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  • 1.
    Aafjes-van Doorn, Katie
    et al.
    Adelphi University, NY 21402 USA; University of Oxford, England.
    Lilliengren, Peter
    Stockholm University, Sweden.
    Cooper, Angela
    Dalhousie University, Canada.
    Macdonald, James
    Headington Psychotherapy, England.
    Falkenström, Fredrik
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences. Uppsala University, Sweden.
    Patients Affective Processes Within Initial Experiential Dynamic Therapy Sessions2017In: Psychotherapy, ISSN 0033-3204, E-ISSN 1939-1536, Vol. 54, no 2, p. 175-183Article in journal (Refereed)
    Abstract [en]

    Research has indicated that patients in-session experience of previously avoided affects may be important for effective psychotherapy. The aim of this study was to investigate patients in-session levels of affect experiencing in relation to their corresponding levels of insight, motivation, and inhibitory affects in initial Experiential Dynamic Therapy (EDT) sessions. Four hundred sixty-six 10-min video segments from 31 initial sessions were rated using the Achievement of Therapeutic Objectives Scale. A series of multilevel growth models, controlling for between-therapist variability, were estimated to predict patients adaptive affect experiencing (Activating Affects) across session segments. In line with our expectations, higher within-person levels of Insight and Motivation related to higher levels of Activating Affects per segment. Contrary to expectations, however, lower levels of Inhibition were not associated with higher levels of Activating Affects. Further, using a time-lagged model, we did not find that the levels of Insight, Motivation, or Inhibition during one session segment predicted Activating Affects in the next, possibly indicating that 10-min segments may be suboptimal for testing temporal relationships in affective processes. Our results suggest that, to intensify patients immediate affect experiencing in initial EDT sessions, therapists should focus on increasing insight into defensive patterns and, in particular, motivation to give them up. Future research should examine the impact of specific inhibitory affects more closely, as well as between-therapist variability in patients in-session adaptive affect experiencing.

  • 2.
    Ankarberg, Peter
    et al.
    Young Adults Counselling Centre (Samtalscentrum Unga Vuxna), Nyköping, Sweden.
    Falkenström, Fredrik
    Young Adults Counselling Centre (Samtalscentrum Unga Vuxna), Nyköping, Sweden .
    Treatment of depression with antidepressants is primarily a psychological treatment2008In: Psychotherapy, ISSN 0033-3204, E-ISSN 1939-1536, Vol. 45, no 3, p. 329-339Article in journal (Refereed)
    Abstract [sv]

    Depression treatment with antidepressants is generally described as evidence-based. However, generalizations to practice recommendations seem to us to rest on the tacit assumption that treatment outcome in research trials is the sum of three factors: specific effects of the drug, expectancy effects (placebo), and spontaneous recovery. Because randomization isolates the specific effects of the drug, trials showing significant drug effects are used as evidence for prescribing the drug regardless of context. Drawing on Wampold's (2001) description of two metamodels of psychotherapy, the authors argue that available empirical evidence indicates that depression treatment with antidepressants is primarily a psychological treatment. This conclusion has far-reaching consequences for the scientific status of contemporary treatments for depression. It also affects what the doctor should focus on in a treatment with antidepressants and how to act when the patient is treatment resistant. In order to achieve the results obtained in clinical trials, the quantity and quality of support from the doctor is more important than pharmacological concerns, such as adequate doses of medicine. When faced with a treatment resistant patient, relationship factors rather than pharmacological factors should be in focus

  • 3.
    Berg, Johan
    et al.
    Lund Univ, Sweden.
    Lundh, Lars-Gunnar
    Lund Univ, Sweden.
    Falkenström, Fredrik
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Countertransference in Swedish psychotherapists: testing the factor structure of the Therapist Response Questionnaire2019In: RESEARCH IN PSYCHOTHERAPY-PSYCHOPATHOLOGY PROCESS AND OUTCOME, ISSN 2239-8031, Vol. 22, no 1, p. 99-112Article in journal (Refereed)
    Abstract [en]

    Questionnaires need testing of reliability and factor structure before clinical use or research in new languages or cultures. The aim of this study was to evaluate the Therapist Response Questionnaire (TRQ) in Sweden compared to corresponding factor analyses in USA and Italy. A national sample of psychotherapists (N=242) registered their countertransference with a single client using TRQ. The data were analyzed with confirmatory factor analysis (CFA) to test factor structures from previous studies, and exploratory factor analysis (EFA). The CFA did not verify the factor structure from the previous studies. The EFA extracted seven factors as the best solution: Helpless/Inadequate, Overwhelmed/Disorganized, Hostile/Angry, Parental/Protective, Disengaged, Special/Overinvolved, Sex-ualized. Analysis of convergent validity indicated that five of these could be considered equivalent to factors in the previous studies, and the remaining two were conceptually related to corresponding factors. Even though the factor structure was not confirmed by the CFA, the concordance was large, indicating a reliable self-report instrument with promising validity for measurement of complex aspects of countertransference. Common countertransference themes can inform psychotherapy supervision and education, give feedback to the therapist, and lay ground for a taxonomy for therapist reactions and feelings.

