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  • 1. Armelius, K.
    et al.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences.
    Staff members' feelings toward psychiatric patients related to their own and the patient's self-image and gender2003In: Scandinavian Journal of Psychology, ISSN 0036-5564, E-ISSN 1467-9450, Vol. 44, no 2, p. 69-77Article in journal (Refereed)
    Abstract [en]

    The relation between staff members' feelings toward a patient and their own and the patient's self-image in different gender combination groups was studied. Staff at 16 psychiatric treatment homes for patients with severe psychopathology reported their feelings toward their patients on a number of occasions. At the start of treatment, both staff members and patients rated their self-images using the Structural Analysis of Social Behavior (SASB). Male staff seemed less influenced by the patient, with their feelings relating mainly to aspects of their own self-image, while the feelings of the female staff were more related to the patient's self-image. The patient's diagnosis was less important for a staff member's feelings than that member's self-image. Generally, the relation between feelings and self-image was stronger for negative feelings. The results point to the importance of understanding more about the influence of staff members' self-structure on their negative feelings toward their patients and how this relates to both the staff member's and patient's gender.

  • 2.
    Ekeblad, Annika
    et al.
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences. Sundsvall Hospital, Sweden.
    Falkenström, Fredrik
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Uppsala University, Sweden.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Reflective Functioning as Predictor of Working Alliance and Outcome in the Treatment of Depression2016In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 84, no 1, p. 67-78Article in journal (Refereed)
    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.

  • 3.
    Falkenström, Fredrik
    et al.
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Ekeblad, Annika
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Sandell, Rolf
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Patient Reflective Functioning as Predictor of Early Psychotherapy Process in the Treatment of DepressionManuscript (preprint) (Other academic)
    Abstract [en]

    Aims: Despite considerable clinical attention to the concept of mentalization in psychotherapy, research on mentalization and the psychotherapy process is virtually absent. Using data from two ongoing randomized controlled trials of psychotherapy for depression, we studied mentalization in 45 patients diagnosed with DSM-IV Major Depressive Disorder. The initial psychotherapy process was hypothesized to be experienced as more difficult with patients showing lower capacity for mentalization because of their difficulty understanding behavior in terms of mental states.

    Methods: Mentalization was measured as Reflective Functioning (RF) on the Adult Attachment Interview, conducted before therapy start. Additionally, a measure of Depression-Specific Reflective Functioning (DSRF) measuring mentalization about depressive symptoms was tested. Psychotherapy process was measured by the Working Alliance Inventory – Short form (WAI-S) and the Feeling Checklist (FC), which were completed after each session by both therapist and patient.

    Results: Pre-treatment RF on the AAI was on average low (M = 3.1), but variation in RF did not predict any aspect of the initial (first four sessions) psychotherapy process. Higher DSRF predicted better working alliance and more positive feelings as rated by the patient. RF on the AAI did not predict any process measure significantly.

    Discussion: The low RF in depression replicates two previous studies, and may help explaining why maternal depression is a risk factor for infant developmental problems. If the results for DSRF are replicated, this measure might be used for identifying patients who are not easy candidates for psychotherapy.

  • 4.
    Falkenström, Fredrik
    et al.
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Granstrom, Fredrik
    Uppsala University, Sweden.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Therapeutic Alliance Predicts Symptomatic Improvement Session by Session2013In: Journal of counseling psychology, ISSN 0022-0167, E-ISSN 1939-2168, Vol. 60, no 3, p. 317-328Article in journal (Refereed)
    Abstract [en]

    The therapeutic alliance has been found to predict psychotherapy outcome in numerous studies. However, critics maintain that the therapeutic alliance is a by-product of prior symptomatic improvements. Moreover, almost all alliance research to date has used differences between patients in alliance as predictor of outcome, and results of such analyses do not necessarily mean that improving the alliance with a given patient will improve outcome (i.e., a within-patient effect). In a sample of 646 patients (76% women, 24% men) in primary care psychotherapy, the effect of working alliance on next session symptom level was analyzed using multilevel models. The Clinical Outcomes in Routine Evaluation–Outcome Measure was used to measure symptom level, and the patient version of the Working Alliance Inventory–Short form revised (Hatcher & Gillaspy, 2006) was used to measure alliance. There was evidence for a reciprocal causal model, in which the alliance predicted subsequent change in symptoms while prior symptom change also affected the alliance. The alliance effect varied considerably between patients. This variation was partially explained by patients with personality problems showing stronger alliance effect. These results indicate that the alliance is not just a by-product of prior symptomatic improvements, even though improvement in symptoms is likely to enhance the alliance. Results also point to the importance of therapists paying attention to ruptures and repair of the therapy alliance. Generalization of results may be limited to relatively brief primary care psychotherapy.

  • 5.
    Falkenström, Fredrik
    et al.
    Centre for Clinical Research Sörmland, Uppsala University, Sweden.
    Granström, Fredrik
    Centre for Clinical Research Sörmland, Uppsala University, Sweden.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Working alliance predicts psychotherapy outcome even while controlling for prior symptom improvement2014In: Psychotherapy Research, ISSN 1050-3307, E-ISSN 1468-4381, Vol. 24, no 2, p. 146-159Article in journal (Refereed)
    Abstract [en]

    Objective: Although the working alliance as been found to be a robust predictor of psychotherapy outcome, critics have questioned the causal status of this effect. Specifically, the effect of the alliance may be confounded with the effect of prior symptom improvement. The objective of the present study was to test this possibility. Method: A large dataset from primary care psychotherapy was used to study relationships between alliance and outcome using piecewise multilevel path analysis. Results: Initial symptom level and symptom change up to session three predicted the alliance at session three. Working alliance significantly predicted symptom change rate from session three to termination, even while controlling for several possible confounds. Conclusions: The alliance predicts outcome over and above the effect of prior symptom improvement, supporting a reciprocal influence model of the relationship between alliance and symptom change.

  • 6.
    Falkenström, Fredrik
    et al.
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences. Uppsala University, Sweden.
    Hatcher, Robert L.
    CUNY, NY 10021 USA.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Confirmatory Factor Analysis of the Patient Version of the Working Alliance Inventory-Short Form Revised2015In: Assessment (Odessa, Fla.), ISSN 1073-1911, E-ISSN 1552-3489, Vol. 22, no 5, p. 581-593Article in journal (Refereed)
    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.

  • 7.
    Falkenström, Fredrik
    et al.
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences. Uppsala University, Sweden.
    Hatcher, Robert L.
    CUNY, NY USA.
    Skjulsvik, Tommy
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Holmqvist Larsson, Mattias
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Development and Validation of a 6-item Working Alliance Questionnaire for Repeated Administrations During Psychotherapy2015In: Psychological Assessment, ISSN 1040-3590, E-ISSN 1939-134X, Vol. 27, no 1, p. 169-183Article in journal (Refereed)
    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.

