Search

Abstract Responsiveness is currently a hot topic in the psychotherapy literature with a large variation in what the term means to colleagues of various orientations. This adds to its popularity but limits the scope of whatever is written or said about responsiveness. The fact that the meaning of responsiveness has developed over time within the approaches adds also to the variation, while an understanding of development has the potential of deepening the understanding of each approach. As a fair description and comparison of even just the most important approaches is by far out of reach for a page-limited article, the development of one approach, which may be termed the "Bernese" approach is described here, along with lessons learnt and general comments. The approach includes Plan Analysis case formulations, the concept of complementary or Motive-Oriented Relationship, a description of a combined qualitative and quantitative assessment, and many methodological and conceptual considerations. Personal development is woven in. Overall, it seems fair to say that this approach, at its core developed long before responsiveness became popular, has turned out to still be useful, with a gain in depth as far as concepts and assessment are concerned.

Objective Resistance management in psychotherapy remains a foundational skill that is associated with positive client outcomes (Westra, H. A., & Norouzian, N. (2018). Using motivational interviewing to manage process markers of ambivalence and resistance in cognitive behavioral therapy. Cognitive Therapy and Research , 42 (2), 193-203). However, little is known about which therapist characteristics contribute to successful management of resistance. Research has suggested that psychotherapy performance does not improve with experience (Goldberg, S. B., Rousmaniere, T., Miller, S. D., Whipple, J., Nielsen, S. L., Hoyt, W. T., & Wampold, B. E. (2016). Do psychotherapists improve with time and experience? A longitudinal analysis of outcomes in a clinical setting. Journal of Counseling Psychology , 63 (1), 1-11), that psychotherapists lack humility (Macdonald, J., & Mellor-Clark, J. (2015). Correcting psychotherapists' blindsidedness: Formal feedback as a means of overcoming the natural limitations of therapists. Clinical Psychology & Psychotherapy , 22 (3), 249-257), and that difficult therapeutic moments may dysregulate therapist emotions (Muran, J. C., & Eubanks, C. F. (2020). Therapist performance under pressure: Negotiating emotion, difference, and rupture . American Psychological Association). This study aimed to 1) identify whether psychotherapy experience (i.e., training versus no training and number of years of psychotherapy experience) was associated with resistance management skill, and 2) identify whether humility and difficulties regulating emotions among trained individuals were each associated with resistance management. Method: A sample of 76 trained and 98 untrained participants were recruited for the present study. All participants completed the Comprehensive Intellectual Humility Scale (CIHS, Krumrei-Mancuso, E. J., & Rouse, S. V. (2016). The development and validation of the comprehensive intellectual humility scale. Journal of Personality Assessment , 98 (2), 209-221), the Difficulties in Emotion Regulation Scale (DERS; Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of Psychopathology and Behavioral Assessment , 26 (1), 41-54), and the Resistance Vignette Task (RVT; Westra, H. A., Nourazian, N., Poulin, L., Hara, K., Coyne, A., Constantino, M. J., Olson, D., & Antony, M. M. (2021). Testing a deliberate practice workshop for developing appropriate responsivity to resistance markers: A randomized clinical trial. Psychotherapy , 58 , 175-185 ) which was used to assess resistance management skill. Results: Trained individuals performed significantly better on resistance management than untrained individuals; however, years of experience within the trained sample were not associated with resistance management. Conversely, lower humility and greater difficulties regulating emotions were each associated with significantly poorer resistance management in trained individuals. Conclusion: These findings suggest the possibility of improving training to focus on key skills, like resistance management, through supporting humility and emotion regulation in training, as opposed to simply acquiring more experience.

Objective This study investigated the reasons why pedohebephilic clients disclose their sexual attraction to children in therapy and the experiences associated with this decision among English-speaking samples. Method : The pre-registered online survey combined (1) quantitative correlational data of self-reported improvement, alliance, therapist reaction to disclosure, and the belief that mandatory reporting laws were in place, and (2) qualitative data about reasons for disclosure or no disclosure as well as perceived consequences. The sample consisted of pedohebephilic people who have been clients in therapy and have disclosed ( n  = 96) or not disclosed ( n  = 40). Results: While the disclosure and no disclosure groups did not differ in improvement or beliefs about mandatory reporting, those who had disclosed reported a stronger alliance. Clients who did not perceive the therapist's reaction as supportive reported less improvement than the no disclosure group. Thematic analysis of qualitative data identified three themes concerning motives for disclosing or not disclosing and a fourth regarding differential impacts of disclosure. Discussion : This study indicates that disclosing pedohebephilia does not in and of itself lead to improvement but is contingent on a therapist's reaction.

Objective: The experience of frontline clinicians is an underutilized source of knowledge about improving youth suicide intervention. This qualitative study explored the perspectives of highly experienced, specialized mental health clinicians on the practical application of risk assessment, stabilization, and treatment and their experience of working in this practice area. Method: Data were collected from seven focus groups with 28 clinicians and analyzed using consensual qualitative research methods. Results: Four domains emerged, describing 1) youth suicide intervention as relationally focused and attachment-informed, 2) the need for flexible and tailored care balancing individual and family intervention in the context of family complexity and fractured relationships, 3) a nuanced, therapeutic approach to managing the complexity and uncertainty of adolescent suicide risk, and 4) working in youth suicide intervention as emotionally demanding and facilitated or hampered by the organizational and systems context. Conclusion: The importance of harnessing family systems and attachment-informed approaches to alliance, risk assessment, and treatment was emphasized, along with the parallel need for systemic clinician support and consideration of the potential negative consequences of administrative and risk management protocols.

