BACKGROUND:Emotion-Focused Therapy (EFT) is an effective form of psychotherapy for a range of psychological problems. While earlier research demonstrated the effect of in-session processes as being central for explaining the effects of EFT, it is unclear what the role of clients' self-reported quality of emotional processing assessed right after each therapy session is for the prediction of therapy outcome. Specifically, we are assuming that session-by-session trajectories of clients' self-assessed clarification processes and treatment outcome are moderated by their self-reported post-session feelings. METHODS:A total of N = 48 clients with a variety of psychological problems and undergoing EFT within a naturalistic context have been included in the present study. Symptom change was assessed using CORE-10 after each therapy session, in addition to pre- and post-therapy. After each session, the client self-assessed a range of session feelings and the quality of clarification experienced in the session. Longitudinal trajectory analyses with moderation effects and exploratory dynamic network analyses were conducted. RESULTS:The post-session client experience of sadness or grief and joy moderate the trajectory of clarification depth over the course of EFT. Post-session feelings influenced the trajectory of symptom levels over the course of therapy (clarification was non-significant in the model). Specific emotion-based dynamic pathways to clarification and symptom load were explored. CONCLUSIONS:The session-by-session interplay between session feelings (sadness and joy), as self-rated by the client after each session, was a moderator of self-rated clarification and symptom-level trajectories across Emotion-Focused Therapy. This study adds to the understanding of the client's self-perceived mechanisms of change in EFT as it is conducted in a naturalistic context.
OBJECTIVE:Approximately half of patients with generalised anxiety disorder (GAD) do not recover following psychological treatment. Accurate prognostic judgement may support clinical decision-making and planning. This study compared the predictive accuracy of clinicians and a validated machine learning model and examined factors clinicians reported using when forming predictions. METHOD:Clinicians from two routine psychological therapies services in the UK predicted post-treatment GAD-7 scores and categorical outcomes (reliable improvement, reliable recovery, deterioration) for 100 patients prior to treatment, providing confidence ratings and free-text explanations. Predictions were compared with those generated by a pre-trained Bayesian Additive Regression Tree model using mean absolute error (MAE), root mean squared error (RMSE), and area under the receiver operating characteristic curve (AUC). Clinician rationales were analysed thematically. RESULTS:Among 66 patients with complete outcomes, the model showed numerically greater accuracy for post-treatment GAD-7 scores, reliable improvement, and recovery, although these differences were not statistically significant. Both approaches performed poorly for deterioration. Clinicians reported high confidence (M = 67.3%), which was unrelated to accuracy. Thematic analysis identified contextual factors such as motivation and engagement not captured in routinely collected data. CONCLUSION:Structured prediction models may enhance prognostic accuracy in routine psychotherapy and complement clinician judgement.
Objective: Current routine outcome monitoring in psychotherapy relies heavily on self-reports. In the present study, we developed and evaluated a brief implicit measure based on the Affect Misattribution Procedure (AMP) designed to complement the CORE-OM or other ROM measures. Method: Individuals seeking psychotherapy at a university-based service (n = 109) and non-clinical undergraduate controls (n = 46) completed a self-referential Affect Misattribution Procedure and the CORE-OM. We examined group differences, associations between implicit and explicit distress, split-half reliability, and exploratory longitudinal change. Results: Implicit scores were significantly higher in the clinical than in the control group, with a small to medium effect size (g = 0.41), whereas the CORE-OM difference was large (g = 1.07). Implicit and explicit distress showed moderate convergence, and CORE-OM scores accounted for approximately 12% of the variance in AMP scores. The AMP also showed high split-half reliability (rsβ = .92) and preliminary sensitivity to therapeutic change over 12 sessions (dz = 0.54). Conclusion: These findings support the feasibility of a brief implicit task that yields a reliable and partially distinct index of self-identification related to distress, supporting its use as a complementary component for triangulation between implicit measures and explicit self-report measures within routine outcome monitoring.
