Contribution of the therapeutic bond, therapist interventions and their interaction to outcome in psychotherapy

Empirical research has established that both individual and group psychotherapy is effective for a broad range of psychiatric disorders, but less is known about the processes associated with positive treatment outcomes. The aim of the present thesis was to examine the individual and combined contribution of two essential aspects of the Generic Model of Psychotherapy to outcome, namely the therapeutic bond (therapeutic alliance; group climate) and therapist interventions (homework assignments; transference work). Data was taken from two previously published randomized controlled trials. The first trial examined the effectiveness of cognitive behavioral group therapy (CBGT) for patients with comorbid disorders, whereas the second trial examined the effectiveness of short-term dynamic psychotherapy (STDP) and cognitive therapy (CT) for patients with cluster C personality disorders. Paper I found support for the use of a trans-theoretical measure of group climate as a predictor of long-term followup outcome in CBGT for comorbid disorders, particularly the dimension of engagement. In paper II, early ratings of therapist competence in assigning homework was found to predict both mid- and post treatment outcomes in CT with cluster C personality disorders. The use of homework assignments was not observable in STDP. This finding emphasizes the quality of homework assignments as an important and measurable therapist skill essential for treatment outcome, at least in CT. Paper III reported that a stronger emphasis on transference work, especially in the context of a weak therapeutic alliance, was associated with a smaller reduction in interpersonal problems at treatment termination in STDP and CT with cluster C personality disorders. The findings demonstrate the “risks” involved in having a stronger emphasis on transference work, especially in the context of a weak therapeutic alliance early in treatment. The results add to the importance of examining the contribution of the therapeutic bond, therapist interventions and their interaction to outcome in psychotherapy, and have noteworthy clinical implications for practicing therapists

An apprenticeship model in the training of psychotherapy students. Study protocol for a randomized controlled trial and qualitative investigation

Background One approach towards advancing the quality of mental health care is to improve psychotherapists\u27 skills through education and training. Recently, psychotherapy training has benefitted from adapting training methods from other professions (e.g., deliberate practice). The apprenticeship model has a long history in skill trades and medicine, but has yet to be adopted in training mental health professionals. This study aims to investigate the impact of apprenticeship training on clinical psychology students\u27 skills. Methods In a pragmatic mixed-methods trial, 120 first year students in a Master\u27s degree clinical psychology program will be randomized to either training-as-usual or training-as-usual plus psychotherapy apprenticeship. In the intervention group, students will participate, over a period of 10 weeks, in weekly treatment sessions together with licensed therapists at outpatient mental health and substance use treatment clinics. Outcomes are assessed post-intervention and at two-year follow-up. The main outcome measure is the Facilitative Interpersonal Skills (FIS) performance test. Additional self-report measures tap self-efficacy, self-compassion, worry, rumination, and stress. Weekly reflection log entries written by the students will be qualitatively analyzed in order to gain an in-depth understanding of the learning process. Students\u27 and therapists\u27 experiences with the intervention will be explored in focus group interviews. Discussion To the best of our knowledge, this is the first controlled study to investigate the impact of apprenticeship as an isolated training component in the education of clinical psychologists. The study is designed so as to yield a comprehensive understanding of an approach which could prove to be a valuable supplement to the existing educational methods in this field and ultimately, contribute to improve the quality of mental health care

Protective and vulnerability factors in self-esteem: The role of metacognitions, brooding, and resilience.

The aim of the current study was to explore protective (resilience) and vulnerability factors (dysfunctional metacognitions and brooding) for self-esteem. A total of 725 participants were included in a cross-sectional study. A path analysis revealed five paths to self-esteem. The three main paths were as follows: (1) symptoms −> metacognitions −> brooding −> self-esteem, (2) symptoms −> resilience −> self-esteem, and (3) a direct path from symptoms. The first path corresponds with the metacognitive model of psychopathology and suggests that triggers in the form of anxiety and depression symptoms lead to the activation of metacognitive beliefs, which in turn activates brooding in response to these triggers. When a person engages in brooding, this makes the person vulnerable to experiencing low self-esteem. The second path suggests a protective role of resilience factors. The overall model explained 55% of the variance in self-esteem. Regression analysis found that unique predictors of self-esteem were female sex, symptoms of anxiety and depression, brooding, and resilience. These findings have possible clinical implications, as treatment may benefit from addressing both protective and vulnerability factors in individuals suffering from low self-esteem

Interpersonal problems as a predictor of pain catastrophizing in patients with chronic pain

Background and aims Pain catastrophizing has consistently been related to a variety of negative outcomes within chronic pain conditions, but competing models exist explaining the role of catastrophizing. According to the fear-avoidance model (FAM), catastrophizing is primarily related to the appraisal of pain (i.e. “intrapersonal”), whereas the communal coping model (CCM) suggests that catastrophizing is a strategy to elicit support (i.e. “interpersonal”). In order to examine the interpersonal nature of catastrophizing, this cross-sectional study examined interpersonal problems as a predictor of pain catastrophizing in a sample of patients (n = 97) with chronic pain. Methods Self-report data was taken from patients entering a multidisciplinary, inpatient rehabilitation program. The four quadrants of the Inventory of Interpersonal Problems circumplex model (Hostile-Dominant, Hostile-Submissive, Friendly-Submissive, Friendly-Dominant) were used as predictors of pain catastrophizing in a series of separate, hierarchical regression analyses. Results After controlling for relevant confounding variables such as demographics (gender, age), pain severity, psychiatric symptoms (anxiety/depression, fatigue, insomnia), adverse life experiences and perceived social support, higher levels of Hostile-Dominant interpersonal problems predicted higher levels of pain catastrophizing (p ≤ 0.01, d = 0.56). Conclusions The results add support to the notion that pain catastrophizing may serve a communicative functioning, as predicted by the CCM, with cold, dominant and controlling behaviors as a maladaptive interpersonal strategy to elicit support. It may thus be useful to consider the broader interpersonal context of the individual, and not only the patient’s appraisal of pain, when conceptualizing the role of pain catastrophizing in patients with chronic pain. Implications Future psychosocial research and treatment of chronic pain could be informed by including interpersonal theory as a useful theoretical framework, which may help shed more light on how interpersonal problems relates to pain catastrophizing

Worry and Metacognitions as Predictors of Anxiety Symptoms: A Prospective Study

Both worry and metacognitive beliefs have been found to be related to the development of anxiety, but metacognitive theory (Wells and Matthews, 1994; Wells, 2009) suggest that metacognitive beliefs may play a more prominent role. The aim of the present prospective study was to examine whether worry, metacognitive beliefs or the interaction between worry and metacognitive beliefs, were the best predictor of anxiety over time, utilizing a longitudinal, prospective study design. An undergraduate student sample (N = 190) was assessed on measures of worry (PSWQ), metacognitive beliefs (MCQ-30) and anxiety (BAI) at three points in time over a 7-month period. A mixed-model analysis revealed that both worry and metacognitive beliefs predicted development of anxiety, independently of each other, with no indication of an interaction-effect (PSWQ * MCQ-30). Further, analyses of the MCQ-30 subscales indicated that negative metacognitive beliefs may be particularly important in the development of anxiety. While gender was correlated with worry, gender predicted anxiety beyond the effect of worry. Taken together, the results imply that both worry and metacognitive beliefs play a prominent role for the development of anxiety

The relationship of acute delirium with cognitive and psychiatric symptoms after stroke: a longitudinal study

Objective Delirium, a common complication after stroke, is often overlooked, and long-term consequences are poorly understood. This study aims to explore whether delirium in the acute phase of stroke predicts cognitive and psychiatric symptoms three, 18 and 36 months later. Method As part of the Norwegian Cognitive Impairment After Stroke Study (Nor-COAST), 139 hospitalized stroke patients (49% women, mean (SD) age: 71.4 (13.4) years; mean (SD) National Institutes of Health Stroke Scale (NIHSS) 3.0 (4.0)) were screened for delirium with the Confusion Assessment Method (CAM). Global cognition was measured with the Montreal Cognitive Assessment (MoCA), while psychiatric symptoms were measured using the Hospital Anxiety and Depression Scale (HADS) and the Neuropsychiatric Inventory-Questionnaire (NPI-Q). Data was analyzed using mixed-model linear regression, adjusting for age, gender, education, NIHSS score at baseline and premorbid dementia. Results Thirteen patients met the criteria for delirium. Patients with delirium had lower MoCA scores compared to non-delirious patients, with the largest between-group difference found at 18 months (Mean (SE): 20.8 (1.4) versus (25.1 (0.4)). Delirium was associated with higher NPI-Q scores at 3 months (Mean (SE): 2.4 (0.6) versus 0.8 (0.1)), and higher HADS anxiety scores at 18 and 36 months, with the largest difference found at 36 months (Mean (SE): 6.2 (1.3) versus 2.2 (0.3)). Conclusions Suffering a delirium in the acute phase of stroke predicted more cognitive and psychiatric symptoms at follow-up, compared to non-delirious patients. Preventing and treating delirium may be important for decreasing the burden of post-stroke disability

The Relationship of Psychiatric Symptoms with Performance-Based and Self-Reported Cognitive Function After Ischemic Stroke