Objectives: The therapist-facilitative interpersonal skills (FIS) has shown to predict therapy outcomes, demonstrating that high FIS therapists are more effective than low FIS therapists. There is a need for more insight into the variability in strengths and weaknesses in therapist skills. This study investigates whether a revised and extended FIS-scoring leads to more differentiation in measuring therapists' interpersonal skills. Furthermore, we explorative examine whether subgroups of therapists can be distinguished in terms of differences in their interpersonal responses., Method: Using secondary data analysis, 93 therapists were exposed to seven FIS-clips. Responses of therapists using the original and the extended FIS scoring were rated., Results: Three factors were found on the extended FIS scoring distinguishing supportive, expressive, and persuasive interpersonal responses of therapists. A latent profile analysis enlightened the presence of six subgroups of therapists., Conclusion: Using the revised and extended FIS-scoring contributes to our understanding of the role of interpersonal skills in the therapeutic setting by unraveling the question what works for whom., (© 2024 The Authors. Journal of Clinical Psychology published by Wiley Periodicals LLC.)

Objective: The Cooper-Norcross Inventory of Preferences (C-NIP) is a brief, multidimensional measure of clients' therapy preferences. This study aimed to examine the factor structure and measurement invariance of the C-NIP., Method: Fifteen datasets ( N  = 10,088 observations) representing the C-NIP in nine language versions were obtained from authors of psychometric studies. Confirmatory factor analysis and exploratory structural equation modeling were used to analyze the data., Results: None of the proposed models adequately fit the data. Therefore, a new model was developed that sufficiently fit most of the C-NIP version 1.1 datasets. The new model was invariant up to the strict and means levels across genders, ages, and psychotherapy experience but only up to the metric level across translations., Conclusions: The C-NIP can be used to compare men and women, people of diverse ages, and people with some vs. no experience with psychotherapy. Lower reliabilities of the C-NIP scales are a limitation.

Clinical decision making by psychiatrists and informed consent by patients require knowledge of evidence-based psychotherapies (EBPs) and their indications. However, many mental health professionals are not versed in the empirical literature on EBPs or the consensus guideline recommendations derived from this literature. The authors compared rigorous national consensus guidelines for EBP treatment of DSM -defined adult psychiatric disorders-derived from well-conducted randomized controlled trials and meta-analyses and from expert opinions from the United States, United Kingdom, and Canada-to create the Psychotherapies-at-a-Glance tool. Recommended EBPs are cognitive-behavioral therapy, family therapy, contingency management, dialectical behavior therapy, eye movement desensitization reprocessing, interpersonal psychotherapy, mentalization-based treatment, motivational interviewing, peer support, problem-solving therapy, psychoeducation, short-term psychodynamic psychotherapy, and 12-step facilitation. The Psychotherapies-at-a-Glance tool summarizes the indications, rationales, and therapeutic tasks that characterize these differing psychotherapies and psychosocial treatments. The tool is intended for use in clinical teaching, treatment planning, and patient communications., Competing Interests: Drs. Ravitz and Watson receive royalties from W.W. Norton. Dr. Swartz reports receiving royalties from UpToDate (Wolters Kluwer) and the American Psychiatric Association and has served as a consultant to the Clinical Education Alliance, Intra-Cellular Therapies, Mediflix, Medscape (Internet Brands/WebMD), and Physicians Postgraduate Press. The other authors report no financial relationships with commercial interests. Dr. Swartz is editor of the journal. Lois W. Choi-Kain, M.D., M.Ed., served as decision editor on the manuscript.

This article serves as an introduction to a special section devoted to the psychotherapy relationship and digital interventions. The nature of the therapy relationship is explored, and the question is raised as to whether machines can have relationships with their users. Finally, an overview and synthesis of the articles in the special section is provided.

Objective Video-based therapy has been used increasingly since the onset of the COVID-19 pandemic. Yet, video-based initial psychotherapeutic contact can be problematic due to the limitations of computer-mediated communication. At present, little is known about the effects of video first contact on important psychotherapeutic processes. Method: Forty-three individuals ( n video  = 18, n face-to-face  = 25) were recruited via an outpatient clinic waiting list and were randomly assigned to video or face-to-face initial psychotherapeutic sessions. Participants rated treatment expectancy before and after the session, and the therapist's empathy, working alliance, and credibility after the session and several days later. Results: Empathy and working alliance ratings of patients and therapists were high and did not differ between the two communication conditions after the appointment or at follow-up. Treatment expectancy increased to a similar extent for the video and face-to-face modalities from pre to post. Willingness to continue with video-based therapy increased in participants who had video contact, but not in those with face-to-face contact. Conclusion: This study indicates that crucial processes related to the therapeutic relationship can be initiated via video, without prior face-to-face contact. Given the limited nonverbal communication cues in video appointments, it remains unclear as to how such processes evolve. Trial registration: German Clinical Trials Register identifier: DRKS00031262..

Objective: Although teletherapy is increasingly common, very little is known about its impact on therapeutic relationships. We aimed to examine differences between therapists' experiences of teletherapy and in-person therapy post-pandemic with regard to three variables pertinent to the therapeutic relationship: working alliance, real relationship, and therapeutic presence., Methods: In a sample of 826 practicing therapists, we examined these relationship variables, as well as potential moderators of these perceived differences including professional and patient characteristics and covid-related variables., Results: Therapists reported feeling significantly less present in teletherapy and their perceptions of the real relationship were somewhat impacted, but there were no average effects on their perceived quality of the working alliance. Perceived differences in the real relationship did not persist with clinical experience controlled. The relative reduction in therapeutic presence in teletherapy was driven by the ratings of process-oriented therapists and therapists conducting mostly individual therapy. Evidence for moderation by covid-related issues was also found, with larger perceived differences in the working alliance reported by therapists who used teletherapy because it was mandated and/or not by choice., Conclusion: Our findings might have important implications for generating awareness around the therapists' lowered sense of presence in teletherapy compared to in-person teletherapy.

