionales, colaboraciones internacionales y conferencias para nombrar algunos. Este número especial de nuestra revista da testimonio de uno de ellos. Gracias a la confianza, apoyo y mentoría de los grandes exponentes de las psicoterapias integrativas de América Latina y de la valiosa y comprometida colaboración de un comité organizador, pudo realizarse en Guatemala, de manera virtual con sólido apoyo tecnológico, el VIII Encuentro Latinoamericano de Psicoterapias Integrativas (ELAPSI). Si bien, el producto final fue de una excelente calidad académica, científica, profesional y sociocultural, también fue de inmenso valor el llegar a concretarlo. Desde el momento en que nos fue confiada la realización del mismo en el marco del VII Encuentro Latinoamericano que se llevó a cabo en Uruguay en 2018, sabíamos que estábamos abriendo brecha. Por primera vez, un ELAPSI sería realizado fuera de América del Sur, en donde históricamente se había congregado la comunidad académica y profesional de las psicoterapias integrativas. Por lo tanto, iniciar el proceso de organización implicaba no solo colocar a Guatemala en el mapa latinoamericano de la integración psicoterapéutica sino también consolidar un equipo organizador que representara las voces integrativas de las Américas particularmente de aquellos países donde hasta el momento estaban casi silenciadas. Los valores de solidaridad, apoyo, entusiasmo y compromiso se hicieron presentes para emprender una tarea que, aunque ambiciosa desde sus albores, fue apasionante.

This study explores in cognitive-behavioral therapy (CBT) for generalized anxiety disorder (GAD) to what degree therapists' perceptions of their patients as interpersonally challenging (IC) is explained by the therapist or patient effects, if baseline patients' characteristics predict IC, and if IC is related to outcome.Eighty patients diagnosed with GAD and treated by 20 therapists with 16 sessions of CBT were randomized to two different implementation conditions. Patients completed baseline measures of depression, anxiety, interpersonal problems, and interpersonal strengths. The therapists completed a single-item assessing IC session-by-session. As an outcome, patients completed a worry measure at baseline, session 5, session 10, and posttreatment.Multilevel models showed meaningful therapist effects, explaining 18% of IC variance. Interpersonal strengths were the only baseline predictor significantly and negatively associated with IC during treatment. Structural equation models showed significant negative IC effects on subsequent patient worry during therapy.IC might represent a risk factor for psychotherapy outcome. Patient interpersonal strengths at baseline may buffer therapists perceiving their patients as ICs. The therapist effects on IC suggest that CBT clinicians treating GAD might benefit from identifying cases that are interpersonally challenging for them and reflecting about what might trigger that perception.

BACKGROUND There has been an increased interest in understanding social anxiety (SA) and social anxiety disorder (SAD) antecedents and consequences as they occur in real-time, resulting in a proliferation of studies utilizing ambulatory assessment (AA). Despite the exponential growth of research in this area, these studies have not been synthesized yet. OBJECTIVE To identify and describe the latest advances in the understanding of social anxiety by means of the use of ambulatory assessment METHODS Following PRISMA guidelines a Scopus, Pubmed and Web of Science systematic literature search was conducted. RESULTS 55 articles met the inclusion criteria. The qualitative synthesis of these studies showed that AA permitted the exploration of the emotional, cognitive and behavioral dynamics associated with the experience of SA and SAD. In line with the available models of SA and SAD, emotion regulation, perseverative cognition, cognitive factors, substance use and interactional patterns were the principal topics among the included studies. Besides, the incorporation of AA to study psychological interventions, the multimodal assessment through the use of sensors and biosensors and transcultural differences were some of the identified emerging topics. CONCLUSIONS AA constitutes a very powerful methodology to grasp SA from a complementary perspective to laboratory experiments and usual self-report measures, shedding light upon the cognitive, emotional and behavioral antecedents and consequences of SA and the development and maintenance of the experience of SA as a mental disorder.

Background Exposure-based treatments have demonstrated some of the largest effect sizes in the treatment of specific phobias (SP). There are different ways of delivering exposure such as Augmented Reality Exposure which has become an interesting alternative to In Vivo Exposure for treating SP. The present study aimed to investigate the therapeutic alliance and treatment expectations as possible predictors of treatment outcomes in these two exposure treatment conditions. Methods Participants were 63 adults who met diagnostic criteria for the diagnosis of a SP of cockroaches or spiders (animal subtype). Patients were randomized to receive a one-session treatment of either In Vivo Exposure (N = 31) or Augmented Reality Exposure (N = 32). The assessment protocol included diagnostic, as well as primary-, and secondary outcome measures. Materials included the Behavioral Avoidance Test for measuring symptoms and outcomes, the Expectations and Satisfaction Questionnaire, and the Working Alliance Inventory. We ran multilevel analyses for the study of predictors controlling for the treatment effect conditions. Results Results showed a significant effect of expectations on treatment outcomes (specifically avoidance and beliefs scores). The therapeutic alliance did not have a significant effect on treatment outcome. Patients reduced their symptoms of phobia. Conclusion These results empirically support treatment expectations as a relevant predictor of change in exposure treatments for SP.

Objective We aimed to develop and test an algorithm for individual patient predictions of problem coping experiences (PCE) (i.e., patients' understanding and ability to deal with their problems) effects in cognitive-behavioral therapy. Method: In an outpatient sample with a variety of diagnoses (n=1010), we conducted Dynamic Structural Equation Modelling to estimate within-patient cross-lagged PCE effects on outcome during the first ten sessions. In a randomly selected training sample (2/3 of the cases), we tried different machine learning algorithms (i.e., ridge regression, LASSO, elastic net, and random forest) to predict PCE effects (i.e., the degree to which PCE was a time-lagged predictor of symptoms), using baseline demographic, diagnostic, and clinically-relevant patient features. Then, we validated the best algorithm on a test sample (1/3 of the cases). Results The random forest algorithm performed best, explaining 14.7% of PCE effects variance in the training set. The results remained stable in the test set, explaining 15.4% of PCE effects variance. Conclusions The results show the suitability to perform individual predictions of process effects, based on patients' initial information. If the results are replicated, the algorithm might have the potential to be implemented in clinical practice by integrating it into monitoring and therapist feedback systems.

