OBJECTIVE:Social anxiety disorder (SAD) is one of the most common mental disorders, with the majority of those affected not receiving primary care or psychotherapy. Internet-based treatments may be an alternative for individuals with SAD. We hypothesize that interpersonal characteristics differ between SAD patients in face-to-face (ftf) and online treatments, and that these factors predict treatment outcomes. METHODS:The sample consisted of 539 patients with SAD from four different online treatment studies (N = 376) and one university outpatient clinic in Europe (N = 163) who received integrative CBT. Interpersonal problems were assessed at baseline and symptom severity at baseline and treatment termination. RESULTS:Results showed similar interpersonal patterns of being nonassertive and socially inhibited in both treatment groups at baseline, with patients in online treatment being more severely affected than those in ftf therapy. Interpersonal problems of communion were predictive of outcome in both treatments. Low communion reflects interpersonal coldness, distance, and difficulty forming close bonds, whereas high communion reflects excessive dependence, submissiveness, and overinvolvement with others. Patients with interpersonal problems of low communion benefited more from ftf therapy, while patients with interpersonal problems of high communion benefited more from online therapy. CONCLUSION:These findings underscore the importance of considering interpersonal problems when planning and evaluating treatment for SAD. In the future, it may be possible to predict if a particular SAD patient benefits more from online versus ftf treatment from their baseline interpersonal problems and recommend the suitable treatment.

In this study, we aimed to explore interpersonal distress as a moderator of the effects of supportive treatment (ST) versus supportive expressive treatment (SET) on the therapeutic alliance and outcome in patients with depression. We drew on data from a randomized controlled trial where 100 patients were randomized to receive 16 sessions of either ST or SET. Patients completed a measure of interpersonal problems at baseline. Therapy outcome and the strength of the therapeutic alliance were measured by patient self-report, before and after each session, respectively. We conducted interactive three-level mixed effect models, accounting for the nested structure of the data, with repeated measures nested within patients, nested within therapists. The results showed significant interactive effects of treatment by baseline interpersonal problems on both the evolution of outcome and the alliance. Patients with greater interpersonal problems had a greater reduction in depressive severity and greater improvements in the alliance when treated with SET versus ST. If further replicated, the results of this study suggest that therapists of patients with depression would benefit from evaluating their interpersonal distress at baseline and incorporating this evaluation in their decision-making process regarding the most suitable intervention strategy for each individual patient. To conclude, the results of this study might enhance evidence-based treatment personalization in patients with depression using a parsimonious personalization approach. (PsycInfo Database Record (c) 2025 APA, all rights reserved).

The therapeutic alliance is a well-established predictor of psychotherapy outcome, and the ability to mentalize has been discussed as a change mechanism in psychotherapy. Low mentalization may lead to impairments in the alliance. In the present study, we assessed mentalization effects on the therapeutic alliance over the course of treatment. Thirty-seven patients diagnosed with depression or anxiety disorders received 25 +/- 3 sessions of integrative cognitive behavioral therapy (outpatient setting). Patient's mentalization was coded by external raters based on transcripts of the first, eighth, 16th, and 24th therapy sessions, and the alliance quality was assessed from both patient and therapist perspectives after each session. The effects of mentalization on the alliance were investigated both within and between patients using hierarchical linear modeling. A higher patient ability to mentalize was related to a better therapist-reported but not patient-reported alliance during treatment. Mentalization did not show significant within-patient effects on the therapeutic alliance. To conclude, therapists may perceive a stronger therapeutic alliance with patients who exhibit a greater capacity for mentalization. It might be important for therapists to pay attention to a possible positive bias when patients present with a high ability to mentalize.

OBJECTIVE:We investigated whether defense mechanisms in patients with borderline personality disorder (BPD) predict treatment response of dialectical behavior therapy (DBT) and whether they moderate outcome in different treatment lengths. METHOD:We analyzed a subsample of 60 outpatients with BPD, randomized into either 6 (n = 30) or 12 (n = 30) months of DBT. The average level of defensive adaptiveness, assessed with observer-rated overall defensive functioning (ODF) and "immature" (i.e., maladaptive) defenses were used as predictors and moderators of self-reported frequency of self-harm. We conducted a Generalized Linear Mixed Model (GLMM). RESULTS:A lower ODF at treatment onset predicted smaller reductions in self-harm, irrespective of treatment length (IRR = 0.92, 95% CI = [0.86, 0.99], p = .020). Lower order "immature" ("major image distorting") defenses showed significantly smaller (IRR = 1.13, 95% CI = [1.06, 1.21], p < .001) and higher order "immature" ("minor image distorting") defenses showed significantly larger (IRR = .91, 95% CI = [.85, .97], p = .006) reductions in self harm in the 6-month but not in the 12-month treatment. CONCLUSION:Even though the results have to be regarded as preliminary due to the small sample size, findings might indicate that patients with BPD and lower average defensive adaptiveness may benefit from individualized treatment plans including specific interventions targeting defense function.

[Background] Despite the finding that the majority of psychotherapists adopt a rather process-oriented and integrative stance, it is uncommon that psychotherapy trainings are transtheoretical and transdiagnostic. Considering principles of change that cut across different schools of therapy holds promise for developing truly research-informed psychotherapy trainings. Common principles of change may answer the question what should be trained. Another important question is how to train. In current psychotherapy training programs, transfer of theory into practice relies mainly on role-playing exercises and supervised practice, both of which have their limitations. [Aims] A fantasy for the future would be the development, implementation, and evaluation of a complementary 21st century online principle-based and marker-led psychotherapy training: incorporating the concepts of deliberate practice as well as expert training, the huge potential of technologies, and considering the importance of (context) responsiveness. [Conclusion] To illustrate this idea, we present a training that we are currently developing, an online Alliance-Focused Training.

Objective: During treatment, the therapeutic alliance is characterized by rupture and repair episodes, which in turn are associated with psychotherapy outcome. It would be important to have a parsimonious tool to identify ruptures in psychotherapy sessions to provide therapists with meaningful feedback about when they occur. The present study thus aims to establish whether measuring self-reported alliance dynamics can function as a measure of alliance ruptures. Method: The sample consisted of 58 depressed patients, who received 22 sessions of cognitive therapy for depression in an outpatient setting. The observer-rated Rupture Resolution Rating System (3RS) was applied to 58 sessions where the self-reported Working Alliance Inventory (WAI) completed by patients after each therapy session indicated that alliance ratings declined more than 2 SDs from that patient's individual mean. For comparison purposes, the 3RS was also applied to 58 randomly chosen sessions from the same treatment phase (early, middle, late). Results: Results showed significant differences between sessions where the WAI indicated a drop in the alliance and randomly chosen sessions of the same treatment phase with regard to the frequency and impact of ruptures. Conclusion: This speaks for the construct validity of the 3RS. Session-by-session alliance ruptures may reliably be measured using a case-sensitive approach to identify meaningful drops in alliance self-report (WAI).

There are few studies exploring intake diagnostic characteristics as predictors of change in integrative naturalistic settings. The aim of this study is to explore baseline variables at the intake process and establish the predictive value of the individual trajectories of the patients. We recruited 259 patients undergoing an integrative psychotherapy network of psychotherapists from Buenos Aires, Argentina. Every therapist completed the intake form of each patient involved in the routine outcome monitoring. Thereafter step-wise regressions based on forward selection strategies were used, in order to identify meaningful baseline predictors of patients’ clinical evolution, derived from the intake process. The selected predictors were social support network, subjective distress, the initial measure of clinical distress, unemployment, sociocultural status and reactance. When including those six variables in a multilevel model, the results indicate that social support network, subