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.

BackgroundNonsuicidal self-injury (NSSI) is associated with stigma, and negative attitudes among healthcare professionals toward NSSI have been reported. A person-centered approach that focuses on how individuals with lived experience of NSSI perceive the treatment and care they receive is invaluable in reducing barriers to help-seeking and improving treatment and mental healthcare services. The aim of the current qualitative study was to explore the perceptions of young adults when they look back upon their experiences of psychiatric treatment for NSSI during adolescence.MethodsTwenty-six individuals with lived experience of NSSI who were in contact with child and adolescent psychiatry during adolescence were interviewed. The interviews were analyzed using thematic analysis.ResultsThree main themes were developed: Changed perceptions in retrospect, The importance of a collaborative conceptualization and Lasting impression of the relationship. Participants' perception of themselves as well as the treatment changed over time. The importance of a joint understanding of NSSI and an agreed-upon treatment focus was emphasized. The relationship to the mental health professionals, and experiences of how NSSI was communicated, were salient several years later.ConclusionsHealthcare professionals need to communicate about NSSI in a respectful manner and include the perspective of the adolescent with lived experience of NSSI in a joint conceptualization of NSSI and treatment focus.

There is little research about the long-term effects on childrenthat were separated from their parents and moved fromFinland to Sweden during World War II. The aim of this studywas to capture these now-lifelong reflections, and so questionnaireswere sent to 14 potential participants. Ten personsaged 7381 responded. The themes that emerged concernedpride over professional achievements, the pain of separation,and feelings of alienation and loneliness. The informantsemphasized the importance of sibling relationships. The conclusionwas that the participants, despite the hardships connectedwith the migration, had successfully lived a good lifein Sweden.ARTICLE HISTORYReceived 16 July 2018Accepted 11 May 2018KEYWORDSFinnish war children; childseparations; childevacuation; importance ofsibling relationsAt

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

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.

Background: In addition to theoretical education, clinical psychology programs should include practical skills training. This skill training may be tied to specific assessment and treatment methods; other skills, such as the ability to create a collaborative alliance with patients, are more generic. Previous research has shown that the ability to build a therapeutic alliance (TA) is often not systematically taught in clinical psychology programs and it is uncertain how this competence is examined. A lack of competence in establishing TA on the part of the psychologist might diminish the effects of psychotherapy. To meet the Bologna Declaration, European universities need to demonstrate constructive alignment, i.e. a relationship between elements of the course content and intended learning outcomes in course documents, and show how the acquired knowledge, abilities, and approaches are assessed. Method: This conceptual paper reviewed the syllabuses for universities in Sweden offering the five-year clinical psychology program to illustrate how higher education in Sweden adheres to the Bologna recommendation on constructive alignment when teaching TA to future clinical psychologists. Results: Only two universities out of all eleven universities in Sweden offering a psychology program described satisfactory constructive alignment concerning TA. Conclusion: This conceptual paper raises awareness of the importance of pedagogic structure when teaching TA in higher education by pointing to the prevailing lack of constructive alignment in teaching TA. The increased awareness will hopefully lead to improved structuring in the teaching of TA.

Objective: Patients with eating disorders (ED) often suffer from co-morbid depression, which may complicate the ED treatment. Previous studies have found that ED interventions seem to have limited capacity to reduce depressive symptoms. Several studies of interpersonal psychotherapy (IPT), have found that when patients have been treated for depression, co-morbid symptoms have diminished. As depression and EDs are commonly co-occurring conditions, this pilot study aimed to examine the effect of an IPT treatment for these conditions, with the focus on the depressive symptoms. Method: In this multi-centre study, 16 patients with EDs and co-occurring major depression received 16 weeks of depression-focused IPT. Results: Significant improvements with substantial effect sizes were found for both depression (d = 1.48) and ED (d =.93). Symptom reduction in the two syndromes were strongly correlated (r =.625, p =.004). Patients with a restrictive ED did not improve on either depression or ED symptoms. Conclusion: These findings point to the usefulness of IPT for concurrent depression and ED with a bingeing/purging symptomatology. Working with negative affect and problem-solving related to current interpersonal problems may alleviate general psychological distress among these patients. © 2017 Informa UK Limited, trading as Taylor amp; Francis Group.

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.

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.

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.

Therapists' in-session feelings in psychotherapy can be seen as indications of the development of the therapeutic relationship and the therapeutic process. To manage them appropriately, it is important to know to what extent they may be influenced by patients' pretreatment characteristics. This study aims to improve the understanding of therapists' emotional reactions in the psychotherapeutic setting by investigating if patients' pretreatment mentalization ability and attachment style predicted therapist in-session feelings. In a sample of 87 therapy dyads treated with interpersonal psychotherapy and cognitive behavioral therapy for depression, patient attachment was measured using self-reported Experiences in Close Relationships (ECR) and mentalization using Reflective Functioning (RF). ECR and RF were hypothesized to predict therapist feelings measured by the Feeling Word Checklist-24 at different treatment phases over the full course of treatment. Treatment method, patient age, gender, and pretreatment depression were evaluated as potential confounders. Multilevel modeling was used to analyze the data. Lower RF in patients predicted more negative therapist feelings in the mid- to late-treatment phases and less positive feelings in the late-treatment phase. Self-reported attachment anxiety or avoidance did not predict therapist feelings. Findings indicate that patients' ability to mentalize is important to consider when conducting psychotherapy, as it can influence therapists' feelings in the therapeutic process. Limitations of the present study's approach are discussed, and directions for future research are considered.

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.

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.