OBJECTIVE:This study explored change in distress during psychotherapy in a training setting from a middle-income country, examining client demographics and between-therapist variability. METHOD:Participants were 220 adults attending ≥5 sessions. Most were women (66.82%); aged 18-62 (Mean = 23.48 [22.61, 24.42], SD = 6.90). Distress was assessed with the CORE-10. Two- and three-level models with linear, quadratic, and logarithmic time functions were compared. Three-level models were fit with and without adjustment for first score, age and gender. RESULTS:The quadratic three-level model including first score, age and gender fit best (R2 = 0.72). Higher initial distress was associated with higher symptom levels across sessions but did not moderate the rate of improvement over time. Therapist effects were small but statistically significant (longitudinal: 2.9%; pre-post: 1.4%). Pre-therapy gender differences were not statistically significant; however, men improved faster initially. Age showed no statistically significant association with pre-therapy distress. CONCLUSION:Clients showed early improvements that decelerated and between-therapist differences were small after accounting for baseline distress. Findings suggest that strengthening early engagement and attending to possible gender-related differences in early response may help inform service delivery in middle-income countries, although these strategies were not directly tested in the present study.
Objective: Research has found an association between sudden gains (SGs), known as rapid symptom improvements, and positive therapeutic outcomes. Experiential therapies, like Emotion Focused Therapy for Youth (EFT-Y), provide opportunities for SGs. Our study is the first to evaluate within-session SGs in EFT-Y. Method: Participants who completed treatment from a previous randomized, waitlist-control design were analysed for within-session symptom shifts. The subsample comprised 22 youth (ages 9-17), evaluating their emotion regulation (ER) and symptoms of depression. Measures were taken at eight time points: before treatment, at the beginning and end of sessions 2, 4, and 6, and after session 8. Results: Half of the participants experienced at least one SG in their ER, and 33% of participants experienced SGs in their depression symptoms. Regardless of SG status, all participants' symptoms significantly improved post-treatment. Conclusion: Within EFT-Y, rapid improvements can occur within a single session, unlike the commonly studied phenomenon of SGs between sessions. Both SG-responders and non-SG-responders showed symptom improvements during and post-treatment, suggesting that EFT-Y is an effective treatment for young clients and that SGs may provide valuable insight into key moments of transformation and therapeutic progress.
OBJECTIVE:This study examined rupture-repair processes in child psychotherapy, focusing on therapist-reported repair strategies and their relation to child therapeutic alliance. The role of parental alliance and child's diagnostic profile in shaping rupture type and severity was also examined. METHODS:Ninety-four child psychotherapists attended workshops on rupture and repair strategies adapted for children and reported on a single therapy session with children aged 3-13. Therapists completed measures of child and parent alliance, rupture type and intensity, and reported interventions based on 3RS repair strategies adapted for children. ANOVAs were used to assess group comparability; multiple linear regressions tested associations among child alliance, rupture intensity, repair strategies, parental alliance, and diagnostic group; and chi-square tests examined the association between diagnostic group and rupture type. RESULTS:Parental alliance was the strongest predictor of child alliance. Repair strategy frequency was positively associated with child alliance. Unexpectedly, rupture intensity was positively associated with child alliance. More intense ruptures elicited a greater number of therapist interventions. Confrontation ruptures were more common in externalizing disorders, whereas withdrawal ruptures predominated among internalizing disorders. CONCLUSION:Findings highlight parental alliance and frequency of developmentally adapted rupture-repair strategy use as important correlates of therapeutic alliance in child psychotherapy.
OBJECTIVE:Teletherapy has demonstrated outcomes comparable to in-person treatment, yet less is known about how early therapeutic processes and change trajectories unfold across modalities in couple therapy. This study examined whether early alliance predicts outcomes and change trajectories and whether these associations differ by modality and initial distress. METHOD:Data were drawn from 266 different-sex couples at university-based training clinics (2020-2024). Alliance was assessed via the Session Rating Scale (SRS) and functioning via the Outcome Rating Scale (ORS), using dyadic models and latent growth curve analyses. RESULTS:Early alliance predicted outcomes for female but not male partners, with no significant differences across modalities. Greater attendance predicted better outcomes; higher initial distress predicted poorer outcomes, with stronger effects for women in in-person therapy. ORS scores followed a nonlinear trajectory characterized by rapid early improvement followed by stabilization.. In teletherapy, higher alliance was associated with a gradual rate of early improvement. Partner distress reduced improvement for female partners. CONCLUSION:Early change was characterized by rapid gains followed by stabilization across both modalities. However, alliance predicted outcomes for female but not male partners, and partner distress constrained improvement among female partners, underscoring the importance of dyadic processes in couple therapy.