  • 8.
    Falkenström, Fredrik
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Uppsala University, Sweden.
    Josefsson, Albin
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Berggren, Tore
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    How Much Therapy Is Enough? Comparing Dose-Effect and Good-Enough Models in Two Different Settings2016In: Psychotherapy, ISSN 0033-3204, E-ISSN 1939-1536, Vol. 53, no 1, p. 130-139Article in journal (Refereed)
    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.

  • 9.
    Falkenström, Fredrik
    et al.
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Markowitz, John C.
    New York State Psychiatric and Columbia University College of Physicians and Surgeons, New York, USA.
    Jonker, Hanske
    New York State Psychiatric and Columbia University College of Physicians and Surgeons, New York, USA and University of Utrecht, Netherlands .
    Philips, Björn
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Can psychotherapists function as their own controls? Meta-analysis of the crossed therapist design in comparative psychotherapy trials2013In: Journal of Clinical Psychiatry, ISSN 0160-6689, E-ISSN 1555-2101, Vol. 74, no 5, p. 482-491Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE:

    Clinical trials sometimes have the same therapists deliver more than 1 psychotherapy, ostensibly to control for therapist effects. This "crossed therapist" design makes controlling for therapist allegiance imperative, as therapists may prefer one treatment they deliver to the other(s). Research has established a strong relationship between principal investigators' allegiances and treatment outcome. Study therapists' allegiances probably also influence outcome, yet this moderating factor on outcome has never been studied.

    DATA SOURCES:

    English language abstracts in PsycINFO and MEDLINE from January 1985 to December 2011 were searched for keywords psychotherapy and randomized trial.

    STUDY SELECTION:

    The search yielded 990 abstracts that were searched manually. Trials using the same therapists in more than 1 condition were included.

    DATA EXTRACTION:

    Thirty-nine studies fulfilled inclusion criteria. Meta-regression analyses assessed the influence of researchers' allegiance on treatment outcome, testing the hypothesis that studies poorly controlling for therapist allegiance would show stronger influence of researcher allegiance on outcome. A single-item measure assessed researchers' reported attempts to control for therapist allegiance.

    RESULTS:

    Only 1 of 39 studies (3%) measured therapist treatment allegiance. Another 5 (13%) mentioned controlling for, without formally assessing, therapist allegiance. Most publications (67%) did not even mention therapist allegiance. In studies not controlling for therapist allegiance, researcher allegiance strongly influenced outcome, whereas studies reporting control for therapist allegiance showed no differential researcher allegiance. Researchers with cognitive-behavioral therapy allegiance described controlling for therapist allegiance less frequently than other researchers.

    CONCLUSIONS:

    The crossed therapist design is subject to bias due to differential psychotherapist allegiance. Worrisome results suggest that researchers strongly allied to a treatment may ignore therapist allegiance, potentially skewing outcomes. All clinical trials, and especially crossed therapist designs, should measure psychotherapist allegiance to evaluate this possible bias.

  • 10.
    Falkenström, Fredrik
    et al.
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Solbakken, Ole André
    Centre for Clinical Research Sörmland, Uppsala University, Sweden.
    Möller, Clara
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Lech, Börje
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Sandell, Rolf
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Reflective Functioning, Affect Consciousness, and Mindfulness: Are These Different Functions?2014In: Psychoanalytic psychology, ISSN 0736-9735, E-ISSN 1939-1331, Vol. 31, no 1, p. 26-40Article in journal (Refereed)
    Abstract [en]

    Aims: Concepts of mentalization, affect consciousness, and mindfulness have been increasingly emphasized as crucial in psychotherapy of diverse orientations. Different measures have been developed that purportedly measure these concepts, but little is known about their interrelationships. We discuss conceptual overlaps and distinctions between these three concepts, and present results from a preliminary empirical study comparing their measures.

    Methods: To study the relationships between these concepts, data from a group of psychotherapy students (N = 46) was used. Mentalization operationalized as Reflective Functioning (RF) was rated on transcripts of a brief version of the Adult Attachment Interview, the Five Facet Mindfulness Questionnaire (FFMQ) was used to measure mindfulness, and the Affect Consciousness Interview-Self/Other version (ACI-S/O) to measure affect consciousness.

    Results: There was a small but statistically significant relationship between RF and FFMQ, but surprisingly no relationship between AC-S/O and RF or FFMQ. A post-hoc analysis showed a relationship between consciousness of others’ affects and a reduced version of the RF scale.

    Discussion: Results confirm that mentalization and mindfulness share some  common variance, but contrary to expectations affect consciousness seems to be more different from RF and mindfulness than expected. A possible explanation for the counterintuitive finding of no relationship between RF and affect consciousness is that affect consciousness measures a mature capacity for mentalized affectivity, while RF (especially at the high end) is largely a buffer against trauma and adversity. Low or absent findings for the FFMQ are explained more in terms of different methods variance.

  • 11.
    Gradin Franzén, Anna
    et al.
    Stockholm University, Sweden.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    From punishmentto rewards?: Treatment dilemmas at a youth detention home2014In: Punishment & Society, ISSN 1462-4745, E-ISSN 1741-3095, Vol. 16, no 5, p. 542-559Article in journal (Refereed)
    Abstract [en]

    The present article analyses staff members’ discourses on the treatment method token economy, as it is implemented at a detention home for young men. The study draws on interviews with eight staff members and on participant observations at the detention home. Using discursive psychology, the analysis centers on the staff members’ own constructions of token economy as well as paradoxes and dilemmas that appear in their talk. Two paradoxes were found: (1) paradox of transparency and interpretation; token economy is objective and transparent, but requires interpretative work over time; and (2) paradox of rewards and punishments; tokens are rewards, but they can be ‘zeroed’ or withdrawn in order to limit undesirable behavior. Further, the analysis showed that both paradoxes invoke a principal ideological dilemma of control – freedom, which staff members attempt to resolve by positioning the young men as responsible for their own actions and themselves as subordinate parties in the outcome of ‘objective’ token economy practices.

  • 12.
    Holmqvist Larsson, Mattias
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Falkenström, Fredrik
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Center for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Alliance ruptures and repairs in psychotherapy in primary care2018In: Psychotherapy Research, ISSN 1050-3307, E-ISSN 1468-4381, Vol. 28, no 1, p. 123-136Article in journal (Refereed)
    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.

