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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
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten. Uppsala University, Sweden.
    Patients Affective Processes Within Initial Experiential Dynamic Therapy Sessions2017Ingår i: Psychotherapy, ISSN 0033-3204, E-ISSN 1939-1536, Vol. 54, nr 2, s. 175-183Artikel i tidskrift (Refereegranskat)
    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.
    Alexandersson, Klas
    et al.
    Sundsvall Hosp, Sweden.
    Wågberg, Malin
    Sundsvall Hosp, Sweden.
    Ekeblad, Annika
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten. Linköpings universitet, Utbildningsvetenskap. Sundsvall Hosp, Sweden.
    Holmqvist, Rolf
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Falkenström, Fredrik
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten. Linnaeus Univ, Sweden.
    Session-to-session effects of therapist adherence and facilitative conditions on symptom change in CBT and IPT for depression2023Ingår i: Psychotherapy Research, ISSN 1050-3307, E-ISSN 1468-4381, Vol. 33, nr 1: special sektion part 2, s. 57-69Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: The objective of this study was to analyze the effect of adherence to both specific technique factors and facilitative condition variables (e.g., therapists involvement, understanding and support) in Cognitive Behavior Therapy (CBT) and Interpersonal Psychotherapy (IPT). In addition, we were interested in whether the effect of therapist adherence would depend on the level of the working alliance. Method: Three sessions each from 74 patients diagnosed with Major Depressive Disorder who were randomized to 14 sessions of IPT or CBT were rated for adherence using a modified version of The Collaborative Study Psychotherapy Rating Scale-6 (CSPRS-6). Data was analyzed using Multilevel Modeling. Results: No effects of adherence to specific factors on outcome were found in neither CBT nor IPT. Facilitative conditions were associated with better outcome in CBT but not in IPT, even after adjustment for the quality of the working alliance. No interaction effects were found. Conclusions: Our findings highlight the importance of relational factors in CBT, but do not support the need for specific adherence to any of the two treatments. Possible explanations of the findings and directions for future research are discussed.

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  • 3.
    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 treatment2008Ingår i: Psychotherapy, ISSN 0033-3204, E-ISSN 1939-1536, Vol. 45, nr 3, s. 329-339Artikel i tidskrift (Refereegranskat)
    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

  • 4.
    Back, Malin
    et al.
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten. Futurum Acad Hlth & Care, Sweden.
    Falkenström, Fredrik
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Gustafsson, Sanna Aila
    Orebro Univ, Sweden.
    Andersson, Gerhard
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten. Karolinska Inst, Sweden.
    Holmqvist, Rolf
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Reduction in depressive symptoms predicts improvement in eating disorder symptoms in interpersonal psychotherapy: results from a naturalistic study2020Ingår i: Journal of Eating Disorders, E-ISSN 2050-2974, Vol. 8, nr 1, artikel-id 33Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background Interpersonal psychotherapy (IPT) can be effective for both Bulimia Nervosa (BN) and co-occurring depression. While changes in symptoms of Eating disorder (ED) and depression have been found to correlate, it is unclear how they interact during treatment and in which order the symptoms decrease. Methods Thirty-one patients with BN and depressive symptoms received IPT using the manual IPT-BNm in a naturalistic design. The outcome was measured with the Eating Disorder Examination Questionnaire (EDE-Q) and the Montgomery angstrom sberg Depression Rating Scale (MADRS-S). Symptom improvement at each session was measured with Repeated Evaluation of Eating Disorder Symptoms (REDS) and the Patient Health Questionnaire-9 (PHQ-9). Results Significant improvements with large effect sizes were found on both ED symptoms and depression. The rates of change were linear for both BN and depression. A strong correlation between reduction of depressive symptoms and ED symptoms was found. Depressive symptom reduction at one session predicted improvement of ED symptoms at the next session. Conclusions IPT-BNm had an effect on both BN and co-occurring depressive symptoms. The analyses indicated that reduction in depressive symptoms preceded reduction in bulimic symptoms.

  • 5.
    Berg, Johan
    et al.
    Lund Univ, Sweden.
    Lundh, Lars-Gunnar
    Lund Univ, Sweden.
    Falkenström, Fredrik
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Countertransference in Swedish psychotherapists: testing the factor structure of the Therapist Response Questionnaire2019Ingår i: RESEARCH IN PSYCHOTHERAPY-PSYCHOPATHOLOGY PROCESS AND OUTCOME, ISSN 2239-8031, Vol. 22, nr 1, s. 99-112Artikel i tidskrift (Refereegranskat)
    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.

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  • 6.
    Ekeblad, Annika
    et al.
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten. Linköpings universitet, Utbildningsvetenskap.
    Dahlman, Malene
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten.
    Pio, Malin
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten.
    Malmquist, Anna
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Falkenström, Fredrik
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten. Linnaeus Univ, Sweden.
    "What shall we focus on?": A thematic analysis of what characterizes cognitive-behavior therapysessions with high or low quality of working alliance2022Ingår i: Psychotherapy Research, ISSN 1050-3307, E-ISSN 1468-4381, Vol. 32, nr 8, s. 1003-1015Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: Several studies have shown that the quality of the working alliance predicts symptomatic improvement sessionby-session, including in cognitive-behavioral therapy (CBT). We wanted to explore what characterizes CBT sessions with high and low alliances further using qualitative analysis. Method: Ten CBT-sessions were selected from eight patients therapies in a larger research project on psychotherapy for patients with major depression. Five sessions were chosen from high- and five from low-alliance sessions, based on therapist- and patient-reported Working Alliance Inventory scores. Transcripts of these sessions were analyzed using thematic analysis. Results: The analysis yielded four themes, each structured into two sub-themes: Therapist style, Person in focus, Content focus, and Therapeutic direction. In contrast to low-alliance sessions, high-alliance sessions were characterized by a more exploring as opposed to expert therapist style; a focus on the patients thoughts, feelings, and behavior, rather than a diffuse focus or a focus on other peoples actions/external events; and a sense of moving forward rather than stagnation. Conclusion: Our qualitative analysis showed theoretically and clinically meaningful processes in CBT sessions of high- vs low working alliance. This method is a useful complement to quantitative within-patient analyses, to expand on the meaning of quantitative findings.

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  • 7.
    Ekeblad, Annika
    et al.
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten. Vasternorrland County Council, Sweden.
    Falkenström, Fredrik
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten. Uppsala University, Sweden.
    Andersson, Gerhard
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten. Karolinska Institute, Sweden.
    Vestberg, Robert
    Vasternorrland County Council, Sweden.
    Holmqvist, Rolf
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Randomized Trial of Interpersonal Psychotherapy and Cognitive Behavioral Therapy for Major Depressive Disorder in a Community-Based Psychiatric Outpatient Clinic2016Ingår i: Depression and anxiety (Print), ISSN 1091-4269, E-ISSN 1520-6394, Vol. 33, nr 12, s. 1090-1098Artikel i tidskrift (Refereegranskat)
    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.

  • 8.
    Ekeblad, Annika
    et al.
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten. Sundsvall Hospital, Sweden.
    Falkenström, Fredrik
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten. Uppsala University, Sweden.
    Holmqvist, Rolf
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Reflective Functioning as Predictor of Working Alliance and Outcome in the Treatment of Depression2016Ingår i: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 84, nr 1, s. 67-78Artikel i tidskrift (Refereegranskat)
    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.