From 19 meta-analyses comparing active bona fide treatments, Flückiger et al. (2026) recently calculated a between-group effect size (SMD) of -0.17 for primary outcomes and of -0.16 for secondary outcomes. They suggested using these effect sizes as empirically derived non-inferiority margins. However, Flückiger et al.'s approach is conceptually problematic and lacks empirical support. Without a rationale, empirically found differences between active treatments cannot per se be regarded as non-inferiority margins.
OBJECTIVE:To estimate an optimal treatment selection in data from a recent RCT comparing short-term psychodynamic (STPP) and cognitive behavioral therapy (CBT) for depression. METHOD:An estimator from causal inference with a valuesearch optimization was applied to estimate the optimal treatment choice for 100 patients diagnosed with major depressive disorder. Cross-validated prediction was performed, and the population mean outcome under optimal treatment was estimated. RESULTS:Outcomes (psychosocial functioning and depressive symptoms) for estimated optimal treatment were stratified by treatments received and compared for concordant versus discordant assignments. Large effect sizes were observed (range 0.41-2.07). "Positive beliefs about rumination" was found to be an important predictor, with higher baseline levels favoring CBT. An improvement of more than 30% relative to randomized treatment was considered clinically significant. For most patients (75%), CBT was identified as the optimal treatment, whereas patients in the optimal STPP group showed the greatest benefit for concordant assignment. DISCUSSION:The valuesearch method showed effective personalization, with greater improvement than typically reported in other methods of personalization with similar therapies and outcomes. A simple parametric user-specified treatment regime is easy to interpret, and robustness to model misspecification is appealing. Limited external validity is expected (small sample), and prospective validation is needed to guide clinical treatment selection. Head-to-head comparisons with other methods are required to draw conclusions about relative performance.
Objective: Self-assessment of psychotherapeutic skills is assumed to be prone to bias. The present study aimed to investigate psychology students' ability to assess their own psychotherapeutic skills, and to compare it with the assessment from independent raters and supervisors. Method: Data from 73 psychology students were analyzed from a randomized controlled trial investigating the effect of clinical supervision on skill development. Students' basic communication skills, therapeutic alliance, and empathy were assessed by independent raters and students themselves. Supervisors assessed students' basic communication skills and empathy after supervision. A truth and bias model was applied to examine bias and accuracy in students' self-assessment. Results: Across outcomes, the results did not indicate a consistent pattern of overestimation (self-assessment bias). Students only overestimated their therapeutic alliance in comparison with independent observers, and underestimated their empathy in comparison with supervisors. Overall, students' self-assessments did not yield significant accuracy in relation to independent observer or supervisor ratings. Conclusions: Self-assessments of students in the early stages of their training may lack accuracy compared with external assessments, while the role of systematic bias needs further investigation. Future research should explore methods, such as feedback, to improve the precision of self-assessment.
OBJECTIVE:This study examined the development of a vignette-based instrument to assess therapists' microprocess-level clinical discrimination, the ability to identify and differentiate moment-to-moment psychological dynamics within therapeutic dialogue. Addressing a gap in psychotherapy process research, we evaluated whether this capacity can be systematically articulated and measured using a structured, dimensional framework. METHOD:Fifty-three participants (36 trainees, 17 experienced clinicians) completed a vignette-based questionnaire before and after structured exposure to the Dimensional Model, which organizes moment-to-moment therapeutic processes. A nonrandomized pre-post design assessed sensitivity to short-term changes in evaluative judgments. The instrument was developed through expert consensus and administered in parallel forms. RESULTS:Discrimination scores and confidence increased from pre- to post-assessment. Experts showed higher baseline performance, whereas trainees demonstrated larger gains, resulting in comparable post-assessment scores. Participants also reported increased reliance on explicit and reflective judgment processes. CONCLUSIONS:The findings support the feasibility of assessing microprocess-level clinical discrimination using a structured, vignette-based approach and suggest that such discrimination can be systematically measured. The instrument further demonstrates sensitivity to short-term changes in participants' evaluative judgments following structured exposure. The dimensional framework may offer a useful organizing structure for the articulation and interpretation of vignette-based assessments, warranting further longitudinal and ecological.
