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Falkenström, Fredrik
Publications (10 of 23) Show all publications
Holmqvist Larsson, M., Björkman, K., Nilsson, K., Falkenström, F. & Holmqvist, R. (2019). The Alliance and Rupture Observation Scale (AROS): Development and validation of an alliance and rupture measure for repeated observations within psychotherapy sessions. Journal of Clinical Psychology, 75(3), 404-417
Open this publication in new window or tab >>The Alliance and Rupture Observation Scale (AROS): Development and validation of an alliance and rupture measure for repeated observations within psychotherapy sessions
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2019 (English)In: Journal of Clinical Psychology, ISSN 0021-9762, E-ISSN 1097-4679, Vol. 75, no 3, p. 404-417Article in journal (Refereed) Published
Abstract [en]

Objective: The aim of this study was to test a new observer-rated instrument, the Alliance and Rupture Observation Scale (AROS). It was designed for repeated measurements of the alliance within sessions and to detect alliance ruptures.

Method: Videotaped therapy sessions with depressed adults were analyzed. Reliability was mainly assessed as inter-rater reliability. Convergent, predictive, and discriminant validity of the AROS was assessed by comparing the instrument with both observer-rated and patient-rated measures.

Results: The AROS exhibited excellent inter-rater reliability. Alliance levels measured with the AROS predicted patients’ ratings of the alliance in the same session and were highly correlated with another observer-rated alliance measure. Alliance patterns (rupture; repair; and no-rupture) based on AROS scores were significantly correlated with patients’ ratings of the alliance.

Conclusions: Preliminary support for convergent and predictive validity was found. It is yet to be determined whether AROS scores are related to psychotherapy outcomes.

Place, publisher, year, edition, pages
John Wiley & Sons, 2019
Keywords
alliance ruptures and repairs, measurement, observer-based alliance measure, psychotherapy process, test development, therapeutic alliance, therapeutic relationship
National Category
Psychology
Identifiers
urn:nbn:se:liu:diva-154932 (URN)10.1002/jclp.22704 (DOI)000459626300006 ()30431649 (PubMedID)2-s2.0-85056660476 (Scopus ID)
Available from: 2019-03-06 Created: 2019-03-06 Last updated: 2019-06-27Bibliographically approved
Holmqvist Larsson, M., Falkenström, F., Andersson, G. & Holmqvist, R. (2018). Alliance ruptures and repairs in psychotherapy in primary care. Psychotherapy Research, 28(1), 123-136
Open this publication in new window or tab >>Alliance ruptures and repairs in psychotherapy in primary care
2018 (English)In: Psychotherapy Research, ISSN 1050-3307, E-ISSN 1468-4381, Vol. 28, no 1, p. 123-136Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: The association between alliance level and outcome in psychotherapy has been extensively studied. One way to expand this knowledge is to study alliance patterns. The main aims of this study were to examine how frequent alliance patterns with ruptures or rupture-repair episodes were in a naturalistic sample of psychotherapies in primary care, and if three alliance patterns (a Rupture pattern, a Repair pattern, and a No Rupture pattern) were differentially associated with treatment outcome.

METHOD: The psychotherapies (N = 605) included a wide range of different treatment orientations and patient diagnoses. Alliance patterns were studied at session-to-session level, using patient-rated alliance scores. Outcome data were analyzed using longitudinal multilevel modeling with a slopes-as-outcomes model.

RESULTS: The Repair pattern accounted for 14.7% (n = 89) of the treatments, 10.7% (n = 65) exhibited a Rupture pattern, and 74.5% (n = 451) contained no ruptures. The Rupture pattern was associated with inferior treatment outcomes. The Repair pattern was, in longer treatments, associated with better outcomes than the No Rupture pattern.

CONCLUSIONS: The results support theory about the importance of ruptures in the therapeutic alliance and suggest that identification of alliance ruptures is important in alliance-outcome research, for feedback purposes in clinical practice, and in training of therapists.