  • 9.
    Ekeblad, Annika
    et al.
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten. Vasternorrland Cty Council, Sweden.
    Holmqvist, Rolf
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Andersson, Gerhard
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten. Karolinska Inst, Sweden.
    Falkenström, Fredrik
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Change in reflective functioning in interpersonal psychotherapy and cognitive behavioral therapy for major depressive disorder2023Ingår i: Psychotherapy Research, ISSN 1050-3307, E-ISSN 1468-4381, Vol. 33, nr 3, s. 342-349Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background Patients with Major Depressive Disorder (MDD) have been found to have restricted capacity for mentalization, and it is possible that this constitutes a vulnerability factor for developing depression. Due to its focus on linking depressive symptomatology to emotions and interpersonal relations, it was hypothesized that Interpersonal Psychotherapy (IPT) would improve mentalization more than Cognitive Behavioral Therapy (CBT). Methods In a randomized controlled trial of 90 patients undergoing IPT and CBT for MDD, Reflective Functioning (RF) was rated from Adult Attachment and from Depression-Specific Reflective Functioning (DSRF) Interviews before and after therapy. Treatment outcome was assessed using the Beck Depression Inventory-II. Results The interaction between time and treatment approach was statistically significant, with RF improving significantly more in IPT than in CBT. Change in RF was not correlated with change in depression. The difference in DSRF ratings before and after therapy was not statistically significant for any of the treatments. Conclusions IPT may improve mentalization more than CBT. However, although RF increased significantly in IPT, the mean level was still low after therapy. A limitation of the study is the large amount of post-treatment missing data. More research is needed to understand the potential role of mentalization in symptom reduction.

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  • 10.
    Falkenström, Fredrik
    Samtalscentrum Unga Vuxna, Nyköping, Sweden .
    Does psychotherapy for young adults in routine practice show similar results as therapy in randomized clinical trials?2010Ingår i: Psychotherapy Research, ISSN 1050-3307, E-ISSN 1468-4381, Vol. 20, nr 2, s. 181-192Artikel i tidskrift (Refereegranskat)
    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.

  • 11.
    Falkenström, Fredrik
    Linköpings universitet, Filosofiska fakulteten. Linköpings universitet, Institutionen för beteendevetenskap och lärande.
    Studying mindfulness in experienced meditators: A quasi-experimental approach2010Ingår i: PERSONALITY AND INDIVIDUAL DIFFERENCES, ISSN 0191-8869, Vol. 48, nr 3, s. 305-310Artikel i tidskrift (Refereegranskat)
    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.

  • 12. Beställ onlineKöp publikationen >>
    Falkenström, Fredrik
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten.
    The Capacity for Self-Observation in Psychotherapy2012Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
    Abstract [sv]

    Förmågan till självmedvetande och självobservation brukar sägas vara unik för människan, och frågor om hur den uppstår och utvecklas har engagerat filosofer och andliga tänkare genom historien. Under de senaste årtiondena har detta även kommit att intressera psykologer, psykoterapeuter och forskare inom olika kliniska psykologiinriktningar. I denna avhandling utforskades konceptuella frågor och empiriska mätmetoder relaterade till självobservationsförmåga. De fyra studierna tog sig an detta från olika utgångspunkter: I Studie I användes främst kvalitativ metod för att undersöka processer relaterade till fortsatt klinisk förbättring efter avslutning av längre psykoterapeutisk behandling. Beskrivningar av självanalys var relaterade till fortsatt förbättring efter avslutad terapi, men i kontrast till vår hypotes syntes ingen skillnad mellan psykoterapi och den mer intensiva psykoanalysen ur denna aspekt. I Studie II prövades mätning av medveten närvaro (mindfulness) genom självrapport på ett urval erfarna Buddhistiska meditatörer. Resultaten bekräftade samband mellan medveten närvaro och psykologiskt välmående, men visade på osäkerhet kring instrumentens känslighet för förändring. I Studie III jämfördes olika metoder för mätning av teoretiskt relaterade självobservationsbegrepp: medveten närvaro, mentalisering och affektmedvetenhet. Resultaten visade på förvånansvärt liten gemensam varians mellan affektmedvetenhet och mentalisering/medveten närvaro. Slutligen visade resultaten i Studie IV att hos patienter diagnostiserade med klinisk depression predicerade mentalisering om depressiva symptom aspekter av den initiala psykoterapiprocessen bättre än det vanliga måttet på mentalisering utifrån anknytningsintervju. Sammantaget visar dessa studier på komplexiteten i fenomenet självobservationsförmåga och dess utforskande. Relationerna mellan variabler relaterade till självobservation, mätning av dem och samband med psykoterapiprocessen tycks mer komplexa än förväntat utifrån nuvarande teorier. En tentativ modell för samband mellan typer av självobservation i den psykoterapeutiska förändringsprocessen presenteras.

    Delarbeten
    1. Self-analysis and post-termination improvement after psychoanalysis and long-term psychotherapy
    Öppna denna publikation i ny flik eller fönster >>Self-analysis and post-termination improvement after psychoanalysis and long-term psychotherapy
    2007 (Engelska)Ingår i: Journal of the American Psychoanalytic Association, ISSN 0003-0651, E-ISSN 1941-2460, Vol. 55, nr 2, s. 629-674Artikel i tidskrift (Refereegranskat) 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.

    Nationell ämneskategori
    Samhällsvetenskap
    Identifikatorer
    urn:nbn:se:liu:diva-48012 (URN)
    Tillgänglig från: 2009-10-11 Skapad: 2009-10-11 Senast uppdaterad: 2017-12-13
    2. Studying mindfulness in experienced meditators: A quasi-experimental approach
    Öppna denna publikation i ny flik eller fönster >>Studying mindfulness in experienced meditators: A quasi-experimental approach
    2010 (Engelska)Ingår i: PERSONALITY AND INDIVIDUAL DIFFERENCES, ISSN 0191-8869, Vol. 48, nr 3, s. 305-310Artikel i tidskrift (Refereegranskat) 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.

    Nyckelord
    Mindfulness, Meditation, Measurement, Vipassana
    Nationell ämneskategori
    Teknik och teknologier
    Identifikatorer
    urn:nbn:se:liu:diva-54252 (URN)10.1016/j.paid.2009.10.022 (DOI)000274678000009 ()
    Tillgänglig från: 2010-03-05 Skapad: 2010-03-05 Senast uppdaterad: 2012-09-28
    3. Reflective Functioning, Affect Consciousness, and Mindfulness: Are These Different Functions?
    Öppna denna publikation i ny flik eller fönster >>Reflective Functioning, Affect Consciousness, and Mindfulness: Are These Different Functions?
    Visa övriga...
    2014 (Engelska)Ingår i: Psychoanalytic psychology, ISSN 0736-9735, E-ISSN 1939-1331, Vol. 31, nr 1, s. 26-40Artikel i tidskrift (Refereegranskat) 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.

    Ort, förlag, år, upplaga, sidor
    American Psychological Association, 2014
    Nationell ämneskategori
    Psykologi
    Identifikatorer
    urn:nbn:se:liu:diva-82029 (URN)10.1037/a0034049 (DOI)000331876500003 ()
    Tillgänglig från: 2012-09-28 Skapad: 2012-09-28 Senast uppdaterad: 2017-12-07Bibliografiskt granskad
    4. Patient Reflective Functioning as Predictor of Early Psychotherapy Process in the Treatment of Depression
    Öppna denna publikation i ny flik eller fönster >>Patient Reflective Functioning as Predictor of Early Psychotherapy Process in the Treatment of Depression
    (Engelska)Manuskript (preprint) (Övrigt vetenskapligt)
    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.

    Nyckelord
    Psychotherapy process, mentalization, reflective functioning, alliance, depression
    Nationell ämneskategori
    Psykologi
    Identifikatorer
    urn:nbn:se:liu:diva-82031 (URN)
    Tillgänglig från: 2012-09-28 Skapad: 2012-09-28 Senast uppdaterad: 2012-09-28Bibliografiskt granskad
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    The Capacity for Self-Observation in Psychotherapy
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  • 13.
    Falkenström, Fredrik
    Linköpings universitet, Filosofiska fakulteten. Linköpings universitet, Institutionen för beteendevetenskap.
    The psychodynamics of self-observation2007Ingår i: Psychoanalytic dialogues, ISSN 1048-1885, E-ISSN 1940-9222, Vol. 17, nr 4, s. 551-574Artikel i tidskrift (Refereegranskat)
    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.

  • 14.
    Falkenström, Fredrik
    et al.
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten. Uppsala University, Sweden.
    Ekeblad, Annika
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten. Vasternorrland County Council, Sweden.
    Holmqvist, Rolf
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Improvement of the Working Alliance in One Treatment Session Predicts Improvement of Depressive Symptoms by the Next Session2016Ingår i: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 84, nr 8, s. 738-751Artikel i tidskrift (Refereegranskat)
    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.

  • 15.
    Falkenström, Fredrik
    et al.
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten.
    Ekeblad, Annika
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten.
    Sandell, Rolf
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten.
    Holmqvist, Rolf
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Patient Reflective Functioning as Predictor of Early Psychotherapy Process in the Treatment of DepressionManuskript (preprint) (Övrigt vetenskapligt)
    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.

  • 16.
    Falkenström, Fredrik
    et al.
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten.
    Granstrom, Fredrik
    Uppsala University, Sweden.
    Holmqvist, Rolf
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Therapeutic Alliance Predicts Symptomatic Improvement Session by Session2013Ingår i: Journal of counseling psychology, ISSN 0022-0167, E-ISSN 1939-2168, Vol. 60, nr 3, s. 317-328Artikel i tidskrift (Refereegranskat)
    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.

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  • 17.
    Falkenström, Fredrik
    et al.
    Linköpings universitet, Filosofiska fakulteten. Linköpings universitet, Institutionen för beteendevetenskap.
    Grant, Johan
    Broberg, Jeanette
    Sandell, Rolf
    Linköpings universitet, Filosofiska fakulteten. Linköpings universitet, Institutionen för beteendevetenskap.
    Self-analysis and post-termination improvement after psychoanalysis and long-term psychotherapy2007Ingår i: Journal of the American Psychoanalytic Association, ISSN 0003-0651, E-ISSN 1941-2460, Vol. 55, nr 2, s. 629-674Artikel i tidskrift (Refereegranskat)
    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.

  • 18.
    Falkenström, Fredrik
    et al.
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten. Uppsala University, Sweden.
    Grant, Johan
    Lund University, Sweden.
    Holmqvist, Rolf
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Review of organizational effects on the outcome of mental health treatments2018Ingår i: Psychotherapy Research, ISSN 1050-3307, E-ISSN 1468-4381, Vol. 28, nr 1, s. 76-90Artikel, forskningsöversikt (Refereegranskat)
    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.

  • 19.
    Falkenström, Fredrik
    et al.
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten. Uppsala University, Sweden.
    Hatcher, Robert L.
    CUNY, NY 10021 USA.
    Holmqvist, Rolf
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Confirmatory Factor Analysis of the Patient Version of the Working Alliance Inventory-Short Form Revised2015Ingår i: Assessment (Odessa, Fla.), ISSN 1073-1911, E-ISSN 1552-3489, Vol. 22, nr 5, s. 581-593Artikel i tidskrift (Refereegranskat)
    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.

  • 20.
    Falkenström, Fredrik
    et al.
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten. Uppsala University, Sweden.
    Hatcher, Robert L.
    CUNY, NY USA.
    Skjulsvik, Tommy
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten.
    Holmqvist Larsson, Mattias
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Holmqvist, Rolf
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Development and Validation of a 6-item Working Alliance Questionnaire for Repeated Administrations During Psychotherapy2015Ingår i: Psychological Assessment, ISSN 1040-3590, E-ISSN 1939-134X, Vol. 27, nr 1, s. 169-183Artikel i tidskrift (Refereegranskat)
    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.

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  • 21.
    Falkenström, Fredrik
    et al.
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten. Linnaeus Univ, Sweden.
    Holmqvist, Rolf
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Therapist in-session feelings predict change in depressive symptoms in interpersonal and brief relational psychotherapy2022Ingår i: Psychotherapy Research, ISSN 1050-3307, E-ISSN 1468-4381, Vol. 32, nr 5, s. 571-584Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: Brief Relational Therapy (BRT) includes the idea that the therapists use their in-session feelings in meta-communications about the therapy relationship to facilitate resolution of alliance ruptures. The current study aimed to explore the effect of therapist feelings on patient depressive symptoms in BRT compared to Interpersonal Psychotherapy (IPT). Methods: The effects of therapist feelings were studied in 40 patients randomized to 16 sessions of IPT or BRT, using the Feeling Word Checklist-24, the Patient Health Questionnaire-9 and the Working Alliance Inventory. Data was analyzed using dynamic structural equation modeling. Results: Negative therapist feelings predicted increase and positive feelings decrease in next-session PHQ-9 via the alliance and the patients engaged feelings, in both treatments. The direct effect of negative therapist feelings on PHQ-9 differed significantly between BRT and IPT, with more negative feelings predicting a decrease in PHQ-9 in BRT but not in IPT. Conclusion: Negative therapist feelings may cause increase/less decrease and positive feelings more decrease in depressive symptoms via disruptions in the alliance. In BRT, if the alliance is unaffected by negative therapist feelings, the patients depressive symptoms may improve. Findings need replication in a larger sample.

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  • 22.
    Falkenström, Fredrik
    et al.
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten. Uppsala University, Sweden.
    Josefsson, Albin
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten.
    Berggren, Tore
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten.
    Holmqvist, Rolf
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    How Much Therapy Is Enough? Comparing Dose-Effect and Good-Enough Models in Two Different Settings2016Ingår i: Psychotherapy, ISSN 0033-3204, E-ISSN 1939-1536, Vol. 53, nr 1, s. 130-139Artikel i tidskrift (Refereegranskat)
    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.

  • 23.
    Falkenström, Fredrik
    et al.
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    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 sample2018Ingår i: BMC Psychology, E-ISSN 2050-7283, Vol. 6, nr 1, artikel-id 48Artikel i tidskrift (Refereegranskat)
    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.

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  • 24.
    Falkenström, Fredrik
    et al.
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    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, Kenya2019Ingår i: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 87, nr 1, s. 46-55Artikel i tidskrift (Refereegranskat)
    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.

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  • 25.
    Falkenström, Fredrik
    et al.
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten.
    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
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Holmqvist, Rolf
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Can psychotherapists function as their own controls? Meta-analysis of the crossed therapist design in comparative psychotherapy trials2013Ingår i: Journal of Clinical Psychiatry, ISSN 0160-6689, E-ISSN 1555-2101, Vol. 74, nr 5, s. 482-491Artikel i tidskrift (Refereegranskat)
    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.

  • 26.
    Falkenström, Fredrik
    et al.
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten. Linnaeus Univ, Sweden.
    Park, Sungho
    Seoul Natl Univ, South Korea.
    McIntosh, Cameron N.
    Employment & Social Dev Canada, Canada.
    Using Copulas to Enable Causal Inference From Nonexperimental Data: Tutorial and Simulation Studies2023Ingår i: Psychological methods, ISSN 1082-989X, E-ISSN 1939-1463, Vol. 28, nr 2, s. 301-321Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Causal inference in psychological research is typically hampered by unobserved confounding. A copula-based method can be used to statistically control for this problem without the need for instruments or covariates, given relatively lenient distributional assumptions on independent variables and error terms. The current study aims to: (a) provide a user-friendly introduction to the copula method for psychology researchers, and (b) examine the degree of non-normality in the independent variables required for satisfactory performance. A Monte Carlo simulation study was used to assess the behavior of the copula method under various combinations of conditions (sample size, skewness of independent variables, effect size, and magnitude of confounding). In addition, an applied example from research on the effects of parental rearing on adult personality and life satisfaction was used to illustrate the method. Simulations revealed that the copula method performed better at higher levels of skewness in the independent variables, and that the impacts of lower skewness can be offset to some extent by larger sample size. When skewness and/or sample size is too small, the copula method is biased toward the uncorrected model. In the applied example, parental rejection/punishment predicted less adaptive personality and life satisfaction, with no evidence of confounding. For parental control/overprotection, there was evidence that confounding attenuated the estimated relationship with personality/life satisfaction. Copula adjustment is a promising method for handling unobserved confounding. The discussion focuses on how to proceed when assumptions are not quite met, and outlines potential avenues for future research.

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  • 27.
    Falkenström, Fredrik
    et al.
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten.
    Solbakken, Ole André
    Centre for Clinical Research Sörmland, Uppsala University, Sweden.
    Möller, Clara
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Lech, Börje
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten.
    Sandell, Rolf
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten.
    Holmqvist, Rolf
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Reflective Functioning, Affect Consciousness, and Mindfulness: Are These Different Functions?2014Ingår i: Psychoanalytic psychology, ISSN 0736-9735, E-ISSN 1939-1331, Vol. 31, nr 1, s. 26-40Artikel i tidskrift (Refereegranskat)
    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.

  • 28.
    Falkenström, Fredrik
    et al.
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Solomonov, Nili
    Weill Cornell Med Coll, NY USA.
    Rubel, Julian
    Univ Giessen, Germany.
    Using time-lagged panel data analysis to study mechanisms of change in psychotherapy research: Methodological recommendations2020Ingår i: Counselling and Psychotherapy Research, ISSN 1473-3145, E-ISSN 1746-1405, Vol. 20, nr 3, s. 435-441Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    The introduction of novel methodologies in the past decade has advanced research on mechanisms of change in observational studies. Time-lagged panel models allow us to track session-by-session changes and focus on within-patient associations between predictors and outcomes. This shift is crucial as change in mechanisms inherently takes place at a within-patient level. These models also enable preliminary casual inferences, which can guide the development of effective personalised interventions that target mechanisms of change, used at specific treatment phases for optimal effect. Given their complexity, panel models need to be implemented with caution, as different modelling choices can significantly affect results and reduce replicability. We outline three central methodological recommendations for use of time-lagged panel analysis to study mechanisms of change: (a) taking patient-specific effects into account, separating out stable between-person differences from within-person fluctuations over time; (b) properly controlling for autoregressive effects; and (c) considering long-term time trends. We demonstrate these recommendations in an applied example examining the session-by-session alliance-outcome association in a naturalistic psychotherapy study. We present limitations of time-lagged panel analysis and future directions.

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  • 29.
    Falkenström, Fredrik
    et al.
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Solomonov, Nili
    Weill Cornell Med Coll, NY USA.
    Rubel, Julian A.
    Justus Liebig Univ Giessen, Germany.
    Do therapist effects really impact estimates of within-patient mechanisms of change? A Monte Carlo simulation study2020Ingår i: Psychotherapy Research, ISSN 1050-3307, E-ISSN 1468-4381, Vol. 30, nr 7, s. 885-899Artikel i tidskrift (Refereegranskat)
    Abstract [en]

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

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  • 30.
    Falkenström, Fredrik
    et al.
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten. Linnaeus Univ, Sweden.
    Solomonov, Nili
    Weill Cornell Med, NY USA.
    Rubel, Julian A.
    Justus Liebig Univ Giessen, Germany.
    How to Model and Interpret Cross-Lagged Effects in Psychotherapy Mechanisms of Change Research: A Comparison of Multilevel and Structural Equation Models2022Ingår i: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 90, nr 5, s. 446-458Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: Modeling cross-lagged effects in psychotherapy mechanisms of change studies is complex and requires careful attention to model selection and interpretation. However, there is a lack of field-specific guidelines. We aimed to (a) describe the estimation and interpretation of cross lagged effects using multilevel models (MLM) and random-intercept cross lagged panel model (RI-CLPM); (b) compare these models performance and risk of bias using simulations and an applied research example to formulate recommendations for practice. Method: Part 1 is a tutorial focused on introducing/describing dynamic effects in the form of autoregression and bidirectionality. In Part 2, we compare the estimation of cross-lagged effects in RI-CLPM, which takes dynamic effects into account, with three commonly used MLMs that cannot accommodate dynamics. In Part 3, we describe a Monte Carlo simulation study testing model performance of RI-CLPM and MLM under realistic conditions for psychotherapy mechanisms of change studies. Results: Our findings suggested that all three MLMs resulted in severely biased estimates of cross-lagged effects when dynamic effects were present in the data, with some experimental conditions generating statistically significant estimates in the wrong direction. MLMs performed comparably well only in conditions which are conceptually unrealistic for psychotherapy mechanisms of change research (i.e., no inertia in variables and no bidirectional effects). Discussion: Based on conceptual fit and our simulation results, we strongly recommend using fully dynamic structural equation modeling models, such as the RI-CLPM, rather than static, unidirectional regression models (e.g., MLM) to study cross-lagged effects in mechanisms of change research. What is the public health significance of this article? We describe the differences between multilevel and structural equation modeling in the study of mechanisms of change in psychotherapy research. We argue that the common application of multilevel modeling assumes that there is no within-patient inertia in predictor or outcome variable, and the outcome variable does not impact the predictor, both of which seem highly unrealistic in psychotherapy research. Moreover, we demonstrate that violations of these assumptions may lead to severe bias in estimated coefficients, resulting in inaccurate recommendations for clinical practice. Thus, we recommend researchers to use structural equation modeling to estimate the effects of proposed change mechanisms over time.

  • 31.
    Fitzpatrick, Olivia M.
    et al.
    Ohio State Univ, OH 43210 USA; Harvard Univ, MA 02138 USA.
    Whelen, Megan L.
    Ohio State Univ, OH 43210 USA.
    Falkenström, Fredrik
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Strunk, Daniel R.
    Ohio State Univ, OH 43210 USA.
    Who Benefits the Most From Cognitive Change in Cognitive Therapy of Depression? A Study of Interpersonal Factors2020Ingår i: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 88, nr 2, s. 128-136Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: Research suggests that decreases in negative cognitions coincide with symptom improvements over the course of cognitive therapy (CT) of depression, but the role cognitive change (CC) plays in reducing symptoms remains controversial. Method: A total of 126 adults (mean age = 31.7, SD = 13.35; 60% female; 83% Caucasian) participated in CT for depression. Patients completed the Beck Depression Inventory-II and the Immediate Cognitive Change Scale at each session. At intake evaluation, maladaptive personality traits (Personality Inventory for DSM-5, Brief Form) and interpersonal problems (Inventory of Interpersonal Problems, Short Version) were assessed via self-report, and social skills were assessed through patients evaluation of their performance following a series of behavioral role-plays (standardized interaction task). To rule out between-patient differences as potential confounds, our model disaggregated within- and between-patient components of CC and depression scores. Results: Within-patient CC significantly predicted within-patient change in depressive symptoms. This relation was moderated by patients evaluations of their social skills and patients level of interpersonal problems, with CC predicting symptoms more robustly for patients with fewer perceived social skills and for those with greater interpersonal problems. Maladaptive personality traits did not emerge as a moderator. Additional analyses showed the relation of CC and symptom change was particularly strong among those with social anxiety disorder and among those observers rated as having lower social skills. Conclusions: CC in CT sessions appears to foster subsequent depressive symptom reduction, especially among patients with lower levels of self-evaluated social skills and greater interpersonal problems.