Objective: Findings on the relationship of psychiatric symptoms with performance-based and self-reported cognitive function post-stroke are inconclusive. We aimed to (1) study the relation of depression and anxiety to performance-based cognitive function and (2) explore a broader spectrum of psychiatric symptoms and their association with performance-based versus self-reported cognitive function. Method: Individuals with supratentorial ischemic stroke performed neuropsychological examination 3 months after stroke. For primary analyses, composite scores for memory and attention/executive function were calculated based on selected neuropsychological tests, and the Hospital Anxiety and Depression Scale (HADS) was used. Psychiatric symptoms and self-reported cognitive function for secondary aims were assessed using the Symptom-Checklist-90 – Revised (SCL-90-R). Results: In a sample of 86 patients [mean (M) age: 64.6 ± 9.2; Mini-Mental State Examination (MMSE), 3–7 days post-stroke: M = 28.4 ± 1.7; National Institutes of Health Stroke Scale (NIHSS) after 3 months: M = 0.7 ± 1.6] depressive symptoms (HADS) were associated with poorer memory performance after controlling for age, sex, and education (p ≤ .01). In a subsample (n = 41; Age: M = 65.7 ± 8.1; MMSE: M = 28.4 ± 1.8; NIHSS: M = 1.0 ± 1.9), symptoms of phobic anxiety (SCL-90-R) were associated with poorer performance-based memory and attention/executive function, and symptoms of anxiety (SCL-90-R) with lower attention/executive function. Higher levels of self-reported cognitive difficulties were associated with higher scores in all psychiatric domains (p ≤ .05). Conclusion: Even in relatively well-functioning stroke patients, depressive symptoms are associated with poorer memory. The results also suggest that various psychiatric symptoms are more related to self-reported rather than to performance-based cognitive function. Screening for self-reported cognitive difficulties may not only help to identify patients with cognitive impairment, but also those who need psychological treatment

The Relationship of Psychiatric Symptoms with Performance-Based and Self-Reported Cognitive Function After Ischemic Stroke

Objective: Findings on the relationship of psychiatric symptoms with performance-based and self-reported cognitive function post-stroke are inconclusive. We aimed to (1) study the relation of depression and anxiety to performance-based cognitive function and (2) explore a broader spectrum of psychiatric symptoms and their association with performance-based versus self-reported cognitive function. Method: Individuals with supratentorial ischemic stroke performed neuropsychological examination 3 months after stroke. For primary analyses, composite scores for memory and attention/executive function were calculated based on selected neuropsychological tests, and the Hospital Anxiety and Depression Scale (HADS) was used. Psychiatric symptoms and self-reported cognitive function for secondary aims were assessed using the Symptom-Checklist-90 – Revised (SCL-90-R). Results: In a sample of 86 patients [mean (M) age: 64.6 ± 9.2; Mini-Mental State Examination (MMSE), 3–7 days post-stroke: M = 28.4 ± 1.7; National Institutes of Health Stroke Scale (NIHSS) after 3 months: M = 0.7 ± 1.6] depressive symptoms (HADS) were associated with poorer memory performance after controlling for age, sex, and education (p ≤ .01). In a subsample (n = 41; Age: M = 65.7 ± 8.1; MMSE: M = 28.4 ± 1.8; NIHSS: M = 1.0 ± 1.9), symptoms of phobic anxiety (SCL-90-R) were associated with poorer performance-based memory and attention/executive function, and symptoms of anxiety (SCL-90-R) with lower attention/executive function. Higher levels of self-reported cognitive difficulties were associated with higher scores in all psychiatric domains (p ≤ .05). Conclusion: Even in relatively well-functioning stroke patients, depressive symptoms are associated with poorer memory. The results also suggest that various psychiatric symptoms are more related to self-reported rather than to performance-based cognitive function. Screening for self-reported cognitive difficulties may not only help to identify patients with cognitive impairment, but also those who need psychological treatment

The effects of Routine Outcome Monitoring (ROM) in the course of an implementation process - A randomized clinical trial

This study investigated the effects of the Partners for Change Outcome Management System (PCOMS) in adult outpatient treatment at a hospital-based mental health clinic. It also investigated whether the effects differed with the timing of the treatment within a 4-year implementation period, with clients’ initial distress levels, and between therapists. Adult clients (N = 170) were randomized to treatment as usual (TAU) or routine outcome monitoring (ROM). Twenty therapists provided therapy in both conditions. Therapy outcome was measured by the Behavior and Symptoms Identification Scale (BASIS-32). Data were analyzed in a series of multilevel models (MLMs). Clients in the ROM condition were 2.5 times more likely to demonstrate improvement than those in the TAU condition. Controlling for therapist variability, the overall effect size (ES) in favor of ROM was small (d = 0.26, p = .037). The superiority for ROM over TAU increased significantly over the duration of the study. ROM effects were not moderated by clients’ initial distress levels. Differences between therapists accounted for 9%–10% of the variability in outcomes, and there were no significant differences in ROM effects between therapists. ROM was associated with better treatment outcomes independent of clients’ initial distress levels. Clients treated later in the study benefitted more from ROM than those treated earlier