OBJECTIVE:The first aim of this study was to conduct a systematic and meta-analysis review considering both single-group interventions and controlled design to determine the effectiveness of interventions designed to reduce overall perfectionism, its two higher-order factors (Perfectionistic Strivings and Perfectionistic Concerns), and its dimensions measured separately. The second aim was to determine the relevance of moderators in terms of effectiveness. METHOD:A systematic search process was performed in the Web of Science, Scopus, PsycINFO, and Psicodoc databases, using a common search strategy. RESULTS:A total of 33 studies were found. The interventions demonstrated clinical effectiveness with small to moderate effect sizes, except for the baseline-to-post-intervention measures of Perfectionistic Concerns, Socially prescribed perfectionism, and Personal standards. Scale type was found to be a significant moderator of Perfectionistic Concerns, Socially prescribed perfectionism, Perfectionistic Strivings, and Self-oriented perfectionism. The country was found to be significant for Perfectionistic Strivings and Self-oriented perfectionism. The treatment goal was only revealed to be significant for Concerns over mistakes.
OBJECTIVE:Placebo-controlled trials face significant challenges in psychotherapy research due to difficulties in creating credible placebo conditions and the inability of blinding therapists. We tested the open/hidden administration as an alternative approach to differentiate between specific and nonspecific treatment effects. METHOD:68 healthy subjects were randomized to receive one session of person-centered therapy to implement therapeutic alliance either with their knowledge (open; n = 23), without their knowledge (hidden; n = 22), or no treatment (control; n = 23) following experimental guilt induction. The primary outcome was guilt responses after the guilt induction. Secondary outcomes were shame, pride, and affect responses. We hypothesized that both alliance conditions would reduce guilt compared to control, with no difference between alliance conditions. RESULTS:Control participants showed significantly higher guilt responses than alliance conditions (p < .001, d = 1.07), whereas guilt did not differ significantly between open and hidden conditions (p = 0.810, d = 0.07). Similar patterns emerged for shame and pride, but not for affect. CONCLUSION:These results provide evidence that the open/hidden administration offers a novel approach to test the specificity of treatment components in psychotherapy research. Furthermore, our findings indicate that the therapeutic alliance is effective regardless of the provision of a treatment rationale.
OBJECTIVES:This study evaluated the efficacy of a culturally adapted version of the Lighthouse Parenting Programme (LPP) in reducing parenting stress and preventing childhood and early adolescence mental health difficulties in the Chinese context. It further assessed the program's feasibility and acceptability. METHODS:Sixty-four parents of children aged 4-14 years, reporting elevated parenting stress (PSI ≥ 85), were randomly assigned to an LPP immediate intervention group (n = 30) or a waitlist control group (n = 34). Assessments of parenting stress, child behavioral difficulties and temperament, parental personality functioning, mentalizing, self-efficacy, mental health, and parent-child relationship quality were conducted at baseline, post-intervention/waitlist, and at a 3-month follow-up. Participant satisfaction was also measured. RESULTS:Relative to controls, the LPP group showed greater pre-to-post improvements across multiple domains (all p < .05), including parenting stress, child behavioral difficulties, child temperament, parental self-efficacy, personality functioning, mental health, and parent-child relationship quality. These gains appeared to be maintained at 3-month follow-up. Participant satisfaction was also high. CONCLUSION:The culturally adapted LPP was associated with reduced parenting stress and lower early mental health risks in Chinese children, providing preliminary evidence for its feasibility and efficacy in this cultural context.
OBJECTIVE:Alliance ruptures are common in psychotherapy, and their clinical impact depends on how they are recognized and responded to. Little empirical work has examined rupture processes in psychotherapy for schizophrenia-spectrum disorders. The present study investigated whether therapists' adherence to Metacognition Insight Reflection Therapy (MERIT) elements is associated with clients' session-quality evaluations and whether adherence moderates the association between therapist-perceived alliance ruptures and client-perceived session quality. METHOD:Data included 610 therapy sessions from a randomized controlled trial, including 37 clients diagnosed with schizophrenia or schizoaffective disorder. Following each session, therapists rated their adherence to MERIT elements and their perceived intensity of alliance ruptures, while clients independently rated session quality. Multilevel models were used to examine within-client associations across sessions. RESULTS:Therapists' adherence to MERIT elements was positively associated with clients' perceptions of session quality. Higher therapist-perceived rupture intensity was negatively associated with clients' session evaluations. Adherence to MERIT content elements moderated this association: when content adherence was high, therapist-perceived rupture intensity was no longer associated with poorer client-rated session quality, whereas under low adherence conditions, greater rupture intensity predicted worse session evaluations. CONCLUSION:Therapists experienced rupture was negatively related to clients' satisfaction, in sessions characterized by weaker therapist-rated adherence to content elements.