Place, publisher, year, edition, pages
Routledge, 2018
Keywords
alliance, alliance patterns, alliance ruptures, longitudinal multilevel modeling, naturalistic process and outcome research
National Category
Applied Psychology
Identifiers
urn:nbn:se:liu:diva-143855 (URN)10.1080/10503307.2016.1174345 (DOI)000418942800011 ()27139816 (PubMedID)2-s2.0-84965032354 (Scopus ID)
Available from: 2017-12-21 Created: 2017-12-21 Last updated: 2019-06-27Bibliographically approved
Nissen-Lie, H. A., Goldberg, S. B., Hoyt, W. T., Falkenström, F., Holmqvist, R., Nielsen, S. L. & Wampold, B. E. (2016). Are Therapists Uniformly Effective Across Patient Outcome Domains? A Study on Therapist Effectiveness in Two Different Treatment Contexts. Journal of counseling psychology, 63(4), 367-378
Open this publication in new window or tab >>Are Therapists Uniformly Effective Across Patient Outcome Domains? A Study on Therapist Effectiveness in Two Different Treatment Contexts
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2016 (English)In: Journal of counseling psychology, ISSN 0022-0167, E-ISSN 1939-2168, Vol. 63, no 4, p. 367-378Article in journal (Refereed) Published
Abstract [en]

As established in several studies, therapists differ in effectiveness. A vital research task now is to understand what characterizes more or less effective therapists, and investigate whether this differential effectiveness systematically depends on client factors, such as the type of mental health problem. The purpose of the current study was to examine whether therapists are universally effective across patient outcome domains reflecting different areas of mental health functioning. Data were obtained from 2 sites: the Research Consortium of Counseling and Psychological Services in Higher Education (N = 5,828) in the United States and from primary and secondary care units (N = 616) in Sweden. Outcome domains were assessed via the Outcome Questionnaire-45 (Lambert et al., 2004) and the CORE-OM (Evans et al., 2002). Multilevel models with observations nested within patients were used to derive a reliable estimate for each patients change (which we call a multilevel growth d) based on all reported assessment points. Next, 2 multilevel confirmatory factor analytic models were fit in which these effect sizes (multilevel ds) for the 3 subscales of the OQ-45 (Study 1) and 6 subscales of CORE-OM (Study 2) were indicators of 1 common latent factor at the therapist level. In both data sets, such a model, reflecting a global therapist effectiveness factor, yielded large factor loadings and excellent model fit. Results suggest that therapists effective (or ineffective) within one outcome domain are also effective within another outcome domain. Tentatively, therapist effectiveness can thus be conceived of as a global construct.

Place, publisher, year, edition, pages
AMER PSYCHOLOGICAL ASSOC, 2016
Keywords
therapist effects; therapist uniformity; multilevel factor analysis
National Category
Applied Psychology
Identifiers
urn:nbn:se:liu:diva-130661 (URN)10.1037/cou0000151 (DOI)000380110100001 ()27124549 (PubMedID)
Available from: 2016-08-20 Created: 2016-08-19 Last updated: 2017-11-28
Falkenström, F., Josefsson, A., Berggren, T. & Holmqvist, R. (2016). How Much Therapy Is Enough? Comparing Dose-Effect and Good-Enough Models in Two Different Settings. Psychotherapy, 53(1), 130-139
Open this publication in new window or tab >>How Much Therapy Is Enough? Comparing Dose-Effect and Good-Enough Models in Two Different Settings
2016 (English)In: Psychotherapy, ISSN 0033-3204, E-ISSN 1939-1536, Vol. 53, no 1, p. 130-139Article in journal (Refereed) Published
Abstract [en]

The Dose-Effect model holds that longer therapy leads to better outcome, although increasing treatment length will yield diminishing returns, as additional sessions lead to progressively less change in a negatively accelerating fashion. In contrast, the Good-Enough-Level (GEL) model proposes that patients, therapists, or patients-with-therapists decide on ending treatment when treatment outcome is satisfactory, meaning that patients who change faster will have shorter treatments. If true, this means that aggregating among patients with different treatment lengths would yield biased results. Most previous research has shown that symptom change rate depends on treatment length, but all of these studies used data from University counseling centers in the United States. There is a need to test if previous results hold in different settings. Two datasets from Swedish community-based primary care (n = 640) and psychiatric care (n = 284) were used. Patients made session-wise ratings on the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM). Multilevel models indicated better fit for a model in which treatment length moderated symptom change rate. In the primary care sample, patients in longer treatments achieved more symptom change from pre- to posttreatment, despite having slower rate of improvement. The most important aspect of the GEL model was supported, and no evidence was found for a negatively accelerating Dose-Effect curve. Results cannot be generalized beyond about 12 sessions, due to scarcity of data for longer treatments.