  • 32.
    Fluckiger, Christoph
    et al.
    Univ Zurich, Switzerland.
    Rubel, Julian
    Justus Liebig Univ Giessen, Germany.
    Del Re, A. C.
    Univ Zurich, Switzerland.
    Horvath, Adam O.
    Simon Fraser Univ, Canada.
    Wampold, Bruce E.
    Modum Bad Psychiat Ctr, Norway; Univ Wisconsin, WI 53706 USA.
    Crits-Christoph, Paul
    Univ Penn, PA 19104 USA.
    Atzil-Slonim, Dana
    Bar Ilan Univ, Israel.
    Compare, Angelo
    Univ Bergamo, Italy.
    Falkenström, Fredrik
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Ekeblad, Annika
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten.
    Errazuriz, Paula
    Univ Chile, Chile.
    Fisher, Hadar
    Bar Ilan Univ, Israel.
    Hoffart, Asle
    Modum Bad Psychiat Ctr, Norway.
    Huppert, Jonathan D.
    Hebrew Univ Jerusalem, Israel.
    Kivity, Yogev
    Bar Ilan Univ, Israel.
    Kumar, Manasi
    Univ Nairobi, Kenya.
    Lutz, Wolfgang
    Univ Trier, Germany.
    Muran, John Christopher
    Adelphi Univ, NY 21402 USA.
    Strunk, Daniel R.
    Ohio State Univ, OH 43210 USA.
    Tasca, Giorgio A.
    Univ Ottawa, Canada.
    Visla, Andreea
    Univ Zurich, Switzerland.
    Voderholzer, Ulrich
    Univ Munich, Germany.
    Webb, Christian A.
    Harvard Med Sch, MA 02115 USA; McLean Hosp, MA USA.
    Xu, Hui
    Loyola Univ Chicago, IL USA.
    Zilcha-Mano, Sigal
    Univ Haifa, Israel.
    Barber, Jacques P.
    Adelphi Univ, NY 21402 USA.
    The Reciprocal Relationship Between Alliance and Early Treatment Symptoms: A Two-Stage Individual Participant Data Meta-Analysis2020Ingår i: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 88, nr 9, s. 829-843Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective: Even though the early alliance has been shown to robustly predict posttreatment outcomes, the question whether alliance leads to symptom reduction or symptom reduction leads to a better alliance remains unresolved. To better understand the relation between alliance and symptoms early in therapy, we meta-analyzed the lagged session-by-session within-patient effects of alliance and symptoms from Sessions I to 7. Method: We applied a 2-stage individual participant data meta-analytic approach. Based on the data sets of 17 primary studies from 9 countries that comprised 5,350 participants, we first calculated standardized session-by-session within-patient coefficients. Second, we meta-analyzed these coefficients by using random-effects models to calculate omnibus effects across the studies. Results: In line with previous meta-analyses, we found that early alliance predicted posttreatment outcome. We identified significant reciprocal within-patient effects between alliance and symptoms within the first 7 sessions. Cross-level interactions indicated that higher alliances and lower symptoms positively impacted the relation between alliance and symptoms in the subsequent session. Conclusion: The findings provide empirical evidence that in the early phase of therapy. symptoms and alliance were reciprocally related to one other, often resulting in a positive upward spiral of higher alliance/lower symptoms that predicted higher alliances/lower symptoms in the subsequent sessions. Two-stage individual participant data meta-analyses have the potential to move the field forward by generating and interlinking well-replicable process-based knowledge.

  • 33.
    Hatcher, Robert L.
    et al.
    CUNY, NY 10016 USA.
    Lindqvist, Karin
    Stockholm Univ, Sweden.
    Falkenström, Fredrik
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Psychometric evaluation of the Working Alliance Inventory?Therapist version: Current and new short forms2020Ingår i: Psychotherapy Research, ISSN 1050-3307, E-ISSN 1468-4381, Vol. 30, nr 6, s. 706-717Artikel i tidskrift (Refereegranskat)
    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.

  • 34.
    Holmqvist Larsson, Kristina
    et al.
    Linköpings universitet, Institutionen för biomedicinska och kliniska vetenskaper, Centrum för social och affektiv neurovetenskap. Linköpings universitet, Medicinska fakulteten. Region Östergötland, Psykiatricentrum, Barn- och ungdomspsykiatriska kliniken Linköping.
    Thunberg, M.
    Region Östergötland, Psykiatricentrum, Barn- och ungdomspsykiatriska kliniken Norrköping.
    Münger, Ann-Charlotte
    Linköpings universitet, Institutionen för biomedicinska och kliniska vetenskaper, Avdelningen för barnafrid. Linköpings universitet, Medicinska fakulteten.
    Andersson, Gerhard
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten. Linköpings universitet, Institutionen för biomedicinska och kliniska vetenskaper. Linköpings universitet, Medicinska fakulteten. Karolinska Inst, Sweden.
    Falkenström, Fredrik
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten. Linnaeus Univ, Sweden.
    Zetterqvist, Maria
    Linköpings universitet, Institutionen för biomedicinska och kliniska vetenskaper, Centrum för social och affektiv neurovetenskap. Linköpings universitet, Medicinska fakulteten. Region Östergötland, Psykiatricentrum, Barn- och ungdomspsykiatriska kliniken Linköping.
    “It’s ok that I feel like this”: a qualitative study of adolescents’ and parents’ experiences of facilitators, mechanisms of change and outcomes in a joint emotion regulation group skills training2023Ingår i: BMC Psychiatry, E-ISSN 1471-244X, Vol. 23, nr 1, artikel-id 591Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BackgroundEmotion regulation difficulties underlie several psychiatric conditions, and treatments that focus on improving emotion regulation can have an effect on a broad range of symptoms. However, participants in-depth experiences of participating in emotion regulation treatments have not been much studied. In this qualitative study, we investigated participants experiences of a joint emotion regulation group skills training in a child and adolescent psychiatric outpatient setting.MethodsTwenty-one participants (10 adolescents and 11 parents) were interviewed about their experiences after they had participated in a seven-session transdiagnostic emotion regulation skills training for adolescents and parents. The aim of the skills training was to decrease emotion regulation difficulties, increase emotional awareness, reduce psychiatric symptoms, and enhance quality of life. The skills training consisted of psychoeducation about emotions and skills for regulating emotions. The interviews were transcribed and analysed using reflexive thematic analysis.ResultsThe analysis resulted in three overarching themes: Parent - Child processes, Individual processes, and Group processes. The result showed that participants considered an improved parent-child relationship to be the main outcome. Increased knowledge, emotion regulation skills and behavioural change were conceptualised as both mechanisms of change and outcomes. The group format, and the fact that parents and adolescents participated together, were seen as facilitators. Furthermore, the participants experienced targeting emotions in skills training as meaningful and helpful.ConclusionThe results highlight the potential benefits of providing emotion regulation skills training for adolescents and parents together in a group format to improve the parent-child relationship and enable the opportunity to learn skills.