Objective: Treatments for adolescent non-suicidal self-injury (NSSI) primarily focus on reducing self-injury behaviors directly, which remain limited in efficacy. Here, we propose a self-compassion-focused integrated training (SCFIT) project to reduce adolescent NSSI through three components: developing self-differentiation abilities of adolescents to block potential threats arising from depleting family environments, conducting self-compassion training to repair positive personal resources, and providing brief DBT skills training to directly alleviate NSSI.Methods: An additive component control design was conducted to test the treatment effect of SCFIT on 165 adolescents with NSSI. Mediation models further examined whether changes in self-compassion and self-differentiation served as mechanisms of this effect.Results: The results showed that compared with the DBT only group, there were more considerable reductions in self-injury behaviors (β = -1.16, p < 0.001) and depression symptoms (β = -0.37, p = 0.006) and significant improvements in psychological well-being (β = 2.51, p < 0.001) in the SCFIT group over the 8-week intervention, and the effects remained significant at 1-month follow-up. Mediation analyses indicated that changes in self-compassion and self-differentiation mediated the impact of intervention on changes in both NSSI and depression symptoms.Conclusions: The SCFIT project effectively reduced adolescent NSSI through blocking, repairing, and alleviating processes, offering encouraging and comprehensive evidence for future NSSI treatment.
OBJECTIVE:Alliance ruptures are central to psychotherapy process and outcome, yet therapists often fail to detect them in real time, particularly withdrawal ruptures, which tend to manifest subtly. This study examined whether machine learning applied to moment-to-moment movement dynamics during psychotherapy sessions can identify markers of alliance ruptures. METHOD:We analyzed 474 videotaped psychotherapy sessions from 86 dyads drawn from a randomized controlled trial for major depressive disorder. Alliance ruptures were coded using the Rupture Resolution Rating System (3RS). Patient and therapist movement was quantified using motion energy analysis across head and body regions. Two feature-engineering approaches captured temporal and spatial movement patterns associated with rupture occurrence. RESULTS:Models showed greater discriminative performance for withdrawal ruptures (mean AUC = .73) than for confrontational ruptures (mean AUC = .56). Therapist head movements were the most robust individual marker across rupture types, whereas detecting withdrawal ruptures required integrating movement information across multiple body regions and both dyad members. CONCLUSION:Withdrawal ruptures leave consistent embodied signatures despite being difficult to identify in vivo. These findings advance psychotherapy process research and highlight the potential of machine learning-based movement analysis to identify behavioral and interpretable markers for alliance-focused training and supervision.
Internet-delivered psychotherapies show promise for adolescent major depression (MDD), but little is known about which baseline characteristics predict improvement or moderate differential effects between internet-delivered cognitive-behavioral therapy (ICBT) and psychodynamic therapy (IPDT). This study examined pretreatment predictors and moderators of symptom change in a randomized trial comparing the treatments. This secondary analysis used data from a non-inferiority trial (n = 272) in which adolescents with MDD received 10 weeks of guided ICBT or IPDT. Mixed-effects models tested predictors and moderators of change in self-rated depression. Anxiety symptoms, length of depressive episode, emotion regulation, personality disorder severity, attachment, self-compassion, suicidal ideation, and baseline depression were examined as predictors and moderators. Higher self-compassion predicted steeper improvement across treatments, as the only significant predictor. Comorbid anxiety moderated outcome where higher anxiety was associated with significantly greater improvement in IPDT relative to ICBT, with no difference at average levels. At the lowest levels of anxiety, ICBT showed significantly better outcomes. No other significant moderators emerged. Findings suggest that baseline variables may influence the rate of improvement in internet-delivered therapy for adolescent MDD, as well as help guide treatment selection. Replication is needed to establish the clinical utility of these variables.