Background Although a wide body of research links depression to interpersonal deficits, Cognitive-Behavioral Therapy (CBT), considered the gold standard in the treatment of this condition, has not been developed to specifically address interpersonal difficulties. However, cognitive changes on a relational level occurring during CBT might play an important role in the treatment of depression. Interpersonal clarification refers to the process of better understanding the nature of one's interpersonal patterns during therapy. The aim of this study is to analyze the effects of interpersonal clarification in CBT and how they are moderated by the therapeutic alliance. Methods A sample of 621 patients diagnosed with depression were treated with CBT by 126 therapists in a university outpatient clinic. Patients completed measures of interpersonal problems and depression severity at baseline, measures of symptomatic evolution before each session and process measures (assessing interpersonal clarification and alliance) after each session. Multilevel models separating between-patient (BP) and within-patient (WP) effects of interpersonal clarification, and including BP and WP alliance effects as covariates and moderators of the interpersonal clarification effects were conducted. Results Analyses showed both significant BP and WP effects interpersonal clarification, even when adjusting for alliance effects. Furthermore, significant interactive effects were found between outcome of WP interpersonal clarification with both BP alliance and WP alliance. Limitations Interpersonal clarification was measured with one single-item and adherence to CBT was not explicitly measured. Conclusions The results present preliminary evidence for considering interpersonal clarification a meaningful change process in CBT for depression, especially in the context of a stronger therapeutic alliance.

Despite that pediatric COVID-19 is usually asymptomatic or mild, SARS-CoV-2 infection typically results in the development of an antibody response. Contradictory observations have been reported when the antibody response of children and adults were compared in terms of strength, specificity and perdurability.This observational study includes three cohorts infected with SARS-CoV-2 between March 2020-July 2021: unvaccinated infected children (n=115), unvaccinated infected adults (n=62), and vaccinated infected children (n=76). Plasma anti-spike IgG antibodies and neutralising activity against Wuhan, Delta and Omicron variants after 7-17 months post-infection were analysed.More than 95% of unvaccinated infected children and adults remained seropositive when evaluated at 382-491 and 386-420 days after infection, respectively. Anti-spike IgG titers and plasma neutralising activity against Wuhan, Delta and Omicron variants were higher in children compared to adults. No differences were found when unvaccinated infected children were stratified by age, gender or presence/absence of symptoms in the acute phase of SARS-CoV-2 infection, but a slight decrease in the antibody response was observed in those with comorbidities. Vaccination of previously infected children with two doses of the inactivated BBIBP-CorV or the mRNA vaccines, BNT162b2 and/or mRNA-1273, further increased anti-spike IgG titers and neutralising activity against Wuhan, Delta and Omicron variants.Unvaccinated infected children mount a more potent and sustained antibody response compared with adults, which is significantly increased after vaccination. Further studies including not only the analysis of the immune response but also the effectiveness to prevent reinfections by the different Omicron lineages are required to optimise vaccination strategy in children.National Agency for Scientific and Technological Promotion from Argentina (PICTO-COVID-SECUELAS-00007 and PMO-BID-PICT2018-2548).

Objective This study aimed to identify differential patient change processes and mechanisms associated with long-term outcome in exposure-based cognitive therapy (EBCT) and cognitive-behavioral therapy (CBT) for depression. Method We drew on a randomized controlled trial in which 149 patients were randomly assigned to either EBCT or CBT, with the treatments showing comparable efficacy at 12-month follow-up (grosse Holtforth et al., 2019). Based on Doss's (2004) 4-step model of psychotherapy change and using sequential multilevel structural equation models, we tested putative theory-based change processes and mechanisms for both treatments. Specifically, we examined emotional processing and cognitive restructuring during treatment as hypothesized change processes of EBCT and CBT, respectively. Furthermore, as potential change mechanisms during follow-up, we examined theory-relevant mechanisms for each treatment, preselected via multilevel models. Results Although the full serial mediational pathways were not supported, EBCT fostered greater during-treatment increases in emotional processing and higher self-efficacy during follow-up than CBT, both of which associated with better long-term depression outcome. Unexpectedly, cognitive restructuring change did not differ between EBCT and CBT. Across both CBT and EBCT, greater during-treatment increases in cognitive restructuring related to lower cognitive-behavioral avoidance and greater self-efficacy across follow-up, which associated with lower long-term depression. Conclusions Results suggest that therapists might improve long-term depression outcome by fostering both emotional processing (via emotion-focused techniques as included in EBCT) and cognitive restructuring (by using general CBT techniques included in both treatments), which operate either directly or through varied treatment-common mechanisms (e.g., greater self-efficacy and reduced cognitive-behavioral avoidance). (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Leonard Bickman’s (2020) Festschrift paper in the special issue “The Future of Children’s Mental Health Services” on improving mental health services is an impressive reflection of his career, highlighting his major insights and the development of mental health services research as a whole. Five major difficulties in this field’s current research and practice are attentively delineated: poor diagnostics, measurement problems, disadvantages of randomized controlled trials (RCTs), lack of feedback and personalized treatments. Dr. Bickman recommends possible solutions based on his extensive experience and empirical findings. We agree with his thoughts and illustrate how we, challenged with the same problems, have attempted to develop clinically informed research and evidence-based clinical practice. A comprehensive feedback system that deals with the aforementioned problems is briefly described. It includes pre-treatment recommendations for treatment strategies and an empirically informed dropout prediction based on a variety of data sources. In addition to treatment recommendations, continuous feedback as well as individualized treatment adaptation tools are provided during ongoing therapy. New projects are being implemented to further improve the system by including new data assessment strategies and sources, e.g., ecological momentary assessment (EMA) and automated video analysis.