Place, publisher, year, edition, pages
AMER PSYCHOLOGICAL ASSOC, DIV PSYCHOTHERAPY, 2016
Keywords
psychotherapy; naturalistic research; outcome research; GEL model; Dose-Effect
National Category
Basic Medicine
Identifiers
urn:nbn:se:liu:diva-126834 (URN)10.1037/pst0000039 (DOI)000371345200013 ()26928273 (PubMedID)
Available from: 2016-04-07 Created: 2016-04-05 Last updated: 2018-01-10
Ekeblad, A., Falkenström, F. & Holmqvist, R. (2016). Reflective Functioning as Predictor of Working Alliance and Outcome in the Treatment of Depression. Journal of Consulting and Clinical Psychology, 84(1), 67-78
Open this publication in new window or tab >>Reflective Functioning as Predictor of Working Alliance and Outcome in the Treatment of Depression
2016 (English)In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 84, no 1, p. 67-78Article in journal (Refereed) Published
Abstract [en]

Aims: Although considerable attention has been paid to the concept of mentalization in psychotherapy, there is little research on mentalization as predictor of psychotherapy process and outcome. Using data from a randomized controlled trial of cognitive-behavioral therapy and interpersonal psychotherapy for depression, we studied mentalization in 85 outpatients with major depressive disorder (MDD) according to the Diagnostic and Statistical Manual of Mental Disorders. It was hypothesized that patients showing lower capacity for mentalization would experience poorer quality of alliance and worse outcome. Method: Depressive symptoms were measured each session using the Beck Depression Inventory-II. Mentalization was measured as reflective functioning (RF) on a slightly shortened version of the Adult Attachment Interview. A measure of depression-specific reflective functioning (DSRF), measuring mentalization about depressive symptoms, was also used. The Working Alliance Inventory-Short Form Revised was completed after each session by both therapist and patient. Longitudinal multilevel modeling was used to analyze data. Results: The patients had on average very low RF (M = 2.62, SD = 1.22). Lower pretreatment RF/DSRF predicted significantly lower therapist-rated working alliance during treatment. RF did not affect patient-rated alliance, but lower DSRF predicted lower patient-rated alliance across treatment. Patients with higher RF/DSRF had better outcomes on self-rated depression. Conclusions: The findings showed lower than normal capacity for mentalization in patients with MDD. Lower RF/DSRF predicted worse treatment outcome. More research is needed to understand how RF affects psychotherapy response and how RF is affected after recovery from depression.

Place, publisher, year, edition, pages
AMER PSYCHOLOGICAL ASSOC, 2016
Keywords
psychotherapy process; mentalization; reflective functioning; working alliance; major depression
National Category
Basic Medicine
Identifiers
urn:nbn:se:liu:diva-124490 (URN)10.1037/ccp0000055 (DOI)000367426900006 ()26594944 (PubMedID)
Note

Funding Agencies|Rehsam Fund [2010/013]; Swedish Research Council for Health, Working Life and Welfare [2013-0203]; L. J. Boethius Research Fund; Emil Andersson Research Fund

Available from: 2016-02-02 Created: 2016-02-01 Last updated: 2018-01-10
Falkenström, F., Hatcher, R. L. & Holmqvist, R. (2015). Confirmatory Factor Analysis of the Patient Version of the Working Alliance Inventory-Short Form Revised. Assessment (Odessa, Fla.), 22(5), 581-593
Open this publication in new window or tab >>Confirmatory Factor Analysis of the Patient Version of the Working Alliance Inventory-Short Form Revised
2015 (English)In: Assessment (Odessa, Fla.), ISSN 1073-1911, E-ISSN 1552-3489, Vol. 22, no 5, p. 581-593Article in journal (Refereed) Published
Abstract [en]

The working alliance concerns the quality of collaboration between patient and therapist in psychotherapy. One of the most widely used scales for measuring the working alliance is the Working Alliance Inventory (WAI). For the patient-rated version, the short form developed by Hatcher and Gillaspy (WAI-SR) has shown the best psychometric properties. In two confirmatory factor analyses of the WAI-SR, approximate fit indices were within commonly accepted norms, but the likelihood ratio chi-square test showed significant ill-fit. The present study used Bayesian structural equations modeling with zero mean and small variance priors to test the factor structure of the WAI-SR in three different samples (one American and two Swedish; N = 235, 634, and 234). Results indicated that maximum likelihood confirmatory factor analysis showed poor model fit because of the assumption of exactly zero residual correlations. When residual correlations were estimated using small variance priors, model fit was excellent. A two-factor model had the best psychometric properties. Strong measurement invariance was shown between the two Swedish samples and weak factorial invariance between the Swedish and American samples. The most important limitation concerns the limited knowledge on when the assumption of residual correlations being small enough to be considered trivial is violated.