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  • 35.
    Holmqvist Larsson, Mattias
    et al.
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten. Region Östergötland, Närsjukvården i centrala Östergötland, Psykiatriska kliniken.
    Björkman, Karin
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten.
    Nilsson, Karin
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten.
    Falkenström, Fredrik
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Holmqvist, Rolf
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    The Alliance and Rupture Observation Scale (AROS): Development and validation of an alliance and rupture measure for repeated observations within psychotherapy sessions2019Ingår i: Journal of Clinical Psychology, ISSN 0021-9762, E-ISSN 1097-4679, Vol. 75, nr 3, s. 404-417Artikel i tidskrift (Refereegranskat)
    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.

  • 36.
    Holmqvist Larsson, Mattias
    et al.
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Falkenström, Fredrik
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten. Center for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden.
    Andersson, Gerhard
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten. Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.
    Holmqvist, Rolf
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Alliance ruptures and repairs in psychotherapy in primary care2018Ingår i: Psychotherapy Research, ISSN 1050-3307, E-ISSN 1468-4381, Vol. 28, nr 1, s. 123-136Artikel i tidskrift (Refereegranskat)
    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.

  • 37.
    Katznelson, Hannah
    et al.
    Univ Copenhagen, Denmark.
    Falkenström, Fredrik
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Daniel, Sarah I. F.
    Lunn, Susanne
    Univ Copenhagen, Denmark.
    Folke, Sofie
    Danish Vet Ctr, Denmark.
    Pedersen, Signe Holm
    Child and Adolescents Psychiat Ctr, Denmark.
    Poulsen, Stig
    Univ Copenhagen, Denmark.
    Reflective Functioning, Psychotherapeutic Alliance, and Outcome in Two Psychotherapies for Bulimia Nervosa2020Ingår i: Psychotherapy, ISSN 0033-3204, E-ISSN 1939-1536, Vol. 57, nr 2, s. 129-140Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Mentalization is a developmental achievement defined as the capacity to understand behavior in terms of mental states. This study investigated mentalization in psychoanalytic psychotherapy (PPT) and cognitive behavior therapy (CBT) through a secondary data analysis of findings from a randomized controlled trial for bulimia nervosa. It was hypothesized that mentalization would predict alliance and outcome in both treatments, whereas increase in mentalization was only expected after PPT. Furthermore, it was investigated whether change in mentalization predicted symptom change. A total of 70 participants with bulimia nervosa were randomized to PPT or CBT. Participants were assessed at 3 time points with the Eating Disorder Examination and the Adult Attachment Interview (rated for reflective functioning [RF]). Therapy sessions were rated with the Vanderbilt Therapeutic Alliance Scale. Higher intake RF significantly predicted better alliance, whereas no association was observed between RF and outcome. A significant interaction between time, therapy type, and RF found RF improving more in PPT than in CBT. There was a significant association between RF change and symptom change in the PPT group. The study suggests a relation between RF and psychotherapy process, whereas the relation between RF and outcome is more complex. Furthermore, PPT seems to enhance mentalization, which seems related to symptomatic improvement, suggesting that mentalization might serve as a specific mechanism of change in PPT.

  • 38.
    Kullgard, Niclas
    et al.
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten.
    Persson, Per
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten.
    Möller, Clara
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Falkenström, Fredrik
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten.
    Holmqvist, Rolf
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Reflective functioning in patients with obsessive–compulsive disorder (OCD) – preliminary findings of a comparison between reflective functioning (RF) in general and OCD-specific reflective functioning2013Ingår i: Psychoanalytic Psychotherapy, ISSN 0266-8734, E-ISSN 1474-9734, Vol. 27, nr 2, s. 154-169Artikel i tidskrift (Refereegranskat)
    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.

  • 39.
    Kumar, Manasi
    et al.
    Univ Nairobi, Kenya; UCL, England.
    Wangari Kuria, Mary
    Univ Nairobi, Kenya.
    Othieno, Caleb Joseph
    Univ Nairobi, Kenya.
    Falkenström, Fredrik
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Improving psychotherapies offered in public hospitals in Nairobi, Kenya: extending practice-based research model for LMICs2018Ingår i: International Journal of Mental Health Systems, E-ISSN 1752-4458, Vol. 12, artikel-id 76Artikel i tidskrift (Refereegranskat)
    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.

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  • 40.
    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
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    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 Depression2019Ingår i: Journal of Nervous and Mental Disease, ISSN 0022-3018, E-ISSN 1539-736X, Vol. 207, nr 6, s. 421-422Artikel i tidskrift (Övrigt vetenskapligt)
    Abstract [en]

    n/a

  • 41.
    Lilja, Josefine L.
    et al.
    Univ Gothenburg, Sweden; RandD Primary Hlth Care, Sweden.
    Falkenström, Fredrik
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Zelleroth, Clara
    Gothenburg, Sweden.
    Jacobson, Emma
    Univ Gothenburg, Sweden.
    Risberg, Stina
    Bäckefors, Sweden.
    Nissling, Linnea
    Univ Gothenburg, Sweden; RandD Primary Hlth Care, Sweden.
    Weineland, Sandra
    Univ Gothenburg, Sweden; RandD Primary Hlth Care, Sweden.
    Psychometric properties and validation of the Swedish Five Facet Mindfulness Questionnaire in a clinical and non-clinical sample among meditators and non-meditators2020Ingår i: Scandinavian Journal of Psychology, ISSN 0036-5564, E-ISSN 1467-9450, Vol. 61, nr 3, s. 369-379Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Over a period of 15 years several attempts to conceptualize mindfulness have been presented and revised, but there is still no clear or agreed-upon definition. The use of mindfulness-based interventions has increased in clinical and research settings the last couple of years, including in Sweden. As a clinician it is crucial to know if a treatment works through the theoretically postulated mechanisms of change. Mindfulness is a concept that is difficult to measure. The overall aim of the current project was to examine the psychometric properties of the Swedish version of the Five Facet Mindfulness Questionnaire (FFMQ_SWE) using three different studies. To test the construct validity of the FFMQ_SWE a hierarchal confirmatory factor analysis was performed in a meditating non-clinical sample, to examine if all the five facets would load on an overall mindfulness construct. Psychometric properties of the instrument were examined in a non-clinical and a clinical sample, and discriminative relationships with other variables were analysed. The convergent validity was examined by analysing the correlations between FFMQ_SWE and Hospital Anxiety and Depression Scale, Sense of Coherence and Difficulties in Emotion Regulation Scale. Test-retest reliability was tested by distributing FFMQ_SWE at two occasions. The hierarchal confirmatory factor analysis showed good fit in a population of meditators. The FFMQ_SWE showed good convergent validity and test-retest reliability in both clinical and non-clinical populations. In sum, the Swedish version of the FFMQ showed good psychometric properties and can be a useful instrument as an evaluation of treatment effects in both health care settings and research settings.

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  • 42.
    Lilja, Josefine L.
    et al.
    Gothenburg University, Sweden .
    Lundh, Lars-Gunnar
    Lund University, Sweden .
    Josefsson, Torbjorn
    Halmstad University of Coll, Sweden .
    Falkenström, Fredrik
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten.
    Observing as an Essential Facet of Mindfulness: A Comparison of FFMQ Patterns in Meditating and Non-Meditating Individuals2013Ingår i: Mindfulness, ISSN 1868-8527, E-ISSN 1868-8535, Vol. 4, nr 3, s. 203-212Artikel i tidskrift (Refereegranskat)
    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.