  • 4.
    Ekeblad, Annika
    et al.
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences. Vasternorrland County Council, Sweden.
    Falkenström, Fredrik
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences. Uppsala University, Sweden.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Karolinska Institute, Sweden.
    Vestberg, Robert
    Vasternorrland County Council, Sweden.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Randomized Trial of Interpersonal Psychotherapy and Cognitive Behavioral Therapy for Major Depressive Disorder in a Community-Based Psychiatric Outpatient Clinic2016In: Depression and anxiety (Print), ISSN 1091-4269, E-ISSN 1520-6394, Vol. 33, no 12, p. 1090-1098Article in journal (Refereed)
    Abstract [en]

    BackgroundInterpersonal psychotherapy (IPT) and cognitive behavioral therapy (CBT) are both evidence-based treatments for major depressive disorder (MDD). Several head-to-head comparisons have been made, mostly in the United States. In this trial, we compared the two treatments in a small-town outpatient psychiatric clinic in Sweden. The patients had failed previous primary care treatment and had extensive Axis-II comorbidity. Outcome measures were reduction of depressive symptoms and attrition rate. MethodsNinety-six psychiatric patients with MDD (DSM-IV) were randomized to 14 sessions of CBT (n = 48) or IPT (n = 48). A noninferiority design was used with the hypothesis that IPT would be noninferior to CBT. A three-point difference on the Beck Depression Inventory-II (BDI-II) was used as noninferiority margin. ResultsIPT passed the noninferiority test. In the ITT group, 53.5% (23/43) of the IPT patients and 51.0% (24/47) of the CBT patients were reliably improved, and 20.9% (9/43) and 19.1% (9/47), respectively, were recovered (last BDI score amp;lt;10). The dropout rate was significantly higher in CBT (40%; 19/47) compared to IPT (19%; 8/43). Statistically controlling for antidepressant medication use did not change the results. ConclusionsIPT was noninferior to CBT in a sample of depressed psychiatric patients in a community-based outpatient clinic. CBT had significantly more dropouts than IPT, indicating that CBT may be experienced as too demanding. Since about half the patients did not recover, there is a need for further treatment development for these patients. The study should be considered an effectiveness trial, with strong external validity but some limitations in internal validity.

  • 5.
    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.

  • 6.
    Falkenström, Fredrik
    Samtalscentrum Unga Vuxna, Nyköping, Sweden .
    Does psychotherapy for young adults in routine practice show similar results as therapy in randomized clinical trials?2010In: Psychotherapy Research, ISSN 1050-3307, E-ISSN 1468-4381, Vol. 20, no 2, p. 181-192Article in journal (Refereed)
    Abstract [en]

    Previous research indicates that patients treated with psychotherapy in the community do not stay in treatment long enough to achieve clinically significant change. Because the average patient seeking treatment at a community center may not be as informed and motivated for change as the average patient participating in a research trial, the authors compared outcome among all patients presenting to a mental health clinic (n=416) and a subgroup of patients who started psychotherapy at the same clinic (n=101). Outcome was assessing using the Symptom Checklist-90, Inventory of Interpersonal Problems, and Global Assessment of Functioning. Results confirmed that outcome among all patients seeking the centre was worse than in an average clinical trial. However, patients who started psychotherapy after assessment achieved results comparable to those in RCT studies.

  • 7.
    Falkenström, Fredrik
    Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Behavioural Sciences and Learning.
    Studying mindfulness in experienced meditators: A quasi-experimental approach2010In: PERSONALITY AND INDIVIDUAL DIFFERENCES, ISSN 0191-8869, Vol. 48, no 3, p. 305-310Article in journal (Refereed)
    Abstract [en]

    Self-report measures were used to study mindfulness and well-being in experienced meditators in a quasi-experimental intervention study. Seventy-six experienced meditators were studied, 48 who were participating in an intensive meditation retreat in the Vipassana (insight meditation) tradition and 28 who did not. Retreat participants had scheduled meditation practice from early morning to late at night, and were encouraged to practice mindfulness throughout the whole day. The Kentucky Inventory of Mindfulness Skills (KIMS) and the Five Facet Mindfulness Questionnaire (FFMQ) were used to measure mindfulness, and the General Population version of the Clinical Outcomes in Routine Evaluation (GP-CORE) was used to measure well-being. Correlation analyses in the pre-intervention data showed that self-reported mindfulness was strongly related to well-being, with the exception for the observe subscale of FFMQ, Only the acceptance subscales were associated with meditation experience. Mindfulness increased after the retreat, but the increase was not significantly larger for retreat participants than for the control group. However. well-being increased more in the retreat group than the control group, and increase in mindfulness was associated with increase in well-being across both groups. Results are discussed in relation to previous research and methodological aspects.

  • 8.
    Falkenström, Fredrik
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    The Capacity for Self-Observation in Psychotherapy2012Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The phenomena of self-awareness and self-observation are thought by many to be uniquely human qualities, and questions about how they develop have engaged philosophers and spiritual thinkers throughout history. More recently these issues have come to interest psychologists, psychotherapists, and researchers of diverse clinical psychology orientations as well. This dissertation explored conceptual issues and empirical measurement methods related to self-awareness and self-observation capacities. The four studies approached this from different angles: Study I used mainly qualitative methods to study post-treatment processes related to continuing clinical improvement after termination of long-term psychotherapeutic treatments. The main finding was that self-analysis seemed to be related to continued improvement after ending of therapy, but contrary to our hypothesis there was no difference between psychotherapy and the more intensive psychoanalysis in this regard. Study II tested the measurement of mindfulness by self report in a sample of experienced Buddhist meditators. The findings confirmed relationships between mindfulness and psychological well-being, but raised doubt about the instruments’ sensitivity to change. Study III compared different methods for measuring theoretically related concepts of self-observation: mindfulness, mentalization, and affect consciousness. This study showed surprisingly little common variance between affect consciousness and mentalization/mindfulness. Finally, the results of Study IV showed that in patients diagnosed with clinical depression, mentalization about depressive symptoms predicted aspects of the initial psychotherapy process better than mentalization about attachment. Taken together, these studies show the complexity of the phenomenon of self-observation and the corresponding complexity of research on it. The relationships between variables related to self-observation, their measurements, and their relationships to the psychotherapy process seem more complex than would be expected from current theories. A model for types of self-observation in the process of change in psychotherapy is tentatively proposed.