Place, publisher, year, edition, pages
SAGE PUBLICATIONS INC, 2015
Keywords
Working Alliance Inventory; confirmatory factor analysis; Bayesian structural equations modeling; measurement invariance
National Category
Basic Medicine
Identifiers
urn:nbn:se:liu:diva-121733 (URN)10.1177/1073191114552472 (DOI)000360791000004 ()25271007 (PubMedID)
Note

Funding Agencies|Swedish Research Council for Health, Working Life and Wellfare [2013-0203]

Available from: 2015-10-06 Created: 2015-10-05 Last updated: 2018-01-11
Falkenström, F., Hatcher, R. L., Skjulsvik, T., Holmqvist Larsson, M. & Holmqvist, R. (2015). Development and Validation of a 6-item Working Alliance Questionnaire for Repeated Administrations During Psychotherapy. Psychological Assessment, 27(1), 169-183
Open this publication in new window or tab >>Development and Validation of a 6-item Working Alliance Questionnaire for Repeated Administrations During Psychotherapy
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2015 (English)In: Psychological Assessment, ISSN 1040-3590, E-ISSN 1939-134X, Vol. 27, no 1, p. 169-183Article in journal (Refereed) Published
Abstract [en]

Recently, researchers have started to measure the working alliance repeatedly across sessions of psychotherapy, relating the working alliance to symptom change session by session. Responding to questionnaires after each session can become tedious, leading to careless responses and/or increasing levels of missing data. Therefore, assessment with the briefest possible instrument is desirable. Because previous research on the Working Alliance Inventory has found the separation of the Goal and Task factors problematic, the present study examined the psychometric properties of a 2-factor, 6-item working alliance measure, adapted from the Working Alliance Inventory, in 3 patient samples (ns = 1,095, 235, and 234). Results showed that a bifactor model fit the data well across the 3 samples, and the factor structure was stable across 10 sessions of primary care counseling/psychotherapy. Although the bifactor model with 1 general and 2 specific factors outperformed the 1-factor model in terms of model fit, dimensionality analyses based on the bifactor model results indicated that in practice the instrument is best treated as unidimensional. Results support the use of composite scores of all 6 items. The instrument was validated by replicating previous findings of session-by-session prediction of symptom reduction using the Autoregressive Latent Trajectory model. The 6-item working alliance scale, called the Session Alliance Inventory, is a promising alternative for researchers in search for a brief alliance measure to administer after every session.

Place, publisher, year, edition, pages
American Psychological Association, 2015
Keywords
confirmatory factor analysis; longitudinal research; measurement invariance; structural equations modeling; working alliance
National Category
Basic Medicine
Identifiers
urn:nbn:se:liu:diva-116967 (URN)10.1037/pas0000038 (DOI)000350974100015 ()25346997 (PubMedID)
Note

Funding Agencies|Swedish Research Council for Health, Working Life and Wellfare [2013-0203]

Available from: 2015-04-10 Created: 2015-04-10 Last updated: 2019-06-27
Lilliengren, P., Falkenström, F., Sandell, R., Risholm Mothander, P. & Werbart, A. (2015). Secure Attachment to Therapist, Alliance, and Outcome in Psychoanalytic Psychotherapy With Young Adults. Journal of counseling psychology, 62(1)
Open this publication in new window or tab >>Secure Attachment to Therapist, Alliance, and Outcome in Psychoanalytic Psychotherapy With Young Adults
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2015 (English)In: Journal of counseling psychology, ISSN 0022-0167, E-ISSN 1939-2168, Vol. 62, no 1Article in journal (Refereed) Published
Abstract [en]

Using a novel approach to assess attachment to therapist from patient narratives (Patient Attachment to Therapist Rating Scale; PAT-RS), we investigated the relationships between secure attachment to therapist, patient-rated alliance, and outcome in a sample of 70 young adults treated with psychoanalytic psychotherapy. A series of linear mixed-effects models, controlling for length of therapy and therapist effects, indicated that secure attachment to therapist at termination was associated with improvement in symptoms, global functioning, and interpersonal problems. After controlling for the alliance, these relationships were maintained in terms of symptoms and global functioning. Further, for the follow-up period, we found a suppression effect indicating that secure attachment to therapist predicted continued improvement in global functioning, whereas the alliance predicted deterioration when both variables were modeled together. Although limited by the correlational design, this study suggests that the development of a secure attachment to therapist is associated with treatment gains as well as predictive of posttreatment improvement in functioning. Future research should investigate the temporal development of attachment to therapist and its interaction with alliance and outcome more closely. To ensure differentiation from patient-rated alliance, observer-based measurement of attachment to therapist should be considered.