Objective Several studies have reported significant within-patient effects of the therapeutic alliance on outcome. However, it remains uncertain whether there are specific patient groups for whom an improved alliance might be particularly beneficial. The relational nature of the alliance makes patients' interpersonal problems a promising candidate for examining such differential effects. This study aims to analyze (i) between- and within-patient effects of the alliance on depression severity, (ii) the effects of patients' baseline interpersonal problems on the within-patient alliance-outcome association, and (iii) whether within-patient effects of the alliance remain significant when adjusting for patients' initial interpersonal problems. Method A sample of 141 patients with depression and undergoing outpatient psychotherapy completed the Inventory of Interpersonal Problems at baseline as well as a brief version of the Working Alliance Inventory and the Well-Being Index (as a proxy of depression severity) session by session. Results Multilevel models revealed both significant between- and within-patient effects of the alliance on improvements in depression severity. Patients' problems relating to agency had a significant effect on the within-patient effect of alliance, with more submissive patients benefiting more from an improved therapeutic alliance. Finally, the between- and within-patient effects of the alliance remained significant when adjusting for the patients' agentic interpersonal problems and treatment condition. Conclusions The results provide evidence on which types of patients would particularly benefit from an improved therapeutic alliance. For patients suffering from low interpersonal agency and reporting problems with submissiveness, an enhanced alliance during the therapy process might improve treatment outcome. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

IntroductionRoutine Outcome Monitoring (ROM) has emerged as a strong candidate to improve psychotherapy processes and outcome. However, its use and implementation are greatly understudied in Latin-America. Therefore, the aim of the present pilot study conducted in Argentina was to implement a ROM and feedback system grounded on a psychometrically sound instrument to measure session by session outcome in psychotherapy.MethodsThe sample consisted of 40 patients and 13 therapists. At baseline, the patients completed the Patient Health Questionnaire-9 and the Generalized Anxiety Disorder-7, and they also completed the Hopkins Symptom Checklist-11 before each of the first five sessions. To estimate patient change during the first sessions, we conducted a quantitative analysis using Hierarchical Linear Models. Furthermore, we conducted a qualitative analysis using Consensual Qualitative Research to analyze therapist perception regarding the ROM and feedback system.ResultsResults showed a significant reduction in patients’ symptomatic severity during the first five sessions. Additionally, baseline depression significantly predicted the estimated severity at the end of the fifth session. Feedback was given to the therapists after the first four sessions based on these analyses. With regard to the perception of the feedback system, clinicians underlined its usefulness and user-friendly nature. They also mentioned that there was a match between the information provided and their clinical judgment. Furthermore, they provided suggestions to enhance the system that was incorporated in a new and improved version.DiscussionLimitations and clinical implications are discussed.

This study aimed to investigate the effects of changes in interpersonal cognitions on outcome during cognitive behavioral therapy (CBT) for generalized anxiety disorder (GAD) and how these effects are moderated by patients' interpersonal problems at intake.A sample of 80 adult patients diagnosed with GAD who were undergoing CBT within a randomized controlled trial completed a questionnaire concerning interpersonal problems at baseline as well as measures of changes in interpersonal and self-related cognitions and in worry severity session by session. We conducted dynamic structural equation modeling to estimate cross-lagged within-patient effects of changes in interpersonal cognitions on worry, adjusting for the effects of self-related cognitions. Furthermore, we included interpersonal problems as a moderator of the effects of changes in interpersonal cognitions.We found significant cross-lagged effects of changes in both interpersonal cognitions and self-related cognitions on subsequent worry levels. Greater changes in interpersonal cognitions and self-related cognitions in a given session were associated with lower worry levels at the beginning of the next session. When adjusting for self-related cognitions, the effects of changes in interpersonal cognitions on subsequent worry remained significant. However, there were no interactive effects of changes in interpersonal cognitions by patients' interpersonal problems on worry severity.The results present evidence supporting changes in interpersonal cognitions and self-related cognitions as relevant change mechanisms in CBT for GAD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The present study investigates the effects of negative mood regulation expectancies (NMRE) on symptom severity of depression in 2 cognitive therapies for depression. The sample included the first 146 consecutively recruited patients from a randomized controlled trial. Patients received 22 sessions of either cognitive-behavioral therapy or exposure-based cognitive therapy. They completed the Beck Depression Inventory and Negative Mood Regulation Scale at baseline and treatment termination, as well as after Sessions 7 and 14. Multilevel modeling was applied. We found a significant between-patient effect of NMRE on symptom severity of depression, when NMRE within-patient effects were set to random. There was no significant interactive effect of the between-patient NMRE with type of treatment. However, a significant moderation effect of the within-patient NMRE effect by treatment condition on depression severity was detected, with patients receiving cognitive-behavioral therapy benefiting more from improvements in NMRE. Together, these results empirically support NMRE as a relevant mechanism of change in cognitive therapy for depression. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The present study consists of the adaptation and validation of the Difficulties in Emotion Regulation Scale (DERS; Gratz and Roemer, 2004) for its use in the general population of the Buenos Aires metropolitan area. A cross-sectional study was conducted with 315 subjects between 18 and 65 years old. The scale consists of 30 items which, after a confirmatory factor analysis, were found to fit the six original dimensions. Internal consistency was adequate (α = .936; ω = .938). There is also evidence of convergent and discriminant validity, items discrimination ability, differences by sex and age, and normative values for adults in the AMBA. The Spanish adaptation of the DERS represents a valid and reliable tool to measure different aspects of the emotional regulation process.