    List of papers
    1. Self-analysis and post-termination improvement after psychoanalysis and long-term psychotherapy
    Open this publication in new window or tab >>Self-analysis and post-termination improvement after psychoanalysis and long-term psychotherapy
    2007 (English)In: Journal of the American Psychoanalytic Association, ISSN 0003-0651, E-ISSN 1941-2460, Vol. 55, no 2, p. 629-674Article in journal (Refereed) Published
    Abstract [en]

    Long-term follow-up studies of long-term psychoanalytically oriented psychotherapy or psychoanalysis are extremely rare, and few have focused on the post-treatment process itself. In the Stockholm Outcome of Psychoanalysis and Psychotherapy project, one of the results was that patients in psychoanalysis continued to improve after termination to a higher degree than patients in long-term psychotherapy. In this study 20 patients selected from the project were interviewed on two occas ions, one and two years after termination, in order to explore how they described their post-treatment processes. The interviews were studied qualitatively using a multiple case study design, and categories of different types of post-treatment development were created from these case studies. Results indicate that the variation within treatment groups is large, and that development may continue in several ways after termination. The most striking difference between psychoanalysis and psychotherapy was not, as hypothesized, in the self-analytic function, but in various self-supporting strategies described by former analysands but not by former psychotherapy patients. However, only self-analysis was significantly correlated with post-termination improvement across both treatments. Three patients improving after termination and three deteriorating are described in detail as illustrations. Some methodological constraints of the design limit the generalizeability of results.

    National Category
    Social Sciences
    Identifiers
    urn:nbn:se:liu:diva-48012 (URN)
    Available from: 2009-10-11 Created: 2009-10-11 Last updated: 2017-12-13
    2. Studying mindfulness in experienced meditators: A quasi-experimental approach
    Open this publication in new window or tab >>Studying mindfulness in experienced meditators: A quasi-experimental approach
    2010 (English)In: PERSONALITY AND INDIVIDUAL DIFFERENCES, ISSN 0191-8869, Vol. 48, no 3, p. 305-310Article in journal (Refereed) Published
    Abstract [en]

    Self-report measures were used to study mindfulness and well-being in experienced meditators in a quasi-experimental intervention study. Seventy-six experienced meditators were studied, 48 who were participating in an intensive meditation retreat in the Vipassana (insight meditation) tradition and 28 who did not. Retreat participants had scheduled meditation practice from early morning to late at night, and were encouraged to practice mindfulness throughout the whole day. The Kentucky Inventory of Mindfulness Skills (KIMS) and the Five Facet Mindfulness Questionnaire (FFMQ) were used to measure mindfulness, and the General Population version of the Clinical Outcomes in Routine Evaluation (GP-CORE) was used to measure well-being. Correlation analyses in the pre-intervention data showed that self-reported mindfulness was strongly related to well-being, with the exception for the observe subscale of FFMQ, Only the acceptance subscales were associated with meditation experience. Mindfulness increased after the retreat, but the increase was not significantly larger for retreat participants than for the control group. However. well-being increased more in the retreat group than the control group, and increase in mindfulness was associated with increase in well-being across both groups. Results are discussed in relation to previous research and methodological aspects.

    Keywords
    Mindfulness, Meditation, Measurement, Vipassana
    National Category
    Engineering and Technology
    Identifiers
    urn:nbn:se:liu:diva-54252 (URN)10.1016/j.paid.2009.10.022 (DOI)000274678000009 ()
    Available from: 2010-03-05 Created: 2010-03-05 Last updated: 2012-09-28
    3. Reflective Functioning, Affect Consciousness, and Mindfulness: Are These Different Functions?
    Open this publication in new window or tab >>Reflective Functioning, Affect Consciousness, and Mindfulness: Are These Different Functions?
    Show others...
    2014 (English)In: Psychoanalytic psychology, ISSN 0736-9735, E-ISSN 1939-1331, Vol. 31, no 1, p. 26-40Article in journal (Refereed) Published
    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.

    Place, publisher, year, edition, pages
    American Psychological Association, 2014
    National Category
    Psychology
    Identifiers
    urn:nbn:se:liu:diva-82029 (URN)10.1037/a0034049 (DOI)000331876500003 ()
    Available from: 2012-09-28 Created: 2012-09-28 Last updated: 2017-12-07Bibliographically approved
    4. Patient Reflective Functioning as Predictor of Early Psychotherapy Process in the Treatment of Depression
    Open this publication in new window or tab >>Patient Reflective Functioning as Predictor of Early Psychotherapy Process in the Treatment of Depression
    (English)Manuscript (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.

    Keywords
    Psychotherapy process, mentalization, reflective functioning, alliance, depression
    National Category
    Psychology
    Identifiers
    urn:nbn:se:liu:diva-82031 (URN)
    Available from: 2012-09-28 Created: 2012-09-28 Last updated: 2012-09-28Bibliographically approved
  • 9.
    Falkenström, Fredrik
    Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Behavioural Sciences.
    The psychodynamics of self-observation2007In: Psychoanalytic dialogues, ISSN 1048-1885, E-ISSN 1940-9222, Vol. 17, no 4, p. 551-574Article in journal (Refereed)
    Abstract [en]

    A framework for thinking about self-observation in relational psychoanalytic terms is described, in which three different levels of self-observation are distinguished. These levels are differentiated according to the kind of intrapsychic relationship enacted (monadic, dyadic, or triangular). Each level of observation is discussed separately with focus on the dynamic forces inhibiting or facilitating self-observation within each level. Dyadic and triangular levels of self-observation are well known in psychoanalytic theories, but a monadic, or one-dimensional level in which the ego is not split, is also described. This form of observation and the psychodynamics involved is discussed in relation to Bion's concept "O" and theory from Buddhist psychology. Finally, the interrelatedness of levels is described, and a brief case description from a session of psychoanalytic psychotherapy is used to illustrate how the three levels of observation interact. © 2007 The Analytic Press, Inc.

  • 10.
    Falkenström, Fredrik
    et al.
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences. Uppsala University, Sweden.
    Ekeblad, Annika
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences. Vasternorrland County Council, Sweden.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Improvement of the Working Alliance in One Treatment Session Predicts Improvement of Depressive Symptoms by the Next Session2016In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 84, no 8, p. 738-751Article in journal (Refereed)
    Abstract [en]

    Objective: Developments in working alliance theory posit that the therapists attention to fluctuations in the alliance throughout treatment is crucial. Accordingly, researchers have begun studying the alliance as a time-varying mechanism of change rather than as a static moderator. However, most studies to date suffer from bias owing to the nonindependence of error term and predictors (endogeneity). Method: Patients with major depressive disorder (N = 84) from a randomized trial comparing cognitive-behavioral therapy with interpersonal psychotherapy filled out the Beck Depression Inventory-II before each session. After each session, patients and therapists filled out the Working Alliance Inventory short forms. Data were analyzed using the generalized method of moments for dynamic panel data, a method commonly applied in econometrics to eliminate endogeneity bias. Results: Improvement of the alliance predicted significant reduction of depressive symptoms by the next session (patient rating: b = -4.35, SE = 1.96, p = .026, 95% confidence interval [CI] [-8.19, -0.51]; therapist rating: b = -4.92, SE = 1.84, p = .008, 95% CI [-8.53, -1.31]). In addition, there was a significant delayed effect on the session after the next (patient rating: b = -3.25, SE = 1.20, p = .007, 95% CI [-5.61, -0.89]; therapist rating: b = -5.44, SE = 1.92, p = .005, 95% CI [-9.20, -1.68]). Conclusion: If the quality of patient-therapist alliance is improved in a given treatment session, depressive symptoms will likely decrease by the next session. The most important limitation of this study is its relatively small sample size.

  • 11.
    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.

  • 12.
    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.

  • 13.
    Falkenström, Fredrik
    et al.
    Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Behavioural Sciences.
    Grant, Johan
    Broberg, Jeanette
    Sandell, Rolf
    Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Behavioural Sciences.
    Self-analysis and post-termination improvement after psychoanalysis and long-term psychotherapy2007In: Journal of the American Psychoanalytic Association, ISSN 0003-0651, E-ISSN 1941-2460, Vol. 55, no 2, p. 629-674Article in journal (Refereed)
    Abstract [en]

    Long-term follow-up studies of long-term psychoanalytically oriented psychotherapy or psychoanalysis are extremely rare, and few have focused on the post-treatment process itself. In the Stockholm Outcome of Psychoanalysis and Psychotherapy project, one of the results was that patients in psychoanalysis continued to improve after termination to a higher degree than patients in long-term psychotherapy. In this study 20 patients selected from the project were interviewed on two occas ions, one and two years after termination, in order to explore how they described their post-treatment processes. The interviews were studied qualitatively using a multiple case study design, and categories of different types of post-treatment development were created from these case studies. Results indicate that the variation within treatment groups is large, and that development may continue in several ways after termination. The most striking difference between psychoanalysis and psychotherapy was not, as hypothesized, in the self-analytic function, but in various self-supporting strategies described by former analysands but not by former psychotherapy patients. However, only self-analysis was significantly correlated with post-termination improvement across both treatments. Three patients improving after termination and three deteriorating are described in detail as illustrations. Some methodological constraints of the design limit the generalizeability of results.