  • 43.
    Lilliengren, Peter
    et al.
    Stockholm University, Sweden.
    Falkenström, Fredrik
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten. 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 Adults2015Ingår i: Journal of counseling psychology, ISSN 0022-0167, E-ISSN 1939-2168, Vol. 62, nr 1Artikel i tidskrift (Refereegranskat)
    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.

  • 44.
    Lilliengren, Peter
    et al.
    Ersta Skondal Bracke Univ Coll, Sweden.
    Philips, Bjorn
    Stockholm Univ, Sweden.
    Falkenström, Fredrik
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    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 Disorders2019Ingår i: Psychotherapy, ISSN 0033-3204, E-ISSN 1939-1536, Vol. 56, nr 2, s. 285-296Artikel i tidskrift (Refereegranskat)
    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.

  • 45.
    Lindqvist, Karin
    et al.
    Erica Fdn, Sweden.
    Falkenström, Fredrik
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten. Uppsala University, Sweden.
    Sandell, Rolf
    Lund University, Sweden.
    Holmqvist, Rolf
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Ekeblad, Annika
    Linköpings universitet, Institutionen för beteendevetenskap och lärande. Linköpings universitet, Filosofiska fakulteten.
    Thoren, Agneta
    Erica Fdn, Sweden.
    Multilevel Exploratory Factor Analysis of the Feeling Word Checklist-242017Ingår i: Assessment (Odessa, Fla.), ISSN 1073-1911, E-ISSN 1552-3489, Vol. 24, nr 7, s. 907-918Artikel i tidskrift (Refereegranskat)
    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.

  • 46.
    Lindqvist, Karin
    et al.
    Stockholm Univ, Sweden.
    Mechler, Jakob
    Stockholm Univ, Sweden.
    Carlbring, Per
    Stockholm Univ, Sweden.
    Lilliengren, Peter
    Ersta Skondal Bracke Univ Coll, Sweden.
    Falkenström, Fredrik
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Andersson, Gerhard
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten. Karolinska Inst, Sweden.
    Johansson, Robert
    Stockholm Univ, Sweden.
    Edbrooke-Childs, Julian
    Anna Freud Natl Ctr Children and Families, England; UCL, England.
    Dahl, Hanne-Sofie J.
    Vestfold Hosp Trust, Norway; Univ Oslo, Norway.
    Bergsten, Katja Lindert
    Uppsala Univ, Sweden.
    Midgley, Nick
    UCL, England; Anna Freud Natl Ctr Children and Families, England.
    Sandell, Rolf
    Lund Univ, Sweden.
    Thoren, Agneta
    Erica Fdn, Sweden.
    Topooco, Naira
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten. Ctr M2Hlth, CA USA.
    Ulbere, Randi
    Univ Oslo, Norway; Diakonhjemmet Hosp, Norway.
    Philips, Bjorn
    Stockholm Univ, Sweden.
    Affect-Focused Psychodynamic Internet-Based Therapy for Adolescent Depression: Randomized Controlled Trial2020Ingår i: Journal of Medical Internet Research, E-ISSN 1438-8871, Vol. 22, nr 3, artikel-id e18047Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background: Adolescent depression is one of the largest health issues in the world and there is a pressing need for effective and accessible treatments. Objective: This trial examines whether affect-focused internet-based psychodynamic therapy (IPDT) with therapist support is more effective than an internet-based supportive control condition on reducing depression in adolescents. Methods: The trial included 76 adolescents (61/76, 80% female; mean age 16.6 years), self-referred via an open access website and fulfilling criteria for major depressive disorder. Adolescents were randomized to 8 weeks of IPDT (38/76, 50%) or supportive control (38/76, 50%). The primary outcome was self-reported depressive symptoms, measured with the Quick Inventory of Depressive Symptomatology for Adolescents (QIDS-A17-SR). Secondary outcomes were anxiety severity, emotion regulation, self-compassion, and an additional depression measure. Assessments were made at baseline, postassessment, and at 6 months follow-up, in addition to weekly assessments of the primary outcome measure as well as emotion regulation during treatment. Results: IPDT was significantly more effective than the control condition in reducing depression (d=0.82, P=.01), the result of which was corroborated by the second depression measure (d=0.80, Pamp;lt;.001). IPDT was also significantly more effective in reducing anxiety (d=0.78, Pamp;lt;.001) and increasing emotion regulation (d=0.97, Pamp;lt;.001) and self-compassion (d=0.65, P=.003). Significantly more patients in the IPDT group compared to the control group met criteria for response (56% vs 21%, respectively)and remission (35% vs 8%, respectively). Results on depression and anxiety symptoms were stable at 6 months follow-up. On average, participants completed 5.8 (SD 2.4) of the 8 modules. Conclusions: IPDT may be an effective intervention to reduce adolescent depression. Further research is needed, including comparisons with other treatments.

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  • 47.
    Mbuthia, Judy Wanjiru
    et al.
    Univ Nairobi, Kenya.
    Kumar, Manasi
    Univ Nairobi, Kenya; UCL, England.
    Falkenström, Fredrik
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    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 analysis2018Ingår i: Child and Adolescent Psychiatry and Mental Health, E-ISSN 1753-2000, Vol. 12, artikel-id 28Artikel i tidskrift (Refereegranskat)
    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.

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  • 48.
    Mechler, Jakob
    et al.
    Stockholm Univ, Sweden.
    Lindqvist, Karin
    Stockholm Univ, Sweden.
    Carlbring, Per
    Stockholm Univ, Sweden.
    Lilliengren, Peter
    Ersta Skondal Bracke Univ Coll, Sweden.
    Falkenström, Fredrik
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Andersson, Gerhard
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten. Karolinska Inst, Sweden.
    Topooco, Naira
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten. Ctr M2Hlth, CA USA.
    Johansson, Robert
    Stockholm Univ, Sweden.
    Midgley, Nick
    Anna Freud Ctr, England; UCL, England.
    Edbrooke-Childs, Julian
    UCL, England; Anna Freud Natl Ctr Children & Families, England.
    Dahl, Hanne-Sofie J.
    Vestfold Hosp Trust, Norway; Univ Oslo, Norway.
    Sandell, Rolf
    Lund Univ, Sweden.
    Thoren, Agneta
    Erica Fdn, Sweden.
    Ulberg, Randi
    Univ Oslo, Norway; Uppsala Univ, Sweden; Diakonhjemmet Hosp, Norway.
    Bergsten, Katja Lindert
    Uppsala Univ, Sweden.
    Philips, Bjorn
    Stockholm Univ, Sweden.
    Internet-based psychodynamic versus cognitive behaviour therapy for adolescents with depression: study protocol for a non-inferiority randomized controlled trial (the ERiCA study)2020Ingår i: Trials, E-ISSN 1745-6215, Vol. 21, nr 1Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Background

    Adolescent depression is a common mental health problem and there is an urgent need for effective and accessible treatments. Internet-based interventions solve many obstacles for seeking and receiving treatment, thus increasing access to effective treatments. Internet-based cognitive behavioural therapy (ICBT) for adolescent depression has demonstrated efficacy in previous trials. In order to broaden the range of evidence-based treatments for young people, we evaluated a newly developed affect-focused Internet-based psychodynamic treatment (IPDT) in a previous study with promising results. The purpose of the planned study is to evaluate the efficacy of IPDT for adolescent depression in a non-inferiority trial, comparing it to ICBT.