OBJECTIVES: This study aimed to analyze the associations among depressive/anxiety and pain symptoms in patients diagnosed with chronic pain. METHODS: Four hundred and fifty-four inpatients who were consecutively admitted in a multimodal 3-weeks treatment in a tertiary psychosomatic university clinic completed 25 items from the Brief Pain Inventory and the Hospital Anxiety and Depression Scale at baseline and after treatment termination. Associations among symptoms were explored by network analyses using the graphical least absolute shrinkage and selection operator to estimate their partial correlations, while Extended Bayesian Information Criterion was used to select the best network solution for the data. We explored symptoms' centrality and expected influence within the network as well as the minimum spanning tree for the network. RESULTS: Besides expected associations within depressive/anxiety and pain symptoms, the estimated network showed several local associations between depressive and pain interference symptoms. The lacks of being cheerful and of laughing are two of the depressive symptoms that showed the greatest associations with pain interference and a strong centrality within the network. Sleep problems were both associated with anxiety/depressive symptoms and pain intensity symptoms. Although at post-treatment, most of the symptoms showed a significant decrease, the strength of the associations between the symptoms within the network were significantly higher than at baseline. DISCUSSION: The results support focusing psychosocial interventions in chronic pain treatment not only on reducing pain, anxiety and sleep symptoms but also on enhancing positive affect. Future research is needed to replicate these findings using repeated within-person measures designs.

There is a great need to identify predictors of treatment response, and the analysis of defense mechanisms is a promising approach. Defensive functioning may influence psychotherapy outcome in two ways: First, when it is generally higher or lower for some patients relative to others and second, as it shifts in individual patients over time. The present study examined both within- and between patient effects of defenses using hierarchical linear modeling. Forty-seven patients diagnosed with depression, anxiety, or adjustment disorders received 25 ± 3 sessions of integrative cognitive-behavioral therapy in a university outpatient clinic. The Defense Mechanism Rating Scale (DMRS) was used to assess defenses in the 1st, 8th, 16th, and 24th session and relate them to symptom severity of depression and anxiety. A higher number of adaptive defense mechanisms was associated with less severe depressive symptoms during treatment while a higher number of immature defenses was related to more severe depressive and anxiety symptoms. An increase in adaptive and a decrease in immature defenses over the course of treatment predicted symptom reduction of depression whereas a decrease in neurotic and immature defenses was associated with reductions in anxiety symptoms. Our results empirically support defensive functioning as a mechanism of change in psychotherapy.

Objetivos: Este artículo tiene por objetivo presentar la Escala de Intervenciones Comunes (EIC), un instrumento orientado a explorar el uso de intervenciones psicoterapéuticas utilizadas por terapeutas de distintos marcos teóricos y analizar, a su vez, sus propiedades psicométricas. Metodología: Se convocó una primera muestra no probabilística de 101 terapeutas psicoanalíticos y cognitivo-conductuales que completaron una versión online de la escala basándose en la última sesión con un paciente adulto. Sobre la base de estos datos se realizaron análisis preliminares de confiabilidad y un análisis factorial exploratorio. Posteriormente, para validar la estructura factorial del instrumento, se realizó un análisis factorial confirmatorio, a partir de los datos de una nueva muestra de 213 terapeutas identificados con diversos marcos teóricos que completaron la escala. Resultados: El análisis factorial exploratorio sugirió una primera solución de tres factores; como uno de ellos no contaba con el mínimo de ítems requerido por factor se excluyeron dichos ítems y se generó un nuevo análisis factorial que dio lugar a una solución de dos factores, que explicaron el 71,1% de la varianza total. Los coeficientes α ordinales presentaron niveles adecuados de confiabilidad en ambos factores. El análisis factorial confirmatorio, mostró que todas las cargas estandarizadas estimadas de los nueve ítems, presentaron parámetros significativos (p

OBJECTIVE This study analyses the psychometric properties of the Working Alliance Inventory adapted for guided Internet interventions (WAI-I). METHODS We drew on the data set from a multicenter trial that examined a guided Internet intervention (deprexis) for patients with mild to moderate depression. Two hundred twenty-three patients completed the WAI-I and the Patient Satisfaction Questionnaire (ZUF-8) at posttreatment, and the Attitudes toward Psychological Online-Interventions Questionnaire (APOI) at baseline. We ran confirmatory factor analyses (CFA) testing two- and three-factor solutions and calculated Cronbach's α, item-total correlations, and correlations of the WAI-I with APOI and ZUF-8. RESULTS The results suggested a two-factor solution, with a very good model fit and evidence of factor independency, adequate internal consistency, and external validity for the complete scale and the sub-scales. CONCLUSIONS The WAI-I showed as a reliable and valid instrument to capture alliance in guided Internet interventions, which might facilitate process-outcome research and treatment development efforts.

Background Entrapment describes a feeling of being stuck in an inescapable aversive situation. This feeling often arises in the context of uncontrollable and/or chronic stress and is associated with various psychopathologies. Objective Owing to the nature of their disease, also chronic pain, patients might experience their situation as unremitting and inescapable. The aim of the present study was to examine the role of entrapment in patients with a chronic pain disorder and the association of entrapment with treatment outcome. Methods A total of 189 patients with a chronic pain disorder where psychological factors play a decisive role in its severity, exacerbation, and maintenance (International Classification of Diseases, ICD-10: F45.41, “Chronic pain disorder with somatic and psychologic factors”) receiving inpatient care completed a set of standardized self-report questionnaires at intake and discharge of an interdisciplinary pain treatment. To analyze the effects of entrapment on pain-related interference and psychologic distress, hierarchical linear models were used. Results Over treatment, reduced levels of entrapment were observed, which were associated with decreases in psychologic distress and pain-related interference at discharge. Conclusion Results support the relevance of entrapment in chronic pain and its treatment. To further improve interdisciplinary pain treatments, entrapment should be assessed and targeted by according interventions.