  • 14.
    Falkenström, Fredrik
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Uppsala University, Sweden.
    Grant, Johan
    Lund University, Sweden.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Review of organizational effects on the outcome of mental health treatments2018In: Psychotherapy Research, ISSN 1050-3307, E-ISSN 1468-4381, Vol. 28, no 1, p. 76-90Article, review/survey (Refereed)
    Abstract [en]

    Objective: As there are theoretical, clinical, and "common sense" reasons to expect a relationship between organizational factors and outcome in clinics providing psychotherapy and other mental health treatments, a review of empirical research in this area was undertaken with the aim of finding empirical evidence for organizational effects. Methods: A structured search for studies on organizational differences in patient mental health outcomes was performed using EBSCO host, Cochrane Library Database, and the Health Systems Evidence database at McMasters University. Finished studies published in English were included if they presented data from more than one mental health service and used change in symptom, level of functioning, or quality of life as outcome. Results: The search yielded not more than 19 studies fulfilling inclusion criteria. All studies showed some evidence for organization effects, and there was some evidence for organizational climate and culture explaining differences in outcome. Conclusion: Given that mental health treatments are likely to be especially susceptive to organizational effects, it is remarkable that not more research has been devoted to this. Clearly, more research is needed to study the consequences of work organization for the outcome of psychotherapy. Methodological issues in organizational studies are discussed.

  • 15.
    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.

  • 16.
    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.

  • 17.
    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.

  • 18.
    Falkenström, Fredrik
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Kumar, Manasi
    Department of Psychiatry, University of Nairobi, Kenya; Honorary Research Fellow, Research Dept of Clinical Health and Educational Psychology, University College London, UK.
    Zahid, Aiysha
    Queen Marys College, Miles End, London, E1 4NS, UK.
    Kuria, Mary
    Department of Psychiatry, University of Nairobi, Nairobi, Kenya.
    Othieno, Caleb
    Department of Psychiatry, University of Nairobi, P.O. Box 19676, Nairobi, 00202, Kenya.
    Factor analysis of the Clinical Outcomes in Routine Evaluation - Outcome Measures (CORE-OM) in a Kenyan sample2018In: BMC Psychology, E-ISSN 2050-7283, Vol. 6, no 1, article id 48Article in journal (Refereed)
    Abstract [en]

    There is no generic psychotherapy outcome measure validated for Kenyan populations. The objective of this study was to test the acceptability and factor structure of the Clinical Outcomes in Routine Evaluation - Outcome Measure in patients attending psychiatric clinics at two state-owned hospitals in Nairobi.

  • 19.
    Falkenström, Fredrik
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Kuria, Mary
    Univ Nairobi, Kenya.
    Othieno, Caleb
    Univ Nairobi, Kenya.
    Kumar, Manasi
    Univ Nairobi, Kenya.
    Working Alliance Predicts Symptomatic Improvement in Public Hospital-Delivered Psychotherapy in Nairobi, Kenya2019In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 87, no 1, p. 46-55Article in journal (Refereed)
    Abstract [en]

    Objective: Although patient-therapist collaboration (working alliance) has been studied extensively in Europe and America, it is unknown to what extent the importance of working alliance for psychotherapy outcome generalizes to lower-and middle-income countries. Additionally, there is a need for more studies on the alliance using methods that are robust to confounders of its effect on outcome. Method: In this study, 345 outpatients seeking care at the 2 public psychiatric hospitals in Nairobi, Kenya, filled out the Session Alliance Inventory (SAI) and the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) during each session. The effect of alliance on next-session psychological distress was modeled using the random intercept cross-lagged panel model, which estimates a cross-lagged panel model on within- and between-subjects disaggregated data. Results: Changes in the working alliance from session to session significantly predicted change in psychological distress by the next session, with an increase of 1 point of the SAI in a given session resulting in a decrease of 1.27 points on the CORE-OM by the next session (SE = 60, 95% confidence interval [-2.44, -.10]). This finding represents a medium-sized standardized regression coefficient of between.16 and.21. Results were generally robust to sensitivity tests for stationarity, missing data assumptions, and measurement error. Conclusion: Results affirm cross-cultural stability of the session-by-session reciprocal effects model of alliance and psychological distress-symptoms as seen in a Kenyan psychiatric outpatient sample, using the latest developments in cross-lagged panel modeling. A limitation of the study is its naturalistic design and lack of control over several variables.

  • 20.
    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.

  • 21.
    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.

  • 22.
    Hatcher, Robert L.
    et al.
    CUNY, NY 10016 USA.
    Lindqvist, Karin
    Stockholm Univ, Sweden.
    Falkenström, Fredrik
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Psychometric evaluation of the Working Alliance Inventory?Therapist version: Current and new short forms2019In: Psychotherapy Research, ISSN 1050-3307, E-ISSN 1468-4381Article in journal (Refereed)
    Abstract [en]

    Background: The Working Alliance Inventory (WAI) and its short forms are widely used, although the properties of the therapists? versions have been little studied. Method: We examined the psychometric properties of two short forms (WAI-S-T, WAI-SR-T), and explored the creation of a psychometrically stronger short form using contemporary measure development techniques. Well-fitting items from the full 36-item WAI were identified in a development sample (131 therapists, 688 patients) using multi-level Bayesian Structural Equation Modeling, accounting for therapist rated effects. Multi-level Item Response Theory (IRT) methods aided creation of a revised short form (WAI-S-T-IRT). Factor structures of the three forms were assessed using multi-level ML estimation with robust standard errors. Results: Collinearity problems for the Goal and Task dimensions led to testing a two-factor model (Goal?Task, Bond). All three measures showed satisfactory fit; the WAI-S-T-IRT fit slightly better but differences were minor. Testing the structures in an independent sample (N?=?1117) yielded essentially the same results. No version showed strong measurement invariance. Discussion: Continued use of current therapist forms is supported; differentiation of theoretical dimensions is difficult with current measures, and may not be possible with self-report forms.

  • 23.
    Holmqvist Larsson, Mattias
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Region Östergötland, Local Health Care Services in Central Östergötland, Department of Psychiatry.
    Björkman, Karin
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Nilsson, Karin
    Linköping University, Department of Behavioural Sciences and Learning. 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.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    The Alliance and Rupture Observation Scale (AROS): Development and validation of an alliance and rupture measure for repeated observations within psychotherapy sessions2019In: Journal of Clinical Psychology, ISSN 0021-9762, E-ISSN 1097-4679, Vol. 75, no 3, p. 404-417Article in journal (Refereed)
    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.

  • 24.
    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.

  • 25.
    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.

  • 26.
    Kumar, Manasi
    et al.
    Univ Nairobi, Kenya; UCL, England.
    Wangari Kuria, Mary
    Univ Nairobi, Kenya.
    Othieno, Caleb Joseph
    Univ Nairobi, Kenya.
    Falkenström, Fredrik
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Improving psychotherapies offered in public hospitals in Nairobi, Kenya: extending practice-based research model for LMICs2018In: International Journal of Mental Health Systems, ISSN 1752-4458, E-ISSN 1752-4458, Vol. 12, article id 76Article in journal (Refereed)
    Abstract [en]

    BackgroundPsychotherapy and mental health services in Nairobis public hospitals are increasing. Rather than prematurely imposing psychotherapy protocols developed in Western countries to Kenya, we argue that first studying psychological interventions as they are practiced may generate understanding of which psychological problems are common, what interventions therapists use, and what seems to be effective in reducing psychiatric problems in a lower and middle income country like Kenya.MethodWe present preliminary findings from a process-outcome study involving 345 patients from two public institutions, Kenyatta National and Mathare National Hospitals. We asked our patients to fill out a brief personal information questionnaire, Clinical Outcomes in Routine Evaluation-Outcome Measure (Evans et al. in Br J Psychiatry 180:51-60, 2002, and the Session Alliance Inventory (Falkenstrom et al. in Psychol Assess 27:169-183, 2015) after each session. We present descriptives for CORE-OM, patient-therapist concordance on the SAI, and using longitudinal mixed-effects model, test change in CORE-OM over time with various therapy and patient factors as predictors in regression analyses.ResultsThe majority of patients who attended the outpatient care clinics were young males. Our regression analysis suggested that patients with depression reported higher initial distress levels (2.75 CORE-OM scores, se=1.11, z=2.48, p=0.013, 95% CI 0.57-4.93) than patients with addictions, anxiety, or psychosis. Older clients improved slower (0.08 CORE-OM scores slower improvement per session per year older age; se=0.03, z=3.02 p=0.003, 95% CI 0.03, 0.14). Female patients reported higher initial distress than men (2.62 CORE-OM scores, se=1.00, z=2.61, p=0.009, 95% CI 0.65, 4.58). However, interns had patients who reported significantly higher initial distress (3.24 CORE-OM points, se=0.90, z=3.60, pamp;lt;0.001, 95% CI 1.48, 5.00), and improved more over time (-1.20 CORE-OM scores per session, se=0.51, z=-2.35, p=0.019, 95% CI -2.20, -0.20) than patients seeing mental health practitioners. The results showed that at average alliance, CORE-OM decreased by 1.74 points per session (se=0.21, pamp;lt;0.001). For each point higher on the SAI at session 2, the CORE-OM decreased by an additional 0.58 points per session (se=0.25, p=0.02).DiscussionOur objective was to study psychotherapies as they are practiced in naturalistic settings. The overall significant finding is that our participants report improvement in their functioning mental health condition and distress reduced as psychotherapy progressed. There were many more male than female participants in our sample; younger patients improved more than older ones; and while interns had patients with higher distress, their patients improved better than those patients attended by professionals.ConclusionsThese are preliminary observations to consider for a larger sample follow-up study. Before changing practices, evaluating the existing practices by mapping clinical outcomes is a helpful route.

  • 27.
    Leichsenring, Falk
    et al.
    Justus Liebig Univ Giessen, Germany.
    Liliengren, Peter
    Ersta Bracke Univ Coll, Sweden.
    Lindqvist, Karin
    Stockholm Univ, Sweden.
    Mechler, Jakob
    Stockholm Univ, Sweden.
    Falkenström, Fredrik
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Philips, Bjorn
    Stockholm Univ, Sweden.
    Steinert, Christiane
    MSB Med Sch, Germany.
    Abbass, Allan
    Dalhousie Univ, Canada.
    Inadequate Reporting of a Randomized Trial Comparing Cognitive-Behavioral Therapy and Psychodynamic Therapy for Depression2019In: Journal of Nervous and Mental Disease, ISSN 0022-3018, E-ISSN 1539-736X, Vol. 207, no 6, p. 421-422Article in journal (Other academic)
    Abstract [en]

    n/a

  • 28.
    Lilja, Josefine L.
    et al.
    Gothenburg University, Sweden .
    Lundh, Lars-Gunnar
    Lund University, Sweden .
    Josefsson, Torbjorn
    Halmstad University of Coll, Sweden .
    Falkenström, Fredrik
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Observing as an Essential Facet of Mindfulness: A Comparison of FFMQ Patterns in Meditating and Non-Meditating Individuals2013In: Mindfulness, ISSN 1868-8527, E-ISSN 1868-8535, Vol. 4, no 3, p. 203-212Article in journal (Refereed)
    Abstract [en]

    One of the most comprehensive measures of mindfulness is the Five Facet Mindfulness Questionnaire (FFMQ) with five factors-Observing, Describing, Acting with awareness, Non-judging, and Non-reactivity. Hierarchical confirmatory factor analyses, however, have suggested that only four of the FFMQ factors (i.e. all except Observing) were components of "an overall mindfulness construct"-which is puzzling because Observing represents a core aspect of all definitions of mindfulness. The purpose of the present study was to approach this problem by a person-oriented approach, focusing on patterns on the FFMQ scales, rather than linear associations between them. Data on the FFMQ were collected on 817 individuals. Cluster analysis according to the LICUR procedure was used to group these participants in 13 clusters, according to their profiles of scores on the five FFMQ scales. Of the participants, 325 were categorized as meditators and 317 as non-meditators. To test hypotheses about the relation between Observing and mindfulness (which we assumed should be higher among meditators), the meditators/non-meditators categorization was cross-tabulated with the FFMQ clusters. The results showed that all clusters in which meditators were over-represented had high scores on Observing, and all clusters in which meditators were under-represented had low scores on Observing-which supports the hypothesis that mindfulness is related to high levels of Observing. The relationship between Observing and Non-judging, however, was found to be more complex than expected. The results are discussed in terms of mindfulness seen as a multidimensional skill, which may develop differently in various subgroups of individuals.

  • 29.
    Lilliengren, Peter
    et al.
    Stockholm University, Sweden.
    Falkenström, Fredrik
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences. Uppsala University, Sweden.
    Sandell, Rolf
    Lund University, Sweden.
    Risholm Mothander, Pia
    Stockholm University, Sweden.
    Werbart, Andrzej
    Stockholm University, Sweden.
    Secure Attachment to Therapist, Alliance, and Outcome in Psychoanalytic Psychotherapy With Young Adults2015In: Journal of counseling psychology, ISSN 0022-0167, E-ISSN 1939-2168, Vol. 62, no 1Article in journal (Refereed)
    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.

  • 30.
    Lilliengren, Peter
    et al.
    Ersta Skondal Bracke Univ Coll, Sweden.
    Philips, Bjorn
    Stockholm Univ, Sweden.
    Falkenström, Fredrik
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Bergquist, Mia
    Region Västra Götaland, Gothenburg, Sweden.
    Ulvenes, Pal
    Modum Bad Psychiat Ctr, Norway.
    Wampold, Bruce
    Modum Bad Psychiat Ctr, Norway; Univ Wisconsin, WI USA.
    Comparing the Treatment Process in Successful and Unsuccessful Cases in Two Forms of Psychotherapy for Cluster C Personality Disorders2019In: Psychotherapy, ISSN 0033-3204, E-ISSN 1939-1536, Vol. 56, no 2, p. 285-296Article in journal (Refereed)
    Abstract [en]

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

  • 31.
    Lindqvist, Karin
    et al.
    Erica Fdn, Sweden.
    Falkenström, Fredrik
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences. Uppsala University, Sweden.
    Sandell, Rolf
    Lund University, Sweden.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Ekeblad, Annika
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Thoren, Agneta
    Erica Fdn, Sweden.
    Multilevel Exploratory Factor Analysis of the Feeling Word Checklist-242017In: Assessment (Odessa, Fla.), ISSN 1073-1911, E-ISSN 1552-3489, Vol. 24, no 7, p. 907-918Article in journal (Refereed)
    Abstract [en]

    Emotional reactions are a vital part of the therapeutic relationship. The Feeling Word Checklist-24 (FWC-24) is an instrument asking the clinician (or the patient) to report to what degree he or she has experienced various feelings during a therapeutic interaction. The aim of this study was to assess the factor structure of the clinician-rated FWC-24 when taking dependencies in the data into account. The sample was deliberately heterogeneous and consisted of 4,443 ratings made by 101 psychotherapists working with different psychotherapy methods in relation to 191 patients of different ages, genders, and with different primary diagnoses. A random intercept-only model revealed large intraclass correlation coefficients at the therapist level, indicating that a multilevel analysis was warranted. A two-level exploratory factor analysis with therapists as the between level and patients plus sessions as the within level was conducted. The items from FWC-24 were found to be best represented by four factors on the between level and four factors on the within level. The factor structures were largely similar on the two levels and were labeled Engaged, Inadequate, Relaxed, and Moved. The different factors explained different amounts of variance on different levels, indicating that some factors are more therapist dependent and some more patient dependent.