  • 13.
    Holmqvist, Rolf
    Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Behavioural Sciences.
    Associations between staff feelings toward patients and treatment outcome at psychiatric treatment homes2000In: Journal of Nervous and Mental Disease, ISSN 0022-3018, E-ISSN 1539-736X, Vol. 188, no 6, p. 366-371Article in journal (Refereed)
    Abstract [en]

    This paper presents, as part of a national Swedish research project, a study of associations between staff feelings toward patients and treatment outcome at 23 small psychiatric inpatient units. The outcome was measured with a composite scale based on structured interviews. Staff feelings were reported on a feeling checklist. Few and scattered correlations were found between staff feelings and treatment outcome when the whole group of patients was analyzed together. More meaningful patterns were found when data for psychotic and borderline patients were analyzed separately. For psychotic patients, positive outcome was associated with low levels of negative feelings throughout treatment. For borderline patients, positive outcome was associated with negative feelings at the beginning of treatment, followed by strong positive feelings in the later part. Staff feelings were more strongly associated with outcome for borderline patients than for psychotic patients. Patients with different structural diagnoses need different kinds of staff 'feeling milieus'.

  • 14.
    Holmqvist, Rolf
    Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Behavioural Sciences.
    Change in self-image and PTSD symptoms in short-term therapies with traumatized refugees2006In: Psychoanalytic Psychotherapy, ISSN 0266-8734, E-ISSN 1474-9734, Vol. 20, no 4, p. 251-265Article in journal (Refereed)
    Abstract [en]

    In this study, an attempt was made to evaluate changes in the self-image of traumatized refugees receiving short-term psychotherapy. Fourteen clients with war and torture experiences were followed during and after trauma-focused therapies with self-rating instruments. Outcome was measured with SCL-90, measuring overall psychiatric symptoms, and with PTSS-10, measuring Post-traumatic Stress Disorder (PTSD) symptoms. Self-image was measured with Structural Analysis of Social Behavior (SASB). The analyses showed considerable remission of both general psychiatric and PTSD-related symptoms, but more moderate changes in self-image aspects. The positive aspect of the self-image was virtually non-related to the symptom measures and did not change after the termination of the therapy, the negative aspect of the self-image was more strongly related to the symptoms and changed mainly on the last measurement occasion, 15 months after the therapy end. When clients with good and poor outcome were compared, it was found that those with good outcome had higher initial levels on both the positive and the negative aspects of the self-images. This was tentatively interpreted as indicating that clients who had invested more energy in their self-image were better able to utilize the therapy. Different development in the self-image for these two groups indicated that for some clients, the treatment process might have entailed too much strain.

  • 15.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences.
    Countertransference in milieu therapy - how much to the therapist's feelings change over time?1998In: Psychiatric care, ISSN 1352-9579, Vol. 5, p. 130-137Article in journal (Refereed)
  • 16.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences.
    Flickor som skadar sig själva. En kartläggning av problemets omfattning och karaktär2004Other (Other (popular science, discussion, etc.))
  • 17.
    Holmqvist, Rolf
    Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Behavioural Sciences.
    Methods of identifying conspicuous countertransference reactions1996In: British journal of psychotherapy, ISSN 0265-9883, Vol. 12, p. 487-450Article in journal (Refereed)
  • 18.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences.
    On the importance of congruence between psychiatric staff and patient about the patient's status.2000In: International Journal of Psychiatric Nursing Research, ISSN 0968-0624, Vol. 5, no 3, p. 622-637Article in journal (Refereed)
    Abstract [en]

    This study explores the usefulness of a method for comparing the congruence of the staff's and the patients' perceptions of the patients' well-being. At a psychiatric rehabilitation clinic, a comparison was made between the patients' and the staff's views of the patients' well-being. The staff and the patients completed questionnaires about the patients' well-being on ten occasions during a 5-year period. Through a principal components analysis of the questionnaire scores, two conceptually similar dimensions (health-illness, and contact-distance) were identified on each set of scores. The staff and patient ratings on the two dimensions could thus be compared. During the time of the study, a reorganisation of the clinic was made. This made it possible to compare older and newer units. The results indicated that the staff at long-existing units rated the patients' health as lower than the patients did, whereas the staff at newer units rated the patients' health as better than the patients did. The staff at units where the patients lived in their own apartments saw the patients as less contact-seeking than the patients did, and the staff at in-patient units saw the patients as more contact-seeking than the patients did. The two-dimensional PC-models made it possible to visually illustrate the developments for three individual patients. The results thus showed that the method is useful for research purposes as well as for clinical evaluations. In the final section, problems and assets of the method are discussed.

  • 19.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences.
    Patterns of consistency and deviation in therapists' countertransference feelings2001In: Journal of Psychotherapy Practice and Research, ISSN 1055-050X, Vol. 10, no 2, p. 104-116Article in journal (Refereed)
    Abstract [en]

    The author addressed the question of consistency in psychotherapists' countertransference feelings. Research findings have indicated that the therapist's own personal feeling style may be more important than the patient's impact on the therapist's feelings. In this study, the feelings of 9 psychotherapists toward 28 patients were followed by using checklist self-report after each session during moderately long psychotherapies. ANOVAs and discriminant analyses showed that the therapists were very consistent in their feeling style over different patients and over time. The consistency in feelings toward the individual patients was smaller. Deviations from consistency are analyzed, and their importance for the understanding of different aspects of the countertransference is discussed. It is suggested that a meaningful use of the countertransference concept ought to be based on systematic identifications of recurrent and deviant patterns in the therapist's reactions.

  • 20.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences. Linköping University, Faculty of Arts and Sciences.
    Psychopathy and affect consciousness in young criminal offenders2008In: Journal of Interpersonal Violence, ISSN 0886-2605, E-ISSN 1552-6518, Vol. 23, no 2, p. 209-224Article in journal (Refereed)
    Abstract [en]

    A key characteristic of psychopathy is the individual's problematic relation to certain affects, particularly shame. Previous research has studied relations between expressed shame and psychopathy. In this study, the author analyzes potential associations between psychopathy and consciousness of feelings (i.e., participants' ability to recognize and tolerate the feeling and describe how they believe it is expressed in their posture and verbal expressions). Psychopathy is assessed with the Psychopathy Checklist: Screening Version, and affect consciousness is assessed with a semistructured interview. Additionally, risk for criminal behavior, moral reasoning, cognitive distortions, and attachment style in the participants was assessed. The participants are 47 adolescent boys who were treated at juvenile delinquency homes. The results indicate that boys with higher ratings of psychopathy had lower consciousness of shame feelings and lower empathy scores. The results in combination with qualitative analyses of the interview answers are interpreted as indicating that consciousness of shame is specifically problematic for psychopathic adolescents.

  • 21.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences.
    Samhällets insatser för LSU-dömda ungdomar efter verkställigheten. Ungdomarnas, föräldrarnas och socialtjänstens perspektiv2002Other (Other (popular science, discussion, etc.))
  • 22.
    Holmqvist, Rolf
    Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Behavioural Sciences and Learning.
    Staff feelings and patient diagnosis2000In: Canadian journal of psychiatry, ISSN 0706-7437, Vol. 45, no 4, p. 349-356Article in journal (Refereed)
    Abstract [en]

    Objective: To assess the associations between staff feelings toward patients and the patients' diagnoses, in view of the fact that clinical reports of such associations have not been corroborated by systematic research. Method: At 24 psychiatric units, 143 patients were assessed according to their personality organization, and staff feelings toward these patients were followed for 5 years. The feelings were reported on a feeling checklist twice yearly, and outcome was assessed as the effect size at year 5, using ratings on Kernberg's structural model complemented with ratings on Strauss-Carpenter's function scale. Results: The study showed that it was possible, using discriminant analyses, to separate diagnostic groups by the different feelings that they evoked in the staff: Patients with borderline personality organization (BPO) evoked fewer relaxed and more aggressive feelings, in contrast to patients with psychotic personality organization (PPO). In contrast to patients with neurotic personality organization (NPO), who evoked feelings of sympathy and helpfulness, PPO patients evoked more feelings of insufficiency and disappointment. A stepwise discriminant analysis of reactions to patients with positive treatment outcome separated the 3 personality organizations with 2 functions using only 2 feelings, "relaxed" and "objective. " The feeling relaxed separated the NPO patients from the BPO patients, and the feeling objective separated the PPO patients from the other groups. The patients' diagnoses accounted for larger proportions of variance in feelings for the patients with positive outcome. Conclusion: The results implied that the patients' different personality organizations evoked different staff feelings in this treatment context and that positive treatment outcome was associated with more pronounced and clear-cut staff reactions.

  • 23.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences.
    The influence of patient diagnosis and self-image on clinicians' feelings1998In: Journal of Nervous and Mental Disease, ISSN 0022-3018, E-ISSN 1539-736X, Vol. 186, p. 455-461Article in journal (Refereed)
  • 24.
    Holmqvist, Rolf
    et al.
    Linköping University, Department of Behavioural Sciences.
    Andersen, K.
    Therapists' reactions to treatment of survivors of political torture2003In: Professional psychology, research and practice, ISSN 0735-7028, E-ISSN 1939-1323, Vol. 34, no 3, p. 294-300Article in journal (Refereed)
    Abstract [en]

    Working with survivors of political torture and war trauma can trigger strong emotional responses in the therapist. As more survivors seek treatment, it is essential to identify and develop robust support systems for therapists who help their clients confront nearly unspeakable experiences. The emotional reactions of 6 psychotherapists who worked with traumatized survivors in a refugee treatment center were explored. The psychotherapists' reactions were compared with those of therapists who worked in different treatment settings with other presenting problems. The results of the study show that the strong level of responsibility therapists feel for their traumatized clients may hide an emotional strain and may lead to burnout. Suggestions are offered for supporting therapists in this difficult but important work.

  • 25.
    Holmqvist, Rolf
    et al.
    Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Behavioural Sciences and Learning.
    Armelius, B.-A.
    Armelius, B.-Å., Department of Psychology, Umeå University, Sweden.
    Sources of psychiatric staff members' feelings towards patients and treatment outcome2006In: Psychology and Psychotherapy: Theory, Research and Practice, ISSN 1476-0835, E-ISSN 2044-8341, Vol. 79, no 4, p. 571-584Article in journal (Refereed)
    Abstract [en]

    This study had two purposes. The first was to assess to what extent psychiatric staff members' feelings towards patients in small psychiatric units could be attributed to (a) the individual staff member's habitual feeling style, (b) stable and consistent feelings towards individual patients (the patient's evocative style) and (c) the interaction between these two factors. The second purpose was to analyse the associations between the proportions of these factors and the average outcome for the patients in the units. The study was based on a previously presented model for analysing sources of staff counter-transference. The model specifies contributions from the different sources by using two-way ANOVAs. In the present study, data from 21 psychiatric treatment units for patients with psychosis and personality disorder were used. The results indicated that the staff members' individual habitual feeling style and the interaction between this habitual feeling style and the patient's evocative style contributed most to the variance in staff feelings. Patients' individual evocative patterns contributed less. Positive treatment outcome was mainly negatively associated with contributions to the staff counter-transference from these sources, implying that fixed patterns in personal feeling style or fixed reaction styles to individual patients had a negative influence on outcome. © 2006 The British Psychological Society.

  • 26.
    Holmqvist, Rolf
    et al.
    Linköping University, Department of Behavioural Sciences.
    Armelius, B-Å.
    Emotional reactions to psychiatric patients1994In: Acta Psychiatrica Scandinavica, ISSN 0001-690X, E-ISSN 1600-0447, Vol. 90, p. 204-209Article in journal (Refereed)
  • 27.
    Holmqvist, Rolf
    et al.
    Linköping University, Department of Behavioural Sciences.
    Armelius, B-Å.
    Sources of therapists' countertransference feelings1996In: Psychotherapy research : official journal of the Society for Psychotherapy Research, ISSN 1050-3307, Vol. 6, p. 70-78Article in journal (Refereed)
  • 28.
    Holmqvist, Rolf
    et al.
    Linköping University, Department of Behavioural Sciences.
    Armelius, B-Å.
    The patient's contribution to the therapist's countertransference feelings1996In: Journal of Nervous and Mental Disease, ISSN 0022-3018, E-ISSN 1539-736X, Vol. 184, p. 660-666Article in journal (Refereed)
  • 29.
    Holmqvist, Rolf
    et al.
    Linköping University, Department of Behavioural Sciences.
    Armelius, K.
    Associations between psychiatric patients' self-image, staff feelings towards them, and treatment outcome2004In: Psychiatry Research, ISSN 0165-1781, E-ISSN 1872-7123, Vol. 128, no 1, p. 89-102Article in journal (Refereed)
    Abstract [en]

    Interpersonal theory, as well as relational models of psychoanalytic and cognitive therapy, posits the importance for positive treatment outcome of the therapist's becoming emotionally involved in the patient's interpersonal patterns. Using the same data as in this study, we have previously found associations between psychiatric patients' self-image and the staff's feelings towards them, and differential associations between staff feelings and outcome for different diagnostic groups. The purpose of the present study was to analyze potential connections between patients' self-image, staff feelings, and outcome. Twice a year, staff at small psychiatric units reported their feelings towards 63 psychotic and 21 borderline patients who had rated their self-image at the beginning of the treatment using the Structural Analysis of Social Behavior (SASB) introject and parent images. Feelings reported on the two first occasions at the beginning of the treatment were used. Outcome was assessed after 5 years. Correlation analyses found different associations between patient self-image and staff feelings for patients with favorable and less favorable outcome. The results indicated for psychotic patients associations between positive outcome and less distant staff feelings connected with the patient's freedom-giving introject, less unfree staff feelings connected with a negative image of mother and less positive feelings connected with a positive image of father. For the borderline patients, positive outcome was associated with the fact that a negative image of mother did not evoke helpful staff feelings, a positive image of the patient himself or herself did not evoke helpful staff feelings and a controlling image of father-evoked distant feelings. © 2004 Elsevier Ireland Ltd. All rights reserved.

  • 30.
    Holmqvist, Rolf
    et al.
    Linköping University, Department of Behavioural Sciences.
    Armelius, K.
    Countertransference feelings and the psychiatric staff's self-image2000In: Journal of Clinical Psychology, ISSN 0021-9762, E-ISSN 1097-4679, Vol. 56, no 4, p. 475-490Article in journal (Refereed)
    Abstract [en]

    This paper presents a study of associations between psychiatric staff's habitual feelings towards their patients and the staff's self-image. At 22 psychiatric treatment homes for psychotic and other severely disturbed patients, 163 male and female staff recurrently rated their feelings towards the individual patients on a feeling checklist. At the beginning of the study period, they also rated different aspects of their self-image (the introject and the mother and father images) using Structural Analysis of Social Behavior (SASB). Over time and over patient, correlations between the individual staff ratings on the feeling checklist and ratings on the SASB were studied for all staff and for male and female staff separately. The analyses showed a number of associations between the staff's feelings and aspects of their self-image. Staff who habitually tended to feel helpful and autonomous towards their patients had a more positive image of mother, whereas staff who tended to feel more rejecting, unhelpful, and controlled had a combination of negative images of mother and father and a protecting introject. Some notable differences between male and female staff were found. Overall, self-image accounted for larger proportions of the male staff's feelings than of the female staff's. Negative feelings for male staff were associated more-with a critical father image, whereas for female staff these feelings were associated more with an image of the father as a freedom giving. (C) 2000 John Wiley and Sons, Inc.

  • 31.
    Holmqvist, Rolf
    et al.
    Linköping University, Department of Behavioural Sciences.
    Armelius, K.
    Psychiatric patients' self-image and staff feelings towards them related to gender combinations2004In: Psychoanalytic Psychotherapy, ISSN 0266-8734, E-ISSN 1474-9734, Vol. 18, no 2, p. 182-201Article in journal (Refereed)
    Abstract [en]

    Psychiatric patients' influence on therapists' feelings has received much clinical attention but scant interest among empirical researchers. In this study, the staff at 25 small psychiatric treatment units for mainly psychotic patients reported their feelings towards the patients twice a year over 5 years. At intake, the patients completed the self-rating version of the Structural Analysis of Social Behavior (SASB) protocol, a circumplex model intended to capture internalized perceptions of self and others. The instrument included ratings of the introject and ratings of how the individual remembered that mother and father had treated him or her in childhood. Correlations between the patients' SASB scores and the staff members' average feelings towards the patients were assessed. The associations varied in the different gender combinations, but some overarching patterns were found. Patients scoring high on both the spontaneous and the controlling introject evoked accepting staff feelings, and patients reporting low scores on both these SASB aspects evoked rejecting feelings. These associations were interpreted as reflecting influence from the patients' engagement in and struggle with themselves on the treatment process. Staff identification with a parent figure was particularly evident in the female staff-male patient combination, where the patient's positive image of mother was associated with positive staff feelings towards the patient. © 2004 The Association for Psychoanalytic Psychotherapy in the NHS.

  • 32.
    Holmqvist, Rolf
    et al.
    Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Behavioural Sciences and Learning.
    Carlberg, M.
    National Board for Health and Welfare, Stockholm, Sweden.
    Hellgren, L.
    National Board for Health and Welfare, Stockholm, Sweden.
    Deliberate self-harm behaviour in Swedish adolescent girls reports from public assessment and treatment agencies2008In: Child and Youth Care Forum, ISSN 1053-1890, E-ISSN 1573-3319, Vol. 37, no 1Article in journal (Refereed)
    Abstract [en]

    Self-harming behaviour among adolescents, and particularly adolescent girls, has evoked much public attention. This article presents a Swedish study about what information assessment and treatment agencies have about self-harming behaviour in the form of cutting and burning in adolescent girls. The study was made on assignment by the Swedish National Board of Health and Welfare. All public agencies assessing or treating adolescents with psychological problems in three Swedish cities were asked to deliver information about self-harming behaviour in the form of self-cutting or self-burning in girls between 13 and 18 years of age. In addition, the young offender institutions within the National Board of Institutional Care treating teenager girls were asked to deliver information about self-harming behaviour in their clients. We found that about 1% of the total population of girls in these ages were known to have cut or burnt themselves and about one third of the girls in the institutions. Attempts to distinguish subgroups among the girls were only partly successful. Although some subgroups could be identified, the overlap between them was large. The conclusion was that this behaviour may be seen as an expression of a wide variety of problems in a heterogeneous group of young persons. © 2007 Springer Science+Business Media, LLC.

  • 33.
    Holmqvist, Rolf
    et al.
    Linköping University, Department of Behavioural Sciences.
    Fogelstam, H.
    Psychological climate and countertransference in psychiatric treatment homes1996In: Acta Psychiatrica Scandinavica, ISSN 0001-690X, E-ISSN 1600-0447, Vol. 93, p. 288-295Article in journal (Refereed)
  • 34.
    Holmqvist, Rolf
    et al.
    Linköping University, Department of Behavioural Sciences.
    Hansjons-Gustafsson, U.
    Gustafsson, J.
    Patients' relationship episodes and therapists' feelings2002In: Psychology and Psychotherapy: Theory, Research and Practice, ISSN 1476-0835, E-ISSN 2044-8341, Vol. 75, no 4, p. 393-409Article in journal (Refereed)
    Abstract [en]

    The idea that psychotherapists' feelings may reflect some aspect of the content in the patients' material has long been clinically accepted but on the whole poorly systematically studied. The aim of this study was to analyse associations between relationship episodes told by patients at evaluation interviews, and therapists' subsequent feelings towards the patients. In total, 28 psychotherapies with nine psychotherapists were studied. Before therapy started, the clients were interviewed separately by the eventual therapist and a second interviewer and six relationship episodes were written down by the interviewers. During the therapy, the therapists reported their feelings on a 'feeling checklist' after each therapy session. In a first analysis, the relationship episodes were categorized according to the CCRT system. The results indicated only scattered associations between CCRT categories and therapist feelings. The results were, however, difficult to interpret as it was found that the therapists' feeling patterns were quite homogenous for each therapist. Considering this, qualitative analyses were made of six therapies carried out by two therapists. These analyses revealed different but theoretically plausible patterns between the feelings attributed to the persons in the patients' relationship episodes and the therapists' subsequent feelings towards the patients. The results were interpreted as a confirmation of the purported relations between patient relationship episodes and therapist feelings, but also as pointing to the need to develop the understanding of these patterns. It seems particularly important to emphasize the importance of the therapist's own habitual feeling patterns when the impact of the patient's internalized relationship patterns on countertransference reactions is evaluated.

  • 35.
    Holmqvist, Rolf
    et al.
    Linköping University, Department of Behavioural Sciences.
    Hill, T.
    Lang, A.
    Ger ART bättre behandlingseffekter? Utvärdering av metoder på tre ungdomshem2005Report (Other academic)
  • 36.
    Holmqvist, Rolf
    et al.
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Hill, Teci
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Lang , Annicka
    Effects of Aggression Replacement Training in Young Offender Institutions2009In: INTERNATIONAL JOURNAL OF OFFENDER THERAPY AND COMPARATIVE CRIMINOLOGY, ISSN 0306-624X , Vol. 53, no 1, p. 74-92Article in journal (Refereed)
    Abstract [en]

    This article reports a study where aggression replacement training ( ART), combined with token economy, was compared with relationally oriented treatment at four residential treatment units in a nonrandomized design. In all, 57 adolescents in the ages between 16 and 19 participated. Outcome was measured as weighted indices of sentences and police suspicion reports. The results show no differences between the treatment models. In a separate analysis, the hypotheses were tested that those adolescents would relapse less frequently who admitted their crimes at intake or who could talk about guilt for their criminal acts. These hypotheses were refuted as main effects, but an interaction effect was found that suggests that adolescents with less consciousness of guilt got better results at the ART institutions. Case descriptions suggest that a more individualized approach to treatment, where ART is used for those adolescents who are motivated for it, would give better results.

  • 37.
    Holmqvist, Rolf
    et al.
    Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Behavioural Sciences.
    Hill, Teci
    Lang, Annicka
    Treatment alliance in residential treatment of criminal adolescents2007In: Child and Youth Care Forum, ISSN 1053-1890, E-ISSN 1573-3319, Vol. 36, no 4, p. 163-178Article in journal (Refereed)
    Abstract [en]

    Research on relationship aspects in residential treatment of criminal young persons has largely been neglected despite the general finding in treatment research that such aspects have a large bearing on outcome. In this article, two studies of associations between relationship aspects and outcome in this treatment context are presented. In one of them, two treatment units practicing Aggression Replacement Training and CBT-techniques and 2 U with more conventional, relationally oriented treatment approaches were studied using process questionnaires and interviews. In the other study, adolescents who had been sentenced to treatment were interviewed about treatment experiences 1 year after release. Despite considerable attrition, several interesting findings were noted: The boys' alliance ratings were associated with the collaborative aspect of the staff's alliance ratings, but not with the bond aspect, warm and close staff feelings were related to negative outcome and the boys' conceptions of the treatment model but not of the relationship with the staff was associated with positive outcome. The results suggest that a distinction should be made between a mutual bond aspect of the staff-boy relationship that was not related to outcome and a collaborative aspect which was related to outcome. © 2007 Springer Science+Business Media, LLC.

  • 38.
    Holmqvist, Rolf
    et al.
    Linköping University, Department of Behavioural Sciences. Linköping University, Faculty of Arts and Sciences.
    Jeanneau, M.
    Burnout and psychiatric staff's feelings towards patients2006In: Psychiatry Research, ISSN 0165-1781, E-ISSN 1872-7123, Vol. 145, no 2-3, p. 207-213Article in journal (Refereed)
    Abstract [en]

    The concept of burnout describes a number of destructive aspects in work relationships. In this study, the relations between psychiatric staff members' feelings towards their patients and burnout were analyzed. Staff feelings were measured with a feeling checklist, and burnout with BM (Burnout Measure) and MBI (Maslach's Burnout Inventory). The staff at 28 treatment units rated their feelings towards the patients as a group. The results indicated that high burnout was associated with negative feelings and low levels of burnout with positive feelings towards patients. The correlation patterns for the different measures of burnout were somewhat different. BM had the strongest correlations with unhelpful and rejecting feelings towards patients, whereas Personal accomplishment, one dimension of MBI, was most strongly correlated with accepting and close feelings. The results were interpreted as opening for the question whether negative staff feelings towards patients most profitably can be seen as an aspect of burnout or whether these two phenomena should be distinguished clinically and theoretically. © 2006 Elsevier Ireland Ltd. All rights reserved.

  • 39.
    Holmqvist, Rolf
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Philips, Björn
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Barkham, Michael
    University of Sheffield, UK.
    Developing practice-based evidence: Benefits, challenges, and tensions2015In: Psychotherapy Research, ISSN 1050-3307, E-ISSN 1468-4381, Vol. 25, no 1, p. 20-31Article in journal (Refereed)
    Abstract [en]

    Attempts to regulate service delivery in line with results from randomized trials have been vigorously debated. In this paper, results from practice-based studies using the CORE System illustrate the potential to enrich knowledge about the actual outcome of psychological therapy in routine care. These studies also provide data for important questions in psychotherapy research, like orientation differences, the importance of the therapist factor, number of sessions needed for clinical effect, and the alliance-outcome question. Obstacles and challenges in making such studies are illustrated. In conclusion, arguments are put forward for introducing a common measurement system that strikes a balance between clinicians' questions and the need for comparable data, and that encompasses the complexities of patients' reasons for seeking psychological help.

  • 40.
    Holmqvist, Rolf
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Philips, Björn
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Barkham, Michael
    University of Sheffield, England.
    Implementing routine outcome monitoring in clinical practice: Benefits, challenges, and solutions2015In: Psychotherapy Research, ISSN 1050-3307, E-ISSN 1468-4381, Vol. 25, no 1, p. 20-31Article in journal (Refereed)
    Abstract [en]

    This article reviews the benefits, obstacles, and challenges that can hinder (and have hindered) implementation of routine outcome monitoring in clinical practice. Recommendations for future routine outcome assessment efforts are also provided. Spanning three generations, as well as multiple developed tools and approaches, the four authors of this article have spent much of their careers working to address these issues and attempt to consolidate this learning and experience briefly here. Potential "elephants in the room" are brought into the discussion wherever relevant, rather than leaving them to obstruct silently the fields efforts. Some of these topics have been largely ignored, yet must be addressed if we are to fulfill our promise of integrating science and practice. This article is an attempt to identify these important issues and start an honest and open dialogue.