Background: Given the low usage of virtual health care prior to the COVID-19 pandemic, it was unclear whether those living in rural locations would benefit from increased availability of virtual mental health care. The rapid transition to virtual services during the COVID-19 pandemic allowed for a unique opportunity to examine how the transition to virtual mental health care impacted psychotherapy disruption (i.e., 45+ days between appointments) among individuals living in rural locations compared with those living in nonrural locations., Methods: Electronic health record and insurance claims data were collected from three health care systems in the United States including rurality status and psychotherapy disruption. Psychotherapy disruption was measured before and after the COVID-19 pandemic onset., Results: Both the nonrural and rural cohorts had significant decreases in the rates of psychotherapy disruption from pre- to post-COVID-19 onset (32.5-16.0% and 44.7-24.8%, respectively, p < 0.001). The nonrural cohort had a greater reduction of in-person visits compared with the rural cohort (96.6-45.0 vs. 98.0-66.2%, respectively, p < 0.001). Among the rural cohort, those who were younger and those with lower education had greater reductions in psychotherapy disruption rates from pre- to post-COVID-19 onset. Several mental health disorders were associated with experiencing psychotherapy disruption., Conclusions: Though the rapid transition to virtual mental health care decreased the rate of psychotherapy disruption for those living in rural locations, the reduction was less compared with nonrural locations. Other strategies are needed to improve psychotherapy disruption, especially among rural locations (i.e., telephone visits)., (© 2023 National Rural Health Association.)

Objective To investigate clients' perceptions of changes in their therapists' provision of positive regard (PR) following their transition from in-person therapy to teletherapy. Method A total of 2,118 clients, predominantly White, female, heterosexual, and in their mid-20s, who had been working with their therapist for an average of 20 months in-person and five months in teletherapy completed a Perceptions of Psychotherapy Process Scale (POPPS). This 42-item measure investigated, at a single time-point, the extent to which participants believed that specific therapist-related behaviors, statements, or attitudes changed since shifting to teletherapy. Results An exploratory factor analysis revealed, among other factors, a factor comprised of six items related to therapist-provided PR (e.g., "my therapist makes me feel cared about"). Clients' scores on this factor indicated a marginal but significant increase in therapists' provision of PR over teletherapy; these scores also significantly predicted scores on a factor reflecting clients' engagement in teletherapy. Conclusions Despite the challenges of an abrupt shift to teletherapy, clients perceive their therapists as communicating PR to the same or even slightly higher degrees as compared to in-person therapy pre-pandemic; therapists and clients have seemingly adapted to the new demands of technology to preserve important elements of the therapeutic relationship.

Objective: The quality of the therapeutic alliance, treatment motivation, outcome expectations (OE), and specific health behaviour predicts psychotherapy success. Therapists should be able to improve these factors to optimize outcomes. This study investigated the therapist's interpersonal behaviour to optimize alliance, motivation, OE, and health behaviour. Method: A stressed study sample ( N  = 465) completed an online analogue experiment. We gave participants positive information about psychotherapy effectiveness and varied the therapist's interpersonal behaviour along the dimensions of warmth and competence. Results: High (vs. low) competence and high (vs. low) warmth increased alliance, OE, and help-seeking scores, while high (vs. low) competence increased motivation to do psychotherapy. We found no effects on health behaviour. Conclusion: In contrast to previous correlational analyses, our experimental study supports the causal role of the therapist's warmth and competence and its impact on alliance, motivation, and OE. We discuss approaches for future studies and clinical implications.

Background: A structural reform of the German psychotherapy guideline in 2017 was intended to facilitate access to outpatient guideline psychotherapy. In the present study, we evaluate the effects of this reform in particular for patients with a comorbidity of mental disorders and chronic physical conditions (cMP)., Methods: Pre-post analyses of the two primary endpoints "percentage of mentally ill persons who have made an initial contact with a psychotherapist" and "waiting time for guideline psychotherapy" were carried out employing population-based and weighted routine statutory health insurance data from the German BARMER. The secondary endpoints included evaluations from the patients' perspective, based on a representative survey of patients in psychotherapy, and an overview of the health care situation based on data from the National Association of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung, KBV) (study registration number: DRKS00020344)., Results: From 2015 to 2018, the percentage of mentally ill persons who had made an initial contact with a psychotherapist rose moderately, from 3.7% (95% confidence interval, [3.6; 3.7]) to 3.9% [3.8; 3.9] among persons with cMP and from 7.3% [7.2; 7.4] to 7.6% [7.5; 7.7] among those with mental disorders but without any chronic physical condition (MnoP). The new structural elements were integrated into patient care. The interval of time between the initial contact and the beginning of guideline psychotherapy became longer in both groups, from a mean of 80.6 [79.4; 81.8] to 114.8 [113.4; 116.2] days among persons with complex disease and from 80.2 [79.2; 81.3] to 109.6 [108.4; 111.0] days among persons with non-complex disease; most patients considered the waiting time. Approximately 8% of the patients who sought psychotherapy reported that they had not obtained access to a psychotherapist., Conclusion: Neither in general nor for patients with cMP did the introduction of the structural reform appreciably lower the access barriers to psychotherapy. Further steps are needed so that outpatient care can meet the needs of all patients and particularly those with cMP.

Background: Exhaustion due to persistent non-traumatic stress (ENTS) is a significant health problem with substantial personal, social, and economic impact. While there are increasing studies of ENTS, there is no international agreement on how it should be diagnosed and treated. This scoping review aimed to map definitions, diagnoses, treatments, outcome measures, and outcomes in psychological treatment studies of ENTS. A further aim was to assess the quality of the treatments and map what change processes are described within ENTS interventions., Methods: A PRISMA-guided scoping review of psychological treatment studies delivered in a clinical setting for ENTS was conducted using the databases of PubMed, PsycINFO, and CINAHL., Results: Of the 60 studies included, the majority (87%) stemmed from Europe. The most recurrent term for ENTS was burnout, and the diagnosis most often utilized was exhaustion disorder. Several treatments were reported, the most frequent being cognitive behavioral therapy (CBT) (68%). Statistically significant outcomes relevant to ENTS were reported in 65% (n = 39) of the studies, with effect sizes between 0.13 and 1.80. In addition, 28% of the treatments were rated as high quality. The most frequent change processes described were dysfunctional sleep, avoidance, behavioral activation, irrational thoughts and beliefs, worry, perceived competence/positive management, psychological flexibility, and recuperation., Conclusions: While several treatments based on CBT show promising results for ENTS, there do not seem to be any uniformly established methods, theoretical models, or change processes. Instead of adopting a monocausal, syndromal, and potentially bio-reductionist perspective on ENTS, a process-based approach to treatment is encouraged., (© 2023. The Author(s).)