  • 32.
    Mbuthia, Judy Wanjiru
    et al.
    Univ Nairobi, Kenya.
    Kumar, Manasi
    Univ Nairobi, Kenya; UCL, England.
    Falkenström, Fredrik
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Kuria, Mary Wangari
    Univ Nairobi, Kenya.
    Othieno, Caleb Joseph
    Univ Nairobi, Kenya.
    Attributions and private theories of mental illness among young adults seeking psychiatric treatment in Nairobi: an interpretive phenomenological analysis2018In: Child and Adolescent Psychiatry and Mental Health, ISSN 1753-2000, E-ISSN 1753-2000, Vol. 12, article id 28Article in journal (Refereed)
    Abstract [en]

    Background: Mental illness affects every segment of population including young adults. The beliefs held by young patients regarding the causes of mental illness impact their treatment-seeking behaviour. It is pertinent to know the commonly held attributions around mental illness so as to effectively provide psychological care, especially in a resource constrained context such as Kenya. This helps in targeting services around issues such as stigma and extending youth-friendly services. Methods: Guided by the private theories interview (PTI-P) and attributional framework, individual semi-structured interviews were carried out with ten young adults of ages 18-25 years about their mental health condition for which they were undergoing treatment. Each interview took 30-45 min. We mapped four attributions (locus of control, stability, controllability and stigma) on PTI-P questions. Data was transcribed verbatim to produce transcripts coded using interpretive phenomenological analysis. These codes were then broken down into categories that could be used to understand various attributions. Results: We found PTI-P to be a useful tool and it elicited three key themes: (a) psychosocial triggers of distress (with themes of negative thoughts, emotions around mental health stigma and negative childhood experiences, parents separation or divorce, death of a loved one etc.), (b) biological conditions and psychopathologies limiting intervention, and (c) preferences and views on treatment. Mapping these themes on our attributional framework, PTI-P themes presented as causal attributions explaining stigma, locus of control dimensions and stability. External factors were mainly ascribed to be the cause of unstable and uncontrollable attributions including persistent negative emotions and thoughts further exacerbating psychological distress. Nine out of the ten participants expressed the need for more intense and supportive therapy. Conclusion: Our study has provided some experiential evidence in understanding how stigma, internal vs external locus of control, stability vs instability attributions play a role in shaping attitudes young people have towards their mental health. Our study points to psychosocial challenges such as stigma, poverty and lack of social support that continue to undermine mental well-being of Kenyan youth. These factors need to be considered when addressing mental health needs of young people in Kenya.

  • 33.
    Möller, Clara
    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. 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.
    MENTALIZING IN YOUNG OFFENDERS2014In: Psychoanalytic psychology, ISSN 0736-9735, E-ISSN 1939-1331, Vol. 31, no 1, p. 84-99Article in journal (Refereed)
    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.

  • 34.
    Möller, Clara
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Karlgren, Linda
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Sandell, Anton
    Linköping University, Department of Behavioural Sciences and Learning. 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. Uppsala University, Sweden.
    Philips, Björn
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Stockholm County Council, Sweden; Karolinska Institute, Sweden.
    Mentalization-based therapy adherence and competence stimulates in-session mentalization in psychotherapy for borderline personality disorder with co-morbid substance dependence2017In: Psychotherapy Research, ISSN 1050-3307, E-ISSN 1468-4381, Vol. 27, no 6, p. 749-765Article in journal (Refereed)
    Abstract [en]

    Objective: To test whether adherence to mentalization-based treatment (MBT) principles predict better patient in-session mentalizing. Methods: Two sessions for each of 15 patients with borderline personality disorder and comorbid substance abuse disorder were rated for MBT adherence and competence. Individual patient statements were rated for Reflective Functioning (RF), therapist statements were rated as demanding RF or not. Data were analysed using multilevel modelling. Results: MBT adherence and competence predicted higher session RF (=.58-.75), even while controlling for pre-treatment RF. In addition, therapist interventions directed toward exploring mental states predicted higher RF of subsequent patient responses (=.11-.12). Conclusions: MBT adherence and competence were significantly related to patient in-session mentalizing, supporting the validity of MBT principles. Results point to the importance of supervision for therapists to become adherent to MBT principles. The small number of patients and sessions limits generalizability of results.

  • 35.
    Nissen-Lie, Helene A.
    et al.
    University of Oslo, Norway.
    Goldberg, Simon B.
    University of Wisconsin Madison, WI USA.
    Hoyt, William T.
    University of Wisconsin Madison, WI USA.
    Falkenström, Fredrik
    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.
    Nielsen, Stevan Lars
    Brigham Young University, UT 84602 USA.
    Wampold, Bruce E.
    University of Wisconsin Madison, WI USA; Modum Bad Psychiat Centre, Norway.
    Are Therapists Uniformly Effective Across Patient Outcome Domains? A Study on Therapist Effectiveness in Two Different Treatment Contexts2016In: Journal of counseling psychology, ISSN 0022-0167, E-ISSN 1939-2168, Vol. 63, no 4, p. 367-378Article in journal (Refereed)
    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.

  • 36.
    Rudden, Marie G
    et al.
    Weill Cornell Medical College.
    Milrod, Barbara
    Weill Cornell Medical College.
    Meehan, Kevin B
    Long Island University.
    Falkenström, Fredrik
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    SYMPTOM-SPECIFIC REFLECTIVE FUNCTIONING: INCORPORATING PSYCHOANALYTIC MEASURES INTO CLINICAL TRIALS2009In: JOURNAL OF THE AMERICAN PSYCHOANALYTIC ASSOCIATION, ISSN 0003-0651, Vol. 57, no 6, p. 1473-1478Article in journal (Refereed)
    Abstract [en]

    n/a

  • 37.
    Söderberg, Anna Karin
    et al.
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Elfors, Caroline
    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.
    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.
    Emotional availability in psychotherapy: The usefulness and validity of the Emotional Availability Scales for analyzing the psychotherapeutic relationship2014In: Psychotherapy Research, ISSN 1050-3307, E-ISSN 1468-4381, Vol. 24, no 1, p. 91-102Article in journal (Refereed)
    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.

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