  • 41.
    Holmqvist, Rolf
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Philips, Björn
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Mellor-Clark, John
    CORE Informat Management Syst, England.
    Client and therapist agreement about the clients problemsAssociations with treatment alliance and outcome2016In: Psychotherapy Research, ISSN 1050-3307, E-ISSN 1468-4381, Vol. 26, no 4, p. 399-409Article in journal (Refereed)
    Abstract [en]

    Objective: A shared understanding of the patients symptoms and problems is seen by most theories as a crucial aspect of the collaboration in therapy, presumably influencing alliance and outcome. The empirical ground for this argument is not solid, however. Several studies have found weak associations between a common view of the patients problems and outcome. The purpose of the present study was to analyze whether agreement in the understanding of the patients depression and anxiety problems was important for alliance and outcome. Method: The study used data from a practice-based study using the CORE system with 846 patients who received psychological treatment in primary care. Results: The analyses indicated that although patients who were assessed by their therapists as having depression and anxiety problems scored higher on these subscales than other patients, about half of the patients reported such problems when the therapists did not, and vice versa. Agreement was not associated with better alliance or outcome. Conclusions: Productive collaboration in psychotherapy may be based on other factors than agreement about symptoms.

  • 42.
    Holmqvist, Rolf
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Ström, Thomas
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Foldemo, Anniqa
    Linköping University, Department of Medical and Health Sciences, Division of Nursing Science. Linköping University, Faculty of Health Sciences.
    The effects of psychological treatment in primary care in Sweden—A practice-based study2014In: Nordic Journal of Psychiatry, ISSN 0803-9488, E-ISSN 1502-4725, Vol. 68, no 3, p. 204-212Article in journal (Refereed)
    Abstract [en]

    Background: Practice-based studies have found substantial effects of psychological treatment in routine care, often equivalent between treatment methods. Factors that moderate treatment outcome may be important to assess.

    Aim: The purpose of this study was to evaluate treatment outcome in psychological treatment in primary care, and to compare outcome between the most frequently used methods. An additional aim was to study factors that might moderate outcome differences.

    Method: The Clinical Outcome in Routine Evaluation (CORE) system was used to evaluate psychological treatment at Swedish primary care centers. Treatment methods were coded by the therapists after treatment. Three major treatment orientations-directive (cognitive, behavioral and CBT), reflective (psychodynamic and relational) and supportive therapy were compared. Patient and therapist variables were studied as treatment moderating factors.

    Results: Analyses of 733 therapies, delivered by 70 therapists, showed good results in short psychological treatments (median session number = 6). Forty-three percent of the patients were remitted, 34% recovered. For patients receiving at least five sessions, the figures were 50% and 40%. Directive therapy and reflective therapy had comparable outcome, and better than supportive treatment. Patients in supportive therapy had higher age and received fewer therapy sessions. The patients' motivation, alliance capacity and reflective ability, as rated by the therapist after treatment, were lower for patients in supportive treatment.

    Conclusions: Psychological treatment in primary care obtains god results. Supportive therapy should be studied more systematically, particularly with regard to variables that may moderate treatment outcome.

     

  • 43.
    Johnson Frankenberg, Sofia
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Rubenson, Birgitta
    Department of Public Health Sciences Karolinska Institute, SE- 171 77 Stockholm, Sweden.
    In Earlier Days Everyone Could Discipline Children, Now They Have Rights: Notions of Responsibility in Focus Group Discussions about Care Giving in urban Tanzania2014In: Journal of Community and Applied Social Phychology, ISSN 1052-9284, E-ISSN 1099-1298, Vol. 24, no 3, p. 191-204Article in journal (Refereed)
    Abstract [en]

    The title of this paper ‘In earlier days we could discipline our children, now they have rights’ is a citation from a focus group discussion undertaken with a group of adult caregivers in Tanzania regarding their guidance and control of their children. It illustrates a dilemma that some caregivers are struggling to make sense of within the current discursive order on the guidance and control of children. In a previous study regarding discipline strategies in urban Tanzania, we have found a discourse regarding the necessity of using corporal punishment in order to properly raise children, findings which are in line with other studies indicating the frequent use of corporal punishment as discipline strategy in East Africa. On a different note, there is an ideological call for change for children and the Government, as well as civil society organizations and other international and bilateral organizations use the Convention on the Rights of the Child (CRC) to argue for the importance of improving the conditions of childhood in Tanzania. The new Child Act (United Republic of Tanzania, 2009) is a landmark in this process as it significantly strengthens the legal rights of the child. It also represents an ideological position in terms of child-adult relationships, regulating the responsibilities of both caregivers and children. In terms of guidance and control of children, the wording of the act was a field of ideological debate concerning the issue of corporal punishment, with some stakeholders advocating for the total ban of corporal punishment. The endorsed version of the Child Act regulates the manner of administering discipline on children but it does not explicitly prohibit corporal punishment.

    It has been argued that the CRC represents an ideological and moralist discourse about childhood, based on Western ideals of an individualistic society and that it disregards the interdependence of human beings. Scholars have further raised concerns regarding the changing nature of childhood related to national development and globalization arguing that, rather than regarding individuals as constituted and fixed, vested with certain rights, it is necessary to focus on the relations in which identities are constructed and how these relationships are co-created by individuals in local space.

  • 44.
    Johnson Frankenberg, Sofia
    et al.
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Rubenson, Birgitta
    Karolinska Institute.
    The care of corporal punishment: Conceptions of early childhood discipline strategies among parents and grandparents in a poor and urban area in Tanzania2010In: Childhood, ISSN 0907-5682, E-ISSN 1461-7013, Vol. 17, no 4, p. 455-469Article in journal (Refereed)
    Abstract [en]

    This study investigates conceptions of early childhood discipline strategies discussed in focus groups with parents and grandparents in a poor urban area in Tanzania. A grounded theory analysis suggested a model that included four discipline strategies related to corporal punishment: to beat with care, to treat like an egg, as if beating a snake and the non-care of non-beating. In order to develop strategies to prevent corporal punishment in the home in accordance with the UN recommendation and article 19 in the Convention on the Rights of the Child, the power of caregiving needs further investigation.