Place, publisher, year, edition, pages
American Psychological Association, 2015
Keywords
attachment to therapist; therapeutic alliance; outcome; psychoanalytic psychotherapy; young adults
National Category
Applied Psychology
Identifiers
urn:nbn:se:liu:diva-114247 (URN)10.1037/cou0000044 (DOI)000348049200001 ()25222907 (PubMedID)
Available from: 2015-02-16 Created: 2015-02-16 Last updated: 2017-12-04
Söderberg, A. K., Elfors, C., Holmqvist Larsson, M., Falkenström, F. & Holmqvist, R. (2014). Emotional availability in psychotherapy: The usefulness and validity of the Emotional Availability Scales for analyzing the psychotherapeutic relationship. Psychotherapy Research, 24(1), 91-102
Open this publication in new window or tab >>Emotional availability in psychotherapy: The usefulness and validity of the Emotional Availability Scales for analyzing the psychotherapeutic relationship
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2014 (English)In: Psychotherapy Research, ISSN 1050-3307, E-ISSN 1468-4381, Vol. 24, no 1, p. 91-102Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to assess whether a modified version of the Emotional Availability Scales (EAS), created to assess interaction quality between parents and children, could be applied to psychotherapy sessions and whether emotional availability (EA), as assessed by the modified EAS-T, was associated with client- and therapist-rated working alliance. EAS-T was used to assess 42 sessions from 16 therapies. The therapies came from the LURIPP project, comparing IPT with BRT for depressed clients. The results showed that sessions could be reliably rated with EAS-T. Most rating scales had acceptable variance. The clients perception of task alliance was associated with several of the EA subscales (sensitivity, nonhostility, responsiveness) assessed over therapies, whereas the perception of bond was associated with Structure on EAS.

Place, publisher, year, edition, pages
Taylor & Francis, 2014
Keywords
alliance; process research; brief psychotherapy; emotion in therapy
National Category
Psychology
Identifiers
urn:nbn:se:liu:diva-103275 (URN)10.1080/10503307.2013.826833 (DOI)000333482600008 ()
Available from: 2014-01-17 Created: 2014-01-16 Last updated: 2019-06-27Bibliographically approved
Möller, C., Falkenström, F., Holmqvist Larsson, M. & Holmqvist, R. (2014). MENTALIZING IN YOUNG OFFENDERS. Psychoanalytic psychology, 31(1), 84-99
Open this publication in new window or tab >>MENTALIZING IN YOUNG OFFENDERS
2014 (English)In: Psychoanalytic psychology, ISSN 0736-9735, E-ISSN 1939-1331, Vol. 31, no 1, p. 84-99Article in journal (Refereed) Published
Abstract [en]

In order to prevent relapse into criminality, it is important to understand what precedes criminal behavior. Two earlier studies found deficits in mentalizing ability to be related to violent and criminal actions. Mentalizing refers to the ability to make human behavior predictable and meaningful by inferring mental states (thoughts, feelings, etc.) as explaining behavior. In this study, mentalizing ability was assessed by rating 42 Adult Attachment Interviews with young male offenders with the Reflective Functioning (RF) scale. In addition, specific mentalizing ability about their crimes was assessed, as well as psychopathy traits (Psychopathy Checklist, Screening Version [PCL: SV]) and alexithymia (Toronto Alexithymia Scale [TAS]). Results suggest impaired mentalizing in criminal offenders. Examples of anti- and prementalizing reasoning about crimes are presented. RF scores were not correlated with the PCL:SV or TAS.

Place, publisher, year, edition, pages
American Psychological Association, 2014
Keywords
mentalizing; reflective functioning; Adult Attachment Interview; criminal behavior; psychopathy
National Category
Social Sciences
Identifiers
urn:nbn:se:liu:diva-105591 (URN)10.1037/a0035555 (DOI)000331876500006 ()
Available from: 2014-03-28 Created: 2014-03-27 Last updated: 2019-06-27
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