In psychotherapy research, the measurement of treatment processes and outcome are predominantly based on self-reports. However, given new technological developments, other potential sources can be considered to improve measurements. In a feasibility study, we examined whether Ecological Momentary Assessments (EMA) using digital phenotyping (stress level) can be a valuable tool to investigate change processes during cognitive behavioral therapy (CBT). Seven outpatients undergoing psychological treatment were assessed using EMA. Continuous stress levels (heart rate variability) were assessed via fitness trackers (Garmin) every 3 min over a 2-week time period (6,720 measurements per patient). Time-varying change point autoregressive (TVCP-AR) models were employed to detect both gradual and abrupt changes in stress levels. Results for seven case examples indicate differential patterns of change processes in stress. More precisely, inertia of stress level changed gradually over time in one of the participants, whereas the other participants showed both gradual and abrupt changes. This feasibility study demonstrates that intensive longitudinal assessments enriched by digitally assessed stress levels have the potential to investigate intra- and interindividual differences in treatment change processes and their relations to treatment outcome. Further, implementation issues and implications for future research and developments using digital phenotyping are discussed.

This chapter aims to analyze which ethical challenges clinicians face when practicing different forms of psychotherapy integration. With this purpose, the authors first define psychotherapy integration and differentiate four types of integrative approaches. Drawing on Beauchamp and Childress’s (2013) principles of biomedical ethics, the chapter highlights important common and particular ethical issues in the four types of integrationist psychotherapy practice. Finally, the authors frame questions for future research into integrative-psychotherapy ethics and consider possible clinical responses to ethics issues raised in integrative therapy.

Specific psychological treatments for depressive disorders delivered on the Internet have shown effectiveness and presented advantages over face-to-face treatments (potentially less expensive, flexible schedules, available in remote areas). This paper aims to describe the characteristics of those who sought help from an online self-guided intervention for depression and to explore hypotheses about predictors of enrollment to the program. Based on a sample of 282 of individuals who filled in screening questionnaires, we verified that the respondents were mainly female, were on average 34.36 years old, were primarily recruited through Facebook, had been previously diagnosed by mental health professionals, presented moderate self-efficacy perception, and had moderately severe symptoms of depression. Respondents who reported comorbid conditions were more likely to attend enrollment interviews, and being in treatment or not did not influence attendance. Such characterization may provide strategies to reach more people and to optimize the design of interventions targeting help-seeking depressed individuals in Brazil., Alguns tratamentos para a depressão baseados na Internet se mostraram efetivos e apresentaram vantagens em relação a tratamentos presenciais (potencialmente menos caros, com horários mais flexíveis e com disponibilidade em áreas remotas). Este artigo descreve as características de indivíduos que procuraram ajuda de uma intervenção autoguiada on-line e explora hipóteses sobre preditores de adesão ao programa. Baseado em uma amostra de 282 indivíduos que preencheram questionários de triagem, verificou-se que os participantes eram majoritariamente mulheres, tinham em média 34,36 anos, foram recrutados em sua maioria pelo Facebook, apresentaram diagnóstico psiquiátrico prévio feito por algum profissional de saúde mental, apresentaram percepção de autoeficácia moderada e sintomas depressivos moderadamente severos. Os respondentes que relataram condições comórbidas apresentaram mais chances de avançar para as entrevistas diagnósticas, e estar ou não em tratamento não influenciou a chegada às entrevistas. Estas descrições podem auxiliar na identificação de estratégias para se atingir mais indivíduos e para otimizar o desenho das intervenções on-line para brasileiros que as buscam.

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.

This study analyzed patient-therapist in-session interpersonal complementarity effects on the therapeutic alliance and depression severity during the initial and working phase of cognitive-behavioral therapy for depression. It also explored whether patients' interpersonal problems moderate those complementarity effects. We drew on a sample of 90 dyads derived from a randomized controlled trial of two cognitive-behavioral therapies for depression. Using an observer-based measure, we assessed patients' and therapists' interpersonal behavior in Sessions 1, 5, 9, and 13 and computed their complementarity regarding interpersonal affiliation (i.e., correspondence) and dominance (i.e., reciprocity). Patients completed measures of interpersonal problems at baseline and session-by-session measures of depression severity and quality of the therapeutic alliance. Response surface analyses based on polynomial regressions showed that patient-therapist complementarity in higher affiliative behaviors was associated with a stronger alliance. Interpersonal problems regarding agency moderated the complementarity effects of the dominance dimensions on depression severity. Overly dominant patients benefited more from a nonreciprocal relationship in the dominance dimension, whereas submissive patients benefited more from complementarity in that dimension. Furthermore, interpersonal problems of communion significantly moderated the effects of complementarity in affiliative behaviors on both the alliance and outcome. These results suggest the relevance of both interpersonal correspondence and reciprocity for the psychotherapy process, informing clinical practice in terms of interpersonal responsiveness. The moderation effects of interpersonal problems provide preliminary evidence, which should be replicated in future research, to determine relevant markers indicating for whom a complementary approach would be beneficial in cognitive therapy for depression. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Background Therapeutic alliance has been well established as a robust predictor of face-to-face psychotherapy outcomes. Although initial evidence positioned alliance as a relevant predictor of internet intervention success, some conceptual and methodological concerns were raised regarding the methods and instruments used to measure the alliance in internet interventions and its association with outcomes. Objective The aim of this study was to explore the alliance-outcome association in a guided internet intervention using a measure of alliance especially developed for and adapted to guided internet interventions, showing evidence of good psychometric properties. Methods A sample of 223 adult participants with moderate depression received an internet intervention (ie, Deprexis) and email support. They completed the Working Alliance Inventory for Guided Internet Intervention (WAI-I) and a measure of treatment satisfaction at treatment termination and measures of depression severity and well-being at termination and 3- and 9-month follow-ups. For data analysis, we used two-level hierarchical linear modeling that included two subscales of the WAI-I (ie, tasks and goals agreement with the program and bond with the supporting therapist) as predictors of the estimated values of the outcome variables at the end of follow-up and their rate of change during the follow-up period. The same models were also used controlling for the effect of patient satisfaction with treatment. Results We found significant effects of the tasks and goals subscale of the WAI-I on the estimated values of residual depressive symptoms (γ02=−1.74, standard error [SE]=0.40, 95% CI −2.52 to −0.96, t206=−4.37, P Conclusions The results of this study point out the importance of attuning internet interventions to patients’ expectations and preferences in order to enhance their agreement with the tasks and goals of the treatment. Thus, the results support the notion that responsiveness to a patient’s individual needs is crucial also in internet interventions. Nevertheless, these findings need to be replicated to establish if they can be generalized to different diagnostic groups, internet interventions, and supporting formats.