Objective: There is a need for rigorous methods to study the mechanisms that lead to individual-level change (i.e., process-outcome research). We argue that panel data (i.e., longitudinal study of a number of individuals) methods have 3 major advantages for psychotherapy researchers: (1) enabling microanalytic study of psychotherapeutic processes in a clinically intuitive way, (2) modeling lagged associations over time to ensure direction of causality, and (3) isolating within-patient changes over time from between-patient differences, thereby protecting against confounding influences because of the effects of unobserved stable attributes of individuals. However, dynamic panel data methods present a complex set of analytical challenges. We focus on 2 particular issues: (1) how long-term trajectories in the variables of interest over the study period should be handled, and (2) how the use of a lagged dependent variable as a predictor in regression-based dynamic panel models induces endogeneity (i.e., violation of independence between predictor and model error term) that must be taken into account in order to appropriately isolate within-and between-person effects. Method: An example from a study of working alliance in psychotherapy in primary care in Sweden is used to illustrate some of these analytic decisions and their impact on parameter estimates. Results: Estimates were strongly influenced by the way linear trajectories were handled; that is, whether variables were "detrended" or not. Conclusions: The issue of when detrending should be done is discussed, and recommendations for research are provided. What is the public health significance of this article? This article provides recommendations on how to study psychotherapy processes using dynamic panel data models to strengthen causal inferences. Accurate estimates of what drives individual development in psychotherapy are needed to generate recommendations on what therapists should focus on in therapy. Using the alliance-outcome association as an example, we show that estimated effect sizes may vary greatly depending on which modeling approach is used, with the decision on whether to remove time-trends from the outcome variable making the largest difference.

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.

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

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.

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.

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.

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.

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.

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.

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.

Objectives

To explore the associations between self-rated attachment style, psychological distress and substance use among substance use disorder (SUD) outpatients in psychological treatment.

Design and Methods

In this practice-based study, 108 outpatients were asked to fill in the Experiences in Close Relationships – Short form, the Clinical Outcomes in Routine Evaluation – Outcome Measure (CORE-OM), the Alcohol Use Disorders Identification Test (AUDIT), and the Drug Use Disorders Identification Test (DUDIT) at treatment start and end. Patients were given psychological treatments with a directive, reflective or supportive orientation.

Results

An insecure attachment style was more common among the SUD outpatients, compared to non-clinical groups. Patients with a fearful attachment style scored higher on psychological distress than patients with a secure attachment style. The associations between the attachment dimensions and psychological distress were stronger than those between attachment and SUD. Significantly more patients had a secure attachment style at treatment end.

Conclusions

This study shows significant relations between patients’ attachment style and their initial psychological distress. The causal relationship between attachment style and psychological distress is, however, not clear and can likely go in both directions. The psychological treatment of patients with SUD contributed significantly to changes from insecure to secure attachment style.

Practitioner Points

We found among patients with SUD a strong relation between patients’ attachment style and their psychological distress. Knowledge of the patient’s attachment style may help the therapist to tailor the treatment to the patient’s needs. A change from insecure to secure attachment style can be an important goal for a SUD treatment, as it may prevent the patient from using defence strategies involving substance use for regulating emotions and interpersonal relationships.

Background: More knowledge is needed about outcome of treatments in routine care for patients with substance use disorders (SUDs). These patients often suffer from psychological distress in addition to SUDs. Objectives: To evaluate the effects of community-based psychological treatment on SUD patients’ psychosocial problems, as well as on their substance use. Design: All patients who were referred or self-referred for psychological treatment to a social worker or a psychotherapist at three outpatient treatment centers for SUD patients were asked to participate in the study. Methods: Ratings at treatment start and end were obtained on Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM, n = 100), Alcohol Use Disorders Identification Test - Consumption (AUDIT-C, n = 49), and Drug Use Disorders Identification Test - Consumption (DUDIT-C, n = 27). Results: CORE-OM mean scores were significantly improved. In total 14% of the patients were recovered, 10% improved, and 5% deteriorated. Both AUDIT-C and DUDIT-C mean scores were significantly improved for patients with alcohol use and patients using illicit drugs, respectively. Conclusions: Routine psychological treatment had positive effects on psychological distress as well as on reduction of substance use. A substantial number of patients remained however unchanged, particularly regarding psychological distress. More studies with larger patient groups are needed to develop treatment for SUD patients in routine care.

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

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.

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.

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

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

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

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

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

Ett utmärkande drag i den relationella terapin är att man konsekvent anlägger ett tvåpersons-perspektiv på interaktionen. Det innebär att samspelet alltid uppfattas som gemensamt skapat. Utforskandet av patientens fantasier och relationsmönster som karakteriserar traditionell psykodynamisk terapi ersätts av en nyfikenhet på det gemensamt skapade samspelet. Ett annat kännetecken för relationell psykoterapi är att den kan användas tillsammans med de flesta andra psykoterapeutiska tekniker. När patienten och terapeuten uppmärksammar att något intressant och förvånande har hänt mellan dem har de förstås redan arbetat ett tag med de problem patienten söker hjälp för. Den meta-kommunikation som startar när de börjar prata med varandra om sitt samspel är grunden för det relationella arbetet. Syftet är att öka patientens förmåga att förstå sig på samspel, att mentalisera och att öka affekttoleransen hos patienten. Relationell psykoterapi har utvecklats ur den psykoanalytiska idétraditionen. Den kan ses som en vidareutveckling från den engelska objektrelationsteorin och den amerikanska interpersonella psykodynamiska psykoterapin. Boken ger läsaren möjlighet att förstå hur denna terapiform används i praktiken.

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

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

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

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

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

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

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