We draw recommendations and conclusions from the articles presented in this special issue and the companion special section in Psychotherapy Research on evidence-based therapist skills and methods. For distal (end-of-treatment) outcome, 10 skills/methods were judged to be demonstrably effective (affirmation/validation, paradoxical interventions, homework, routine outcome monitoring, strength-based methods, emotional regulation, imagery rehearsal therapy and exposure relaxation and rescripting therapy for nightmares, meditation/mindfulness/acceptance, behavioral activation, cognitive restructuring) and four were probably effective (rupture repair, role induction, collaborative assessment methods, chairwork). For intermediate (postsession or midtreatment) outcome, one method was judged to be demonstrably effective (cognitive-experiential dreamwork) and two methods probably effective (paradoxical interventions, homework). For immediate (in-session) outcomes, five skills/methods were judged to be probably effective (in-dialog silences, extended silences, role induction, strength-based methods, and emotion regulation). For the rest of the immediate, intermediate, or distal outcomes for skills/methods, there was either no or insufficient research available upon which to base judgments. Possible harmful effects, diversity considerations, and research limitations are summarized. The article ends with training implications, therapeutic practices, and the formal conclusions of the interorganizational Task Force on Psychotherapy Skills and Methods that Work. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Few service members with posttraumatic stress disorder (PTSD) receive evidence-based psychotherapy (EBP) in the military health system (MHS). Efforts to increase EBP implementation have focused on provider training but have not adequately addressed organizational barriers. Thus, although behavioral health providers are trained in EBPs, clinic-, facility-, and system-level barriers preclude widespread EBP implementation. Building on work examining barriers to EBP use for PTSD across eight military treatment facilities, we propose recommendations for increasing the implementation of EBPs for PTSD and improving the quality of behavioral health care in MHS outpatient behavioral health clinics. Increasing the use of EBPs for PTSD will require that their use is supported and prioritized through MHS policy. We recommend that psychotherapy appointments are scheduled at least once weekly, as clinically indicated, as this frequency of care is prerequisite for EBP delivery. We propose several recommendations designed to increase system capacity for weekly psychotherapy, including improved triaging of potential patients, incentivizing and supporting group psychotherapy, matching the modality (i.e., group vs. individual) and frequency of treatment to patients' needs, and using behavioral health technicians as clinician extenders. Additional recommendations include providing ongoing support for EBP implementation (e.g., protected time to participate in EBP consultation) and matching patients to providers based on patient's clinical needs and treatment preferences. The barriers to EBP implementation that these recommendations target are interrelated. Therefore, adopting multiple policy recommendations is likely necessary to yield a meaningful and sustained increase in the implementation of EBPs for PTSD in the MHS., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Abstract: Although reminiscence therapy alleviates mental illness and improves quality of life in neurocognitive disorders patients, little study reports its clinical application in cancer patients. Thus, this study aimed to explore the effect of reminiscence therapy on anxiety, depression, quality of life, and survival profile in postoperative gastric cancer patients.One hundred sixty surgical gastric cancer patients were enrolled in this randomized, controlled study, then randomly assigned to Reminiscence therapy group (N = 80) and Control group (N = 80) as 1:1 ratio. The evaluation was carried at baseline (M0), month 3 (M3), month 6 (M6), month 9 (M9), and month 12 (M12) after intervention by Hospital Anxiety and Depression Scale and European Organization for Research and Treatment of Cancer quality of life Questionnaire-Core 30 (QLQ-C30). Furthermore, disease-free survival and overall survival were analyzed using follow-up data.Reminiscence therapy decreased HADS for anxiety score at M6, M9, and M12, decreased anxiety rate at M9 and M12 compared to control care; while it did not affect HADS for depression score or depression rate at any time-point. Also, reminiscence therapy raised QLQ-C30 global health status score at M12, reduced QLQ-C30 symptoms score at M6, while did not affect QLQ-C30 function score at any time-point compared to control care. Reminiscence therapy did not affect disease-free survival and overall survival, either. Further subgroup analyses (divided by age and gender) observed that the effect of reminiscence therapy seemed more obvious in patients with age ≤60 years and male patients.Reminiscence therapy exhibits alleviation of anxiety and improvement of quality of life in postoperative gastric cancer patients., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Consideration of client preferences has been emphasized as important to therapeutic outcomes, such as treatment engagement and retention. Although studies have investigated several client and therapist characteristics associated with client preferences, few have considered whether people have preferences regarding a potential therapist's personality. The current study extended prior research on client preferences by examining the influence of participants' Big Five personality traits on preferences for therapist personality characteristics utilizing latent profile analysis. We expected congruence between client personality traits and preferred psychotherapist personality traits. In both undergraduate and community samples, results indicated that participants generally prefer a psychotherapist with personality characteristics similar to their own. Our findings establish the presence of preferences based on personality factors and have implications for future research directions and the role of personality assessment in routine clinical practice.

E-mental health applications (apps) are an increasingly important factor for the treatment of depression. To assess the risks and benefits for patients, an in-depth ethical analysis is necessary. The objective of this paper is to determine the ethical implications of app-based treatment for depression. An evidence-based ethical analysis was conducted. The material was meta-reviews and randomized control studies (RCTs) on app-based treatment. Based on the empirical data, an ethical analysis was conducted using the 3-ACES-approach by Thornicroft and Tansella. Apps may empower autonomy, offer an uninterrupted series of contacts over a period of time, show evidence-based benefits for patients with subclinical and mild-to-moderate-symptoms, are easily accessible, may be used for coordinating information and services within an episode of care, and are on the whole cost-effective. Their risks are that they are not suitable for the whole range of severity of mental illnesses and patient characteristics, show severe deficits in the data privacy policy, and a big variability in quality standards. The use of apps in depression treatment can be beneficial for patients as long as (1) the usefulness of an app-based treatment is assessed for each individual patient, (2) apps are chosen according to symptom severity as well as characteristics like the patient's level of self-reliance, their e-literacy, and their openness vis-à-vis apps, (3) manufacturers improve their privacy policies and the quality of apps.