La brecha entre investigación y práctica clínica constituye uno de los rasgos distintivos de la psicoterapia. Esta brecha se ha conceptualizado históricamente como un problema de diseminación unidireccional. Sin embargo, existen razones consistentes para considerar que la desarticulación entre ciencia y práctica también responde al modo en que se ha venido produciendo el conocimiento científico en el campo. En el presente artículo se desarrollan algunos de los principales aspectos que, hasta la fecha, han obstaculizado la construcción de una ciencia integrada de la psicoterapia y la implementación de la mejor investigación disponible en los entornos clínicos naturales. En particular, se presenta el paradigma de la Investigación Orientada por la Práctica (IOP) como una aproximación que aporta propuestas específicas para articular la brecha entre investigación y práctica con el doble propósito de mejorar tanto la calidad de los proyectos de investigación que se realizan como la práctica clínica habitual The gap between research and clinical practice constitutes one of the distinctive features of psychotherapy. This gap has historically been conceptualized as a problem of unidirectional dissemination. However, there are compelling reasons to consider that the disarticulation between science and practice also responds to the way in which scientific knowledge has been produced. This article describes some of the main aspects that, to date, have hindered the development of an integrated science of psychotherapy and its implementation in naturalistic clinical settings. The paradigm of practice-oriented research (POR) is presented as an approach that provides specific proposals to bridge the gap between research and practice with the dual purpose of improving the quality of both research projects that are carried out and routine clinical practice.

Background Previous research has shown an association between burnout and low emotional competence (EC), defined as the ability to adequately regulate the intensity and expression of emotions. EC might also play a maintaining role in depression. The current paper aimed at studying the effect of improved EC on the course of burnout and depression. Methods 113 psychiatric inpatients completed a set of standardized self-report questionnaires at intake, discharge and three months after treatment, assessing EC, burnout, and depression. Multi-level analyses investigated the effect of improved EC on burnout and depression. Results Improved EC including a better emotion regulation during treatment predicted favourable treatment outcomes regarding burnout and depression symptoms. Limitations The present results should be considered in light of some methodological limitations. Most importantly, the patient sample consists of patients of one inpatient ward and is therefore not representative of all burnout patients. Conclusions This study supports EC as a putative mechanism of change in the multimodal treatment of inpatients with a stress-related depressive disorder and burnout. Clinical and research consequences of the findings will be discussed.

Background and objectives This paper examines the discrepancy between implicit and explicit negative self-associations (NSA) after cognitive psychotherapy for depression as a predictor of long-term outcome. Methods One hundred and twenty patients completed an Implicit-Association Test relating the self with depressive attributes and a self-report questionnaire with identical item content, at the end of time-limited outpatient depression psychotherapy. At post-treatment and at 3-, 6-, and 12-month follow-up, patients completed the BDI-II. We used different strategies to operationalized implicit and explicit NSA discrepancies and three-level Hierarchical linear models to analyze the effects. Results We found significant interactive effects of discrepancy between implicit and explicit NSA and the direction of the discrepancy on long-term outcome. In patients with a greater explicit than implicit NSA (a damaged self-esteem pattern) a greater absolute discrepancy was associated with worse long-term outcome in terms of BDI scores at the end of follow-up and rate of change during follow-up. Consistently, with an alternative method, we found that damaged self-esteem discrepancies were associated with worse estimated BDI-II scores at the end of follow-up. Limitations The inclusion in the sample of only treatment completers limits the generalizability of the results. Furthermore, the follow-up period captured only the first 12 months after treatment. Conclusions Our results support the notion that a discrepancy between implicit and explicit negative self-associations may pose a risk factor for deterioration after psychotherapy for depression.