    Methods

    The study will employ a parallel randomized non-inferiority design (ratio 1:1; n = 270). Eligible participants are adolescents 15–19 years suffering from depression. The primary hypothesis is that IPDT will be non-inferior to ICBT in reducing depressive symptoms from pre-treatment to end of treatment. Secondary research questions include comparing outcomes of IPDT and ICBT regarding anxiety symptoms, emotion regulation and self-compassion. Additional data will be collected to evaluate cost-effectiveness as well as investigating predictors, moderators and mediators of outcome. In addition, we will examine long-term outcome up to 1 year after end of treatment. Diagnostic interviews with MINI 7.0 will be used to establish primary diagnosis of depression as well as ruling out any exclusion criteria. Both treatments consist of eight modules over 10 weeks, complemented with therapist support through text messages and weekly chat sessions. Primary outcome measure is the Quick Inventory of Depressive Symptomatology in Adolescents Self-Rated (QIDS-A17-SR). Primary outcome will be analysed using data from all participants entering the study using a multilevel growth curve strategy based on the weekly measurements of QIDS-A17-SR. The non-inferiority margin is defined as d = 0.30.

    Discussion

    This trial will demonstrate whether IPDT is non-inferior to ICBT in the treatment of adolescent depression. The study might therefore broaden the range of evidence-based treatment alternatives for young people struggling with depression. Further analyses of data from this trial may increase our knowledge about “what works for whom” and the pathways of change for two distinct types of interventions.

    Trial registration

    ISRCTN12552584, Registered on 13 August 2019.

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  • 49.
    Mechler, Jakob
    et al.
    Department of Psychology, Stockholm University, Stockholm, Sweden.
    Lindqvist, Karin
    Department of Psychology, Stockholm University, Stockholm, Sweden.
    Carlbring, Per
    Department of Psychology, Stockholm University, Stockholm, Sweden.
    Topooco, Naira
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten. Center for m2Health, Palo Alto University, CA, USA.
    Falkenström, Fredrik
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten. Department of Psychology, Linnaeus University, Växjö, Sweden.
    Lilliengren, Peter
    Ersta Sköndal Bräcke University College, Stockholm, Sweden.
    Andersson, Gerhard
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten. Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.
    Johansson, Robert
    Department of Psychology, Stockholm University, Stockholm, Sweden.
    Midgley, Nick
    Child Attachment and Psychological Therapies Research Unit, Anna Freud National Centre for Children and Families, London, UK.
    Edbrooke-Childs, Julian
    Evidence-based Practice Unit, Anna Freud National Centre for Children and Families, London, UK and Department of Clinical, Educational and Health Psychology, University College London, London, UK.
    Dahl, Hanne-Sofie J
    Department of Psychology, University of Oslo, Oslo, Norway.
    Sandell, Rolf
    Department of Psychology, Lund University, Lund, Sweden.
    Thorén, Agneta
    The Erica Foundation, Stockholm, Sweden.
    Ulberg, Randi
    Institute of Clinical Medicine, University of Oslo, Oslo, Norway and Department of Psychiatry, Diakonhjemmet Hospital, Oslo, Norway.
    Bergsten, Katja Lindert
    Department of Psychology, Uppsala University, Uppsala, Sweden.
    Philips, Björn
    Department of Psychology, Stockholm University, Stockholm, Sweden.
    Therapist-guided internet-based psychodynamic therapy versus cognitive behavioural therapy for adolescent depression in Sweden: a randomised, clinical, non-inferiority trial2022Ingår i: The Lancet Digital Health, E-ISSN 2589-7500, Vol. 4, nr 8, s. e594-e603Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    BACKGROUND: Adolescent major depressive disorder (MDD) is highly prevalent and associated with lifelong adversity. Evidence-based treatments exist, but accessible treatment alternatives are needed. We aimed to compare internet-based psychodynamic therapy (IPDT) with an established evidence-based treatment (internet-based cognitive behavioural therapy [ICBT]) for the treatment of adolescents with depression.

    METHODS: In this randomised, clinical trial, we tested whether IPDT was non-inferior to ICBT in the treatment of adolescent MDD. Eligible participants were 15-19 years old, presenting with a primary diagnosis of MDD according to DSM-5. Participants were recruited nationwide in Sweden through advertisements on social media, as well as contacts with junior and senior high schools, youth associations, social workers, and health-care providers. Adolescents who scored 9 or higher on the Quick Inventory of Depressive Symptomatology for Adolescents (QIDS-A17-SR) in an initial online screening were contacted by telephone for a diagnostic assessment using the Mini International Neuropsychiatric Interview. Participants were randomly assigned to ICBT or IPDT. Both interventions comprised eight self-help modules delivered over 10 weeks on a secure online platform. The primary outcome was change in depression severity measured weekly by the QIDS-A17-SR. Primary analyses were based on an intention-to-treat sample including all participants randomly assigned. A non-inferiority margin of Cohen's d=0·30 was predefined. The study is registered at ISRCTN, ISRCTN12552584.

    FINDINGS: Between Aug 19, 2019, and Oct 7, 2020, 996 young people completed screening; 516 (52%) were contacted for a diagnostic interview. 272 participants were eligible and randomly assigned to ICBT (n=136) or IPDT (n=136). In the ICBT group, 51 (38%) of 136 participants were classified as remitted, and 54 (40%) of 136 participants were classified as remitted in the IPDT group. Within-group effects were large (ICBT: within-group d=1·75, 95% CI 1·49 to 2·01; IPDT: within-group d=1·93, 1·67 to 2·20; both p<0·0001). No statistically significant treatment difference was found in the intention-to-treat analysis. Non-inferiority for IPDT was shown for the estimated change in depression during treatment (d=-0·18, 90% CI -0·49 to 0·13; p=0·34). All secondary outcomes showed non-significant between-group differences.

    INTERPRETATION: IPDT was non-inferior to ICBT in terms of change in depression for the treatment of adolescents with MDD. This finding increases the range of accessible and effective treatment alternatives for adolescents with depression.

    FUNDING: Kavli trust.

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  • 50.
    Mechler, Jakob
    et al.
    Stockholm Univ, Sweden.
    Lindqvist, Karin
    Stockholm Univ, Sweden.
    Falkenström, Fredrik
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten.
    Carlbring, Per
    Stockholm Univ, Sweden.
    Andersson, Gerhard
    Linköpings universitet, Institutionen för beteendevetenskap och lärande, Psykologi. Linköpings universitet, Filosofiska fakulteten. Karolinska Inst, Sweden.
    Philips, Bjorn
    Stockholm Univ, Sweden.
    Sudden gains and large intersession improvements in internet-based psychodynamic treatment (IPDT) for depressed adolescents2021Ingår i: Psychotherapy Research, ISSN 1050-3307, E-ISSN 1468-4381, Vol. 31, nr 4, s. 455-467Artikel i tidskrift (Refereegranskat)
    Abstract [en]

    Objective:Sudden gains (SGs) have often been found associated with better treatment outcome across different psychiatric disorders. However, no studies have evaluated SGs in internet-based treatment targeting adolescent depression.Method:The sample consisted of 66 adolescents diagnosed with major depressive disorder, attending psychodynamic internet-based treatment. Effects of SGs were evaluated at posttreatment and 6-month follow-up. We also evaluated effects of large intersession improvements (LIIs; sudden and relatively large gains, between sessions, without the stability criterion). Effects of SGs and LIIs early in treatment were also investigated.Results:A total of 17 patients (25.75%) experienced an SG. The effect of having an SG or early SG was non-significant after treatment (d = 0.48) and at follow-up (d= 0.66). However, having an LII was related to better outcome after treatment (d = 0.97) and at follow-up (d = 0.76). Early LIIs were associated with significantly better results at end of treatment (d = 0.72).Conclusions:The original criteria of SGs might be overly conservative and thus miss important improvements in depression. Relatively large intersession gains, regardless of stability, seem to be predictive of outcome.

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