Psychotherapy research aims to investigate predictors and moderators of treatment outcome, but there are few consistent findings. This study aimed to investigate cytokines in patients undergoing treatment for anxiety disorders and whether the level of cytokines moderated the treatment outcome. Thirty-seven patients with comorbid and treatment-resistant anxiety disorders were investigated using multilevel modelling. Serum cytokine levels were measured three times: pretreatment, in the middle of treatment, and at the end of treatment. Anxiety and metacognitions were measured weekly throughout treatment by self-report. The levels of monocyte chemoattractant protein-1, tumour necrosis factor-alpha, and interleukin-1 receptor antagonist did not change during therapy or were not related to the level of anxiety. Metacognitive beliefs predicted anxiety, but the relationship between metacognitions and anxiety was not moderated by cytokines. Limitations of the study include that the patients were not fasting at blood sampling, and we did not assess body mass index, which may affect cytokine levels. The lack of significance for cytokines as a predictor or moderator may be due to a lack of power for testing moderation hypotheses, a problem associated with many psychotherapy studies. Cytokines did not predict the outcome in the treatment of comorbid anxiety disorders in our sample. Furthermore, cytokines did not moderate the relationship between metacognitions and anxiety.

Efforts to help therapists improve their multicultural competence (MCC) rely on measures that can distinguish between different levels of competence. MCC is often assessed by asking clients to rate their experiences with their therapists. However, differences in client ratings of therapist MCC do not necessarily provide information about the relative performance of therapists and can be influenced by other factors including the client's own characteristics. In this study, we used a repeated measures design of 8,497 observations from 1,458 clients across 35 therapists to clarify the proportion of variability in MCC ratings attributed to the therapist versus the client and better understand the extent that an MCC measure detects therapist differences. Overall, we found that a small amount of variability in MCC ratings was attributed to the therapist (2%) and substantial amount attributed to the client (70%). These findings suggest that our measure of MCC primarily detected differences at the client level versus therapist level, indicating that therapist MCC scores were largely dependent on the client. Clinical implications and recommendations for future MCC research and measurement are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Background: In contrast to the hospital setting, today little work has been directed to the definition, measurement, and improvement of the quality of out-patient medical and therapeutic care. We developed a set of indicators to measure the quality of out-patient neuropsychological therapy after stroke., Methods: The indicators cover core and interdisciplinary aspects of out-patient neuropsychological work such as mediation of patients into social care in case of need. Selection of the quality-indicators was done together with a consensus group of out-patient therapists and supported by evidence, validity, reliability as well as estimated relevance and variability with the quality of care. The set of indicators was further tested in a retrospective cohort study. Anonymous data of 104 patients were collected from out-patient clinical records of five clinics between November 2017 and April 2018. Associations between process and outcome quality were estimated exploitatively., Results: Results allowed for the identification of areas with greater variability in the quality of process care and indicated that attention training as recommended by current guidelines had the lowest overall rate for meeting the quality-aim (met in 44% of the cases). This was followed by time < 1 month until the start of therapy (63% met) and mediation into social care in case of need (65% met). We further observed that overall quality and involving relatives in the therapy was associated with higher rates of professional reintegration (p-value = 0.03). However, the need for mediation into social care was associated with a reduced chance for successful professional reintegration (p-value = 0.009)., Conclusion: In conclusion, we describe a first set of quality indicators which cover different aspects of out-patient neuropsychological therapy and sufficient variability with care. First data further suggests that meeting the specified quality aims may indeed have relevant effects on outcomes.

Bipolar disorders are common, recurrent mental health conditions of variable severity that are difficult to diagnose. Affected individuals have higher rates of other mental health disorders, substance use disorders, and comorbid chronic medical illnesses. New diagnostic criteria and specifiers with attention on mixed features and anxious distress aid the physician in recognizing episode severity and prognosis. Physicians should consider bipolar disorder in any patient presenting with depression. Pharmacotherapy with mood stabilizers, such as lithium, anticonvulsants, and antipsychotics, is a first-line treatment that should be continued indefinitely because of the risk of patient relapse. Active lifestyle approaches include good nutrition, exercise, sleep hygiene, and proper weight management. Monotherapy with antidepressants is contraindicated during episodes with mixed features, manic episodes, and in bipolar I disorder. Ongoing management involves monitoring for suicidal ideation, substance use disorders, treatment adherence, and recognizing medical complications of pharmacotherapy. Psychotherapy is a useful adjunct to pharmacotherapy. Patients and their support systems should be educated about the chronic nature of this illness, possible relapse, suicidality, environmental triggers (e.g., seasonal light changes, shift work, other circadian disruption), and the effectiveness of early intervention to reduce complications.