Background: Emotions and their regulation are a phenomenon present in everyday life. Despite its relevance and growing interest, a consensual and univocal definition has not yet been reached. Objective: This paper aims to review contemporary theoretical models of emotion regulation, looking for agreements and divergences between authors. It seeks to identify the main processes considered when working with emotional dysregulation. Method: Our team conducted a systematic review in the form of a narrative synthesis following the guidelines of the PRISMA statement. The database used were SCOPUS, PUBMED, and Dialnet. We included articles published between 2018 and 2020, which have been peer-reviewed in indexed scientific journals, whose central theme was the theoretical presentation of the construct of emotional regulation. We excluded articles that conceptualized only one dimension of the construct focused on specific populations and empirical studies without a theoretical conceptualization of the construct. The information was systematized in a table identifying authors' information, country of institutional affiliation, main characteristics of the given definition of emotion regulation, regulation skills mentioned, and underlying theoretical frameworks. Results: We identified ten different theoretical frameworks that propose models of emotion regulation. The main components found in the definition were the complexity of the construct, goal orientation, intra- or interpersonal regulation, the proposal of moderators, and its voluntary character. Discussion: There is a consensus on the use of emotion regulation strategies to adapt to environmental demands, achieve goals and increase well-being. We identify that people's learning history is an important factor in the development of emotional regulation skills. In addition, context and personality traits are proposed as moderators of the therapeutic efficacy of interventions focused on emotional regulation. Further studies along these lines would favor the implementation of preventive interventions and the personalization of treatments. RESUMEN Antecedentes: Las emociones y su regulación son un fenómeno presente en la vida cotidiana. A pesar de su relevancia y creciente interés, aún no se ha alcanzado una definición consensuada y unívoca. Objetivo: El presente trabajo pretende revisar los modelos teóricos de regulación emocional contemporáneos buscando acuerdos y divergencias entre autores. Se busca identificar los principales procesos tomados en cuenta para el trabajo con la desregulación emocional. Método: Nuestro equipo realizó una revisión sistemática en forma de síntesis narrativa siguiendo las directrices de PRISMA. Las bases de datos utilizadas fueron SCOPUS, PUBMED y Dialnet. Se incluyeron artículos publicados entre 2018 y 2020, que han sido revisados por pares en revistas científicas indexadas, cuyo tema central fuera la presentación teórica del constructo de regulación emocional. Se excluyeron artículos que conceptualizaban una sola dimensión del constructo, se enfocaban en poblaciones específicas y estudios empíricos sin una conceptualización teórica del constructo. La información fue sistematizada en una tabla identificando información de los autores, país de afiliación institucional, características principales de la definición dada de regulación emocional, habilidades de regulación mencionadas y marco teórico de base. Resultados: Se identificaron diez marcos teóricos diferentes que proponen modelos de regulación de las emociones. Los principales componentes encontrados en las definiciones fueron la complejidad del constructo, la orientación a metas, la regulación intra o interpersonal, la propuesta de moderadores y su carácter voluntario. Discusión: Existe un consenso sobre el uso de estrategias de regulación de las emociones para adaptarse a las demandas del entorno, alcanzar metas y aumentar el bienestar. Identificamos que la historia de aprendizaje de las personas es un factor importante en el desarrollo de las habilidades de regulación emocional. Además, el contexto y los rasgos de personalidad son propuestos como moderadores de la eficacia terapéutica de las intervenciones centradas en la regulación emocional. Más estudios en esta línea favorecerían la implementación de intervenciones preventivas y la personalización de los tratamientos.

Con el objetivo de estudiar los procesos de rupturas en la alianza terapéutica y su vínculo con los cambios terapéuticos y abandonos tempranos en psicoterapia. Se analizaron quince pacientes de psicoterapia diagnosticados con trastornos emocionales y divididos en tres grupos, cada uno con cinco participantes: pacientes que abandonaron, que presentaron mejorías clínicas y que no presentaron mejorías. Las primeras cuatro sesiones de los participantes fueron analizadas por cuatro jueces usando el Sistema de Ranqueo y Resolución de Rupturas-Argentina mediante un método consensual. Posteriormente se analizaron patrones diferenciales de rupturas y resoluciones en los grupos. Se observó un promedio de 1,18 (DE= 1,74) rupturas por sesión, encontrando una proporción equitativa de rupturas de retirada (54,72%) y confrontación (45,28%). El grupo de los pacientes que mejoraron presentó mayor tasa de rupturas resueltas (ratio= 0,50) que el grupo de pacientes sin cambio (ratio= 0,30). No se observaron diferencias entre las rupturas del grupo de abandono y los otros dos grupos. Los resultados sugieren que las rupturas en la alianza no implican una amenaza en sí mismo a los tratamientos (en términos de proceso temprano y de abandonos). Sin embargo, la resolución de dichas rupturas podría favorecer mejores respuestas tempranas.

Background Most children and youth develop mild or asymptomatic disease during severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. However, a very small number of patients suffer severe Coronavirus induced disease 2019 (COVID-19). The reasons underlying these different outcomes remain unknown. Methods We analyzed three different cohorts: children with acute infection (n=550), convalescent children (n=138), and MIS-C (multisystem inflammatory syndrome in children, n=42). IgG and IgM antibodies to the spike protein of SARS-CoV-2, serum-neutralizing activity, plasma cytokine levels, and the frequency of circulating Follicular T helper cells (cTfh) and plasmablasts were analyzed by conventional methods. Findings Fifty-eight percent of the children in the acute phase of infection had no detectable antibodies at the time of sampling while a seronegative status was found in 25% and 12% of convalescent and MIS-C children, respectively. When children in the acute phase of the infection were stratified according disease severity, we found that contrasting with the response of children with asymptomatic, mild and moderate disease, children with severe COVID-19 did not develop any detectable response. A defective antibody response was also observed in the convalescent cohort for children with severe disease at the time of admission. This poor antibody response was associated to both, a low frequency of cTfh and a high plasma concentration of inflammatory cytokines. Interpretation A weak and delayed kinetic of antibody response to SARS-CoV-2 together with a systemic pro-inflammatory profile characterize pediatric severe COVID-19. Because comorbidities are highly prevalent in children with severe COVID-19, further studies are needed to clarify their contribution in the weak antibody response observed in severe disease. Funding National Agency for Scientific and Technological Promotion from Argentina (IP-COVID-19-0277 and PMO-BID-PICT2018-2548).

The article “Working Towards the Development and Implementation of Precision Mental Healthcare: An Example” written by “Wolfgang Lutz, Brian Schwartz, Juan Martin Gomez Penedo, Kaitlyn Boyle, Anne‑Katharina Deisenhofer”, was originally published Online First without Open Access. After publication in volume 47, issue 5, pages 856–861 the author decided to opt for Open Choice and to make the article an Open Access publication. Therefore, the copyright of the article has been changed to © The Authors 2021 and the article is forthwith distributed under the terms of the Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit https://creativecommons.org/licenses/by/4.0.

We comment on McWilliams's (2016) article, "Integrative Research for Integrative Practice: A Plea for Respectful Collaboration Across Clinician and Researcher Roles." Above all, we appreciate McWilliams's well-toned plea for considerate collaboration between researchers and clinicians. We also appreciate that obstacles have long made it difficult to meaningfully reduce the scientist-practitioner chasm, and McWilliams shrewdly highlights how some obstacles are becoming even more daunting to traverse. In general, we agreed with most of McWilliams's points. We also provide some respectful challenges or at least extensions or reframes. For example, to us, the researcher-practitioner divide is more than just an urgent conversation problem; rather, it has potential to do harm to patients. Also, although we too appreciate relational factors in the psychotherapy evidence base, it seems important to refrain from contributing to the artificial relational-specific factor dichotomy. We present a resolution of this divide, which we call content-responsive psychotherapy integration (Constantino, Boswell, Bernecker, & Castonguay, 2013). We also offer possible versions of efficient and immediately translational trainings, arguing against continued self- or peernominated experts passing down wisdom in long-form in-services. Similarly, while we champion hearing from "reputable" clinicians about important research topics, we believe that the determination of reputable needs to be based on clinicians' personal outcomes data. We also argue that it is important to move beyond the 4 established integration pathways by pushing for disruptive integrative innovations. Ultimately, our goal is to help locate the common playing field for researchers and clinicians and the most efficient ways to play together on it. Fil: Constantino, Michael J.. University Of Massachusetts; Estados Unidos Fil: Coyne, Alice. University Of Massachusetts; Estados Unidos Fil: Gómez Penedo, Juan Martín. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Universidad de Buenos Aires; Argentina

BACKGROUND Therapeutic alliance has been well established as a robust predictor of face-to-face psychotherapy outcomes. Although initial evidence positioned alliance as a relevant predictor of internet intervention success, some conceptual and methodological concerns were raised regarding the methods and instruments used to measure the alliance in internet interventions and its association with outcomes. OBJECTIVE The aim of this study was to explore the alliance-outcome association in a guided internet intervention using a measure of alliance especially developed for and adapted to guided internet interventions, showing evidence of good psychometric properties. METHODS A sample of 223 adult participants with moderate depression received an internet intervention (ie, Deprexis) and email support. They completed the Working Alliance Inventory for Guided Internet Intervention (WAI-I) and a measure of treatment satisfaction at treatment termination and measures of depression severity and well-being at termination and 3- and 9-month follow-ups. For data analysis, we used two-level hierarchical linear modeling that included two subscales of the WAI-I (ie, tasks and goals agreement with the program and bond with the supporting therapist) as predictors of the estimated values of the outcome variables at the end of follow-up and their rate of change during the follow-up period. The same models were also used controlling for the effect of patient satisfaction with treatment. RESULTS We found significant effects of the tasks and goals subscale of the WAI-I on the estimated values of residual depressive symptoms (γ02=−1.74, standard error [SE]=0.40, 95% CI −2.52 to −0.96, t206=−4.37, P02=3.10, SE=1.14, 95% CI 0.87-5.33, t198=2.72, P=.007) at the end of follow-up. A greater score in this subscale was related to lower levels of residual depressive symptoms and a higher level of well-being. However, there were no significant effects of the tasks and goals subscale on the rate of change in these variables during follow-up (depressive symptoms, P=.48; patient well-being, P=.26). The effects of the bond subscale were also nonsignificant when predicting the estimated values of depressive symptoms and well-being at the end of follow-up and the rate of change during that period (depressive symptoms, P=.08; patient well-being, P=.68). CONCLUSIONS The results of this study point out the importance of attuning internet interventions to patients’ expectations and preferences in order to enhance their agreement with the tasks and goals of the treatment. Thus, the results support the notion that responsiveness to a patient’s individual needs is crucial also in internet interventions. Nevertheless, these findings need to be replicated to establish if they can be generalized to different diagnostic groups, internet interventions, and supporting formats.

OBJECTIVE The aim of this study was to identify differential baseline profiles of interpersonal problems in patients with emotional disorders and investigate their ability to predict the extent to which alliance is important for early treatment outcome in therapy. METHOD Ninety-six patients diagnosed with emotional disorders were admitted to psychotherapy at an independent practice center. After the first session, participants completed the Inventory of Interpersonal Problems and, after each of the first four sessions, the Alliance Negotiation Scale and the Outcome Questionnaire. We characterized the interpersonal problems of the sample using the circular statistics and the structural summary methods. Based on evidence of heterogeneity between patients, we conducted cluster analysis to identify differential profiles of interpersonal problems. We tested whether the identified profiles can predict the strength of the association between alliance negotiation and early treatment outcome using hierarchical linear models. RESULTS A two-cluster solution showed the best fit for the data. One cluster was characterized by Cold interpersonal problems (too hostile) and the other by Overly Nurturant interpersonal problems (too dependent). The identified profiles were significant predictors of the early alliance negotiation-outcome association. Overly Nurturant patients showed greater early improvements in outcome in the face of a stronger alliance negotiation. CONCLUSIONS Results support the importance of personalized approaches using patients' interpersonal profiles to determine the importance of alliance negotiation for early treatment outcome. Findings should be replicated in randomized controlled trials using strategies to manipulate alliance negotiation. (PsycINFO Database Record (c) 2019 APA, all rights reserved).