  • 45.
    Johnson Frankenberg, Sofia
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Rubenson, Birgitta
    Department of Public Health Sciences Karolinska Institute, SE- 171 77 Stockholm, Sweden.
    Rindstedt, Camilla
    Department of Child and Youth Studies University of Stockholm, SE- 106 91 Stockholm, Sweden.
    Being and Becoming a Responsible Caregiver: Negotiating Guidance and Control in Family Relationships in Tanzania2013In: Childhood, ISSN 0907-5682, E-ISSN 1461-7013, Vol. 20, no 4, p. 487-506Article in journal (Refereed)
    Abstract [en]

    This study explores how siblings in Tanzania actively engage in their own socialization through the negotiation and local design of caregiving practices and control between younger siblings (age 1-3), older siblings (age 3-13) and adults. Analyses of moment-to-moment embodied, multimodal sequences of interaction illustrate how caregiving responsibility is negotiated. The analysis is multidisciplinary drawing on concepts developed in the traditions of sociology, language socialization and applied linguistics. The findings highlight the usefulness of a concept of socialization which recognizes the agency of the child and are discussed in relation to constructions of the caregiving child as both being and becoming.

  • 46.
    Johnson Frankenberg, Sofia
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Rubenson, Birgitta
    Karolinska Institute, Stockholm, Sweden.
    Rindstedt, Camilla
    Stockholm University, Stockholm, Sweden.
    Sibling negotiations and the construction of literacy events in an urban area of Tanzania2012In: International Journal of Educational Development, ISSN 0738-0593, E-ISSN 1873-4871, Vol. 32, no 6, p. 773-786Article in journal (Refereed)
    Abstract [en]

    This study presents findings from analyses of naturally occurring literacy events, where children jointly focus on reading and writing letters of the alphabet, illustrating social constructions of learning created through language and embodied action. Video recorded data from two different families living in an urban low-income area in Tanzania is presented to illustrate the findings. The analysis shows how participation frameworks are negotiated in terms of symmetries and asymmetries between younger and older siblings with both older and younger siblings initiating these frameworks: older siblings using different directives to guide the younger child’s focus of attention and younger children both following and resisting such strategies.

  • 47.
    Keselman, Henrich
    et al.
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Osvaldsson Cromdal, Karin
    Linköping University, Department of Thematic Studies, Department of Child Studies. Linköping University, Faculty of Arts and Sciences.
    Kullgard, Niclas
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Responding to mentalization invitations in psychotherapy sessions: A conversation analysis approach2018In: Psychotherapy Research, ISSN 1050-3307, E-ISSN 1468-4381Article in journal (Refereed)
    Abstract [en]

    Objective: Increase in the capacity to mentalize has been proposed to be an important mechanism of change in psychotherapy. However, mentalization has primarily been studied as an individual skill that people either possess or lack, rather than as an interactional phenomenon. 

    Method: In this study, excerpts from three different sessions in a therapy that aimed at increasing the patients mentalizing capacity were identified and studied using conversation analysis. 

    Results: The analysis indicated that resistance to mentalizing may not only be due to lack of capacity but also may be seen as a linguistic resource in which this resistance demonstrates precisely the ability to mentalize. 

    Conclusions: Consequences for psychotherapy practice and process research are discussed.

  • 48.
    Kullgard, Niclas
    et al.
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Persson, Per
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Möller, Clara
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Falkenström, Fredrik
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Reflective functioning in patients with obsessive–compulsive disorder (OCD) – preliminary findings of a comparison between reflective functioning (RF) in general and OCD-specific reflective functioning2013In: Psychoanalytic Psychotherapy, ISSN 0266-8734, E-ISSN 1474-9734, Vol. 27, no 2, p. 154-169Article in journal (Refereed)
    Abstract [en]

    Several scales for rating the reflective function (RF) in different psychiatric syndromes (symptom-specific reflective function [SRF]) have been developed. In this study, the validity of a rating instrument for measuring obsessive–compulsive disorder (OCD)-specific RF (OCD-SRF) was assessed. The study was conducted at two outpatient psychiatric facilities. A total of 18 women and 12 men were interviewed with adult attachment interview and the OCD–SRF interview. The patients also rated their symptoms on a self-rating scale (Yale-Brown Obsessive–Compulsive Scale [Y-BOCS]). The results indicated that there was a significant difference between the levels of RF in general and SRF. No correlations between Y-BOCS and RF or SRF were found. Illustrations of ratings are presented. The difference between RF and SRF, the relationship between SRF and symptom checklists, and a relational perspective on symptoms in OCD were discussed.

  • 49.
    Lech, Börje
    et al.
    Linköping University, Department of Behavioural Sciences. Linköping University, Faculty of Arts and Sciences.
    Andersson, Gerhard
    Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology.
    Holmqvist , Rolf
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Consciousness about own and others affects: A study of the validity of a revised version of the Affect Consciousness Interview2008In: Scandinavian Journal of Psychology, ISSN 0036-5564, E-ISSN 1467-9450, Vol. 49, no 6, p. 515-521Article in journal (Refereed)
    Abstract [en]

    Consciousness about own and others affects: A study of the validity of a revised version of the Affect Consciousness Interview.

    This study presents a modified version of the affect consciousness interview (Monsen, Eilertsen, Melgard & Odegard, 1996), intended to capture the individuals affective consciousness. The aim of the modified version - The Affect Consciousness Interview - Revised (ACI-R) - is to measure consciousness about own and others affects. Three groups of patients (with eating disorder, relational and social problems or stress-related problems), and one non-clinical group were included in the study (N = 95). The results indicated that it was possible to achieve adequate interrater reliability, that the scores correlated meaningfully with other measures of mental functioning, and that the interview discriminated between different clinical groups and non-clinical participants. In conclusion, the results of this study suggest that the ACI-R is a promising instrument and that it should be explored further in order to study the organization of self-experiences and the ability to be emotionally present in interactions with others.

  • 50.
    Lech, Börje
    et al.
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology. Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Affect Consciousness and Adult AttachmentManuscript (preprint) (Other academic)
    Abstract [en]

    The concept of affect consciousness refers to the ability to perceive, reflect upon, express and respond to one’s own or other individuals’ affective experiences. The aim of this study was to investigate how affect consciousness and adult attachment are related. Three clinical groups (eating disorders, relational problems, and stress-related problems), and one non-clinical group (total N = 82) completed the Attachment Style Questionnaire and were interviewed using the Affect Consciousness Interview – Self/Other. Results showed associations between high affect consciousness and secure attachment, and between low affect  consciousness and insecure attachment. Moreover, attachment style was predicted by consciousness about others’ and own affects in general, and specifically by consciousness about others’ anger and guilt, and by own joy. Affect consciousness as a potential dimension or moderator of attachment merits further investigation.

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