Importance: Several psychotherapy protocols have been evaluated as adjuncts to pharmacotherapy for patients with bipolar disorder, but little is known about their comparative effectiveness., Objective: To use systematic review and network meta-analysis to compare the association of using manualized psychotherapies and therapy components with reducing recurrences and stabilizing symptoms in patients with bipolar disorder., Data Sources: Major bibliographic databases (MEDLINE, PsychInfo, and Cochrane Library of Systematic Reviews) and trial registries were searched from inception to June 1, 2019, for randomized clinical trials of psychotherapy for bipolar disorder., Study Selection: Of 3255 abstracts, 39 randomized clinical trials were identified that compared pharmacotherapy plus manualized psychotherapy (cognitive behavioral therapy, family or conjoint therapy, interpersonal therapy, or psychoeducational therapy) with pharmacotherapy plus a control intervention (eg, supportive therapy or treatment as usual) for patients with bipolar disorder., Data Extraction and Synthesis: Binary outcomes (recurrence and study retention) were compared across treatments using odds ratios (ORs). For depression or mania severity scores, data were pooled and compared across treatments using standardized mean differences (SMDs) (Hedges-adjusted g using weighted pooled SDs). In component network meta-analyses, the incremental effectiveness of 13 specific therapy components was examined., Main Outcomes and Measures: The primary outcome was illness recurrence. Secondary outcomes were depressive and manic symptoms at 12 months and acceptability of treatment (study retention)., Results: A total of 39 randomized clinical trials with 3863 participants (2247 of 3693 [60.8%] with data on sex were female; mean [SD] age, 36.5 [8.2] years) were identified. Across 20 two-group trials that provided usable information, manualized treatments were associated with lower recurrence rates than control treatments (OR, 0.56; 95% CI, 0.43-0.74). Psychoeducation with guided practice of illness management skills in a family or group format was associated with reducing recurrences vs the same strategies in an individual format (OR, 0.12; 95% CI, 0.02-0.94). Cognitive behavioral therapy (SMD, -0.32; 95% CI, -0.64 to -0.01) and, with less certainty, family or conjoint therapy (SMD, -0.46; 95% CI, -1.01 to 0.08) and interpersonal therapy (SMD, -0.46; 95% CI, -1.07 to 0.15) were associated with stabilizing depressive symptoms compared with treatment as usual. Higher study retention was associated with family or conjoint therapy (OR, 0.46; 95% CI, 0.26-0.82) and brief psychoeducation (OR, 0.44; 95% CI, 0.23-0.85) compared with standard psychoeducation., Conclusions and Relevance: This study suggests that outpatients with bipolar disorder may benefit from skills-based psychosocial interventions combined with pharmacotherapy. Conclusions are tempered by heterogeneity in populations, treatment duration, and follow-up.

The abolition of the expertise procedure for outpatient psychotherapy - A reduction of quality in the psychotherapy? Abstract. Objectives: This article investigates whether or not the abolishment of the expertise procedure for an outpatient psychotherapy is a reliable quality feature; and whether or not the elimination of this procedure results in a reduction of quality in outpatient psychotherapy. Methods: We conducted a literature research that considered articles written between the years 2000 and 2020 dealing with the expertise procedure as a quality standard of outpatient psychotherapy. In order to discuss the different views of the cited authors, we also refer to further literature. Results: The expertise procedure is not a reliable quality feature of outpatient psychotherapy. The idea that abolishing the expertise procedure results in a reduction of quality in outpatient psychotherapy is not confirmed by the studies summarized.

Background: Major depressive disorder (MDD) shows large heterogeneity of symptoms between patients, but within patients, particular symptom clusters may show similar trajectories. While symptom clusters and networks have mostly been studied using cross-sectional designs, temporal dynamics of symptoms within patients may yield information that facilitates personalized medicine. Here, we aim to cluster depressive symptom dynamics through dynamic time warping (DTW) analysis., Methods: The 17-item Hamilton Rating Scale for Depression (HRSD-17) was administered every 2 weeks for a median of 11 weeks in 255 depressed inpatients. The DTW analysis modeled the temporal dynamics of each pair of individual HRSD-17 items within each patient (i.e., 69,360 calculated "DTW distances"). Subsequently, hierarchical clustering and network models were estimated based on similarities in symptom dynamics both within each patient and at the group level., Results: The sample had a mean age of 51 (SD 15.4), and 64.7% were female. Clusters and networks based on symptom dynamics markedly differed across patients. At the group level, five dynamic symptom clusters emerged, which differed from a previously published cross-sectional network. Patients who showed treatment response or remission had the shortest average DTW distance, indicating denser networks with more synchronous symptom trajectories., Conclusions: Symptom dynamics over time can be clustered and visualized using DTW. DTW represents a promising new approach for studying symptom dynamics with the potential to facilitate personalized psychiatric care.

How women perceive and experience abortion impacts their subsequent psychological well-being. This systematic review evaluated nonpharmacological interventions designed to support women undergoing abortion services and improve their psychological well-being and satisfaction with care. Searches were conducted in MEDLINE, CINAHL, the Cochrane Library, PsycINFO, Sociological Abstracts, Social Services Abstracts, and PTSD Pubs. All searches were limited to peer-reviewed articles published in English from January 2010 to February 2020. Two reviewers independently assessed study eligibility. Ten studies were included, involving four types of interventions: music therapy; social support; information support; and mandated waiting and counseling requirements on abortion access. Outcome measures were divided into four categories comprised of cognitive domains, emotional and psychological well-being, clinical symptoms, and satisfaction with care. However, there is limited evidence on intervention effects. Most studies report null or mixed intervention effects. Even though some positive effects on women's cognitive outcomes and satisfaction with care were seen, findings across studies were inconclusive. Findings also show that methodological limitations such as lack of theoretical basis, inadequate reporting and no power sample size calculation were apparent across studies. There is limited evidence about nonpharmacological interventions designed to improve women's satisfaction with abortion services or psychological outcomes subsequent to accessing abortion services. Well-designed interventions that meet the needs of service-users should be developed and rigorously tested., (© 2020 John Wiley & Sons Australia, Ltd.)

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (UP-A; Ehrenreich-May et al., 2018) has been shown to be effective for reducing symptoms of anxiety and depression in adolescents with emotional disorders. Internet-delivered psychological treatments have great potential to improve access to evidence-based psychological therapy since they are associated with reduced human and economic costs and less social stigma. Recently, our group developed an online version of the UP-A (the iUP-A) for the treatment of emotional disorders in adolescents. The aim of this pilot trial was to test the clinical utility of the iUP-A in a small sample ( n = 12) of adolescents with elevated anxiety and/or depressive symptoms. Intention-to-treat and completer analyses revealed pre- to post-intervention self-reported decreases of anxiety and depressive symptoms, anxiety sensitivity, emotional avoidance, panic disorder symptoms, panic disorder severity, generalized anxiety disorder symptoms, pathological worry, and major depressive disorder symptoms. We found high feasibility and acceptability of the program with all participants and responsible parents reporting an improvement in the adolescents' ability to cope with emotions. Results suggest that the iUP-A may provide a new approach to improve access to treatment for anxious and depressive adolescents in Spain; however, further research must be conducted before firm conclusions can be drawn., Competing Interests: The authors declare no conflict of interest.

Consumers of psychotherapy outcome literature consider meta-analysis the gold standard for assessing the efficacy of interventions across disparate studies. Many assume that findings are valid, especially when published in journals with research credentials. Uncritical acceptance, however, can result in real-world consequences, including whether interventions attain evidence-based status or become marginalized or are considered for implementation in public service arenas. This article examines one meta-analysis, "The Effect of Using the Partners for Change Outcome Management System as Feedback Tool in Psychotherapy-A Systematic Review and Meta-Analysis" (Østergård, Randa, & Hougaard, 2018). The findings are at odds with both the empirical record of routine outcome management as well as professional taskforce recommendations and thus provide an ideal exemplar of the risks of uncritically accepting the conclusions of a meta-analysis. Using guidelines from the Cochrane Handbook for Systematic Reviews of Interventions (Higgins & Green, 2011) and a qualitative case study methodology, this article examines Østergård et al.'s (2018) study selection, quality of evidence, and appropriateness of interpretation, emphasizing the link between flawed method and the ultimate validity of its conclusions. The method illustrated in this case study can be used to assess the legitimacy of meta-analytic findings to inform practice, funding, and policy decisions as well as how rhetoric minimizes flaws and bolsters believability. Our analysis revealed that half of the selected studies of the meta-analysis contained significant limitations, including inadequate dose of treatment and/or adherence problems, thereby calling into question its conclusions. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Leonard Bickman's article on the future of artificial intelligence (AI) in psychotherapy research paints an encouraging picture of the progress to be made in this field. We support his perspective, but we also offer some cautionary notes about the boost AI can provide. We suggest that AI is not likely to transform psychotherapy research or practice to the degree seen in pharmacology and medicine because the factors that contribute to treatment response in these realms differ so markedly from one another, and in ways that do not favor advances in psychotherapy. Despite this limitation, it seems likely that AI will have a beneficial impact, improving empirical analysis through data-driven model development, tools for addressing the limitations of traditional regression methods, and novel means of personalizing treatment. In addition, AI has the potential to augment the reach of the researcher and therapist by expanding our ability to gather data and deliver interventions beyond the confines of the lab or clinical office.

In South Africa, various treatment models from abroad have been implemented for patients diagnosed with borderline personality disorder. This report is based on a South African model that has been developed, implemented, and evaluated for mental health nurses to use in facilitating the self-empowerment of women living with borderline personality disorder. The aim of this study was to describe the implementation of a model to facilitate self-empowerment in women living with borderline personality disorder and to describe mental health nurses' experiences of implementing this model. A qualitative, exploratory, descriptive, and contextual research design was used for the study. Participants were mental health nurses working in an inpatient psychotherapy unit in a mental health hospital. Findings revealed that mental health nurses experienced the model as a secure framework to assist women living with borderline personality disorder in making a shift to being self-empowered. The mental health nurses found that they had to adapt the model's timeframe to the women's own pace. Through use of the model, the mental health nurses also gained self-leadership. This report provides evidence from mental health nurses that the model was practical and helpful in working with women living with borderline personality disorder. The mental health nurses saw signs of self-empowerment in women living with borderline personality disorder., (© 2020 John Wiley & Sons Australia, Ltd.)

Children with functional neurological disorder (FND) present with motor and sensory neurological symptoms that impair health and physical functioning and that create an ongoing clinical burden for caregivers and hospitals worldwide. Treatment programs for these children involve a multidisciplinary approach with physical therapy as a fundamental component. However, standard musculoskeletal approaches to physical therapy are ineffective or may even exacerbate symptoms because they are unresponsive to the biopsychosocial context in which FND emerges: FND typically occurs in the context of stress, either physical or emotional; symptoms are amplified by attention; and presentations are complicated by psychological factors. Informed, in part, by published guidelines for physical therapy with adult FND patients, this article examines common challenges that arise when working with children: overcoming previous negative encounters in the medical system; avoiding amplification of symptoms by drawing attention to them; and managing comorbid pain, falls, faints, nonepileptic seizures, dizziness, fatigue, and breathlessness, plus psychological symptoms such as anticipatory anxiety and panic attacks. What emerges is a psychologically informed therapeutic approach to physical therapy for children with functional neurological symptoms. This approach prioritizes interpersonal processes and physical therapy techniques that establish a therapeutic relationship and create a safe space for physical therapy, that use indirect physical therapy approaches redirecting the focus of attention away from symptoms and emphasizing the completion of tasks and activities engaging the sick body part indirectly, that tailor the intervention to address the needs and presentation of each particular child, and that integrate psychological interventions to manage common challenges.

The Veterans Outcomes Assessment (VOA) program surveys Veteran Health Administration (VHA) patients when they begin mental health treatment and at follow-up at three months to obtain patient-reported outcomes measures (PROM). It complements VA's evolving program in measurement-based care by providing additional data that can be useful for program evaluation including assessments of patients who have not been seen for ongoing mental health care. In principle, it provides data on intention-to-treat outcomes for program evaluation to complement the outcomes for patients who are receiving ongoing treatment that can be derived from measurement-based care. VOA findings confirm differences in outcomes between patients who have continued to be seen for treatment and those who have not. Patients in general mental health clinics with no encounters between the baseline and follow-up assessments who reported discontinuing care because they did not want or need treatment improved more, and those who discontinued due to problems improved less than those who remained in treatment. Experience with VOA has identified a number of issues that must be addressed before it is possible to use intention-to-treat outcomes for program evaluation., (Published by Elsevier B.V.)

Objective: Existing evidence highlights the importance of modeling differential therapist effectiveness when studying psychotherapy outcome. However, no study to date examined whether this assertion applies to the study of within-patient effects in mechanisms of change. The study investigated whether therapist effects should be modeled when studying mechanisms of change on a within-patient level. Methods: We conducted a Monte Carlo simulation study, varying patient- and therapist level sample sizes, degree of therapist-level nesting (intra-class correlation), balanced vs. unbalanced assignment of patients to therapists, and fixed vs random within-patient coefficients. We estimated all models using longitudinal multilevel and structural equation models that ignored (2-level model) or modeled therapist effects (3-level model). Results: Across all conditions, 2-level models performed equally or were superior to 3-level models. Within-patient coefficients were unbiased in both 2- and 3-level models. In 3-level models, standard errors were biased when number of therapists was small, and this bias increased in unbalanced designs. Ignoring random slopes led to biased standard errors when slope variance was large; but 2-level models still outperformed 3-level models. Conclusions: In contrast to treatment outcome research, when studying mechanisms of change on a within-patient level, modeling therapist effects may even reduce model performance and increase bias.

Manage uncomplicated cases following guidelines on medical therapy and with adjunctive psychotherapy. Refer complicated and severe cases to Psychiatry.

The field has struggled with fundamental issues related to evidence-based practice (EBP) implementation and science-practice integration. The development and implementation of routine monitoring and measurement-based care (MBC) strategies in naturalistic psychological service settings has emerged as a promising strategy to address fundamental questions and knowledge gaps. This conceptual paper marks the importance of routine monitoring in real world psychological services. In particular, routine monitoring has facilitated the harnessing of ecologically valid practice-based and patient-focused evidence, which would otherwise be lost to the field. In addition to tracing its historical context, the role and impact of routine monitoring is addressed in the areas of (a) documenting the effectiveness of psychological services, (b) patient-focused research and care, and (c) therapist differences and payment models. Limitations and challenges are also identified. Throughout, the public health significance of routine monitoring as it relates to clinical psychology is highlighted, including its increasingly prominent role in health care systems and mental health care policy. In addition, it is argued that routine monitoring should continue to be a vital transtheoretical and transdiagnostic evidence-based practice.

Objective: Adolescent migrants present psychological disorders more frequently than the corresponding host population but their access to care and to follow-up are less effective. The French method of transcultural psychotherapy (TPT) was conceived to respond to these problems. Our objective is to assess how these adolescents and their families perceive the experience and effectiveness of TPT., Method: We conducted semistructured interviews with the families of adolescents seen for TPT. The data were analyzed by a qualitative thematic methodology., Results: We spoke to 21 participants in 8 families. The families came to TPT with a sense that the teen's current treatment was at an impasse. During the follow-up, they noted that family communication and relationships had improved, as had their connection to their culture of origin. Besides commenting on what they perceived as limitations, families identified specific elements of TPT as therapeutic., Conclusion: The pronounced diversity of the group and the use of both multiperspective narration and an interpreter were specific elements driving the construction of a good therapeutic alliance, despite the initial barriers. Pursuit of the evaluation of TPT is essential to advance the psychiatric care of adolescent migrants., Competing Interests: The authors have declared that no competing interests exist.

Background: Cognitive degeneration and agitated behavior symptoms of dementia in older adults are the main causes of disability and inability and increase the cost of medical care. Agitated behavior symptoms of dementia are the main causes of early institutionalization and make caregivers exhausted., Purpose: The aim of this study was to examine the effects of art therapy and reminiscence therapy on the alleviation of agitated behaviors in older adults with dementia., Methods: An experimental research design with two experimental groups and one comparison group was conducted to examine the effects for each group on agitated behaviors. Participants were recruited from two dementia care centers in central and northern Taiwan. The study included 54 older individuals who met the sampling criteria and completed the data collection process. The participants were randomly allocated into the art therapy group (n = 24), the reminiscence therapy group (n = 22), and the comparison group (n = 8). The intervention consisted of 50-minute sessions conducted weekly for 12 weeks. Regular activities were continued in the comparison group. The structured questionnaires were completed, and observations of agitated behaviors were collected before the intervention and at 1 and 6 weeks after the intervention., Results: Significant differences were found in agitated behavior symptoms at the three time points in the art therapy group, whereas reminiscence therapy was found to have had a clear and immediate effect on decreasing agitated behavior. The generalized estimating equation exchange model test revealed a significant and sustained, postintervention effect of art therapy on agitated behavior. In contrast, no significant and sustained effect on agitated behavior was observed in the reminiscence therapy group., Conclusions: The findings of this study support that art therapy may have a positive effect on dementia-associated agitated behaviors in institutionalized older adults. Reminiscence therapy activities conducted weekly for 50 minutes each session did not reach statistically significant implications. It is suggested that future studies consider conducting art and reminiscence therapies for a 16-week duration with two weekly sessions to evaluate the effectiveness of the therapy. The duration of follow-up should be extended as well in future studies.

The best evidence for effective treatment of personality disorder supports the use of specialized forms of psychotherapy. However, these forms of treatment are generally unavailable in health care systems. This may be partly due to the expense of routinely offering long-term therapies. There is evidence that psychotherapy for personality disorder is cost-effective. One way to address this problem is to treat most patients more briefly. © 2020 John Wiley & Sons, Ltd., (© 2020 John Wiley & Sons, Ltd.)

Despite a call to action by accreditation bodies and payers alike, the infrastructure needed to continuously improve the quality and safety of behavioral health care has been slow to develop. The causes of this are complex and multifactorial yet likely include underdeveloped leadership and capacity to sustainably improve the quality of psychiatric care. This article proposes the use of a quality improvement maturity matrix to serve as both an implementation strategy and a self-assessment measure to strategically guide this infrastructure development. The matrix describes six phases of development across three domains that are generalizable to various behavioral health care settings.

During the COVID-19 pandemic, Spain ranked 1st in number of infected health workers. Despite the fact that up to 75% of them were women, psychological interventions to prevent distress usually lacked a gender perspective and a biopsychosocial approach. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Suicide is the second leading cause of death in young adults (15-24 years old). There continues to be limited access to mental health services for many patients who are in mental health crisis because of shortage of trained psychiatrist and mental health providers. Patients identified with high risk factors should get a full comprehensive psychiatric evaluation. Management should focus on preventative strategies, early identification as well as treatment with appropriate psychopharmacology and psychotherapy., (Copyright 2020 by the Missouri State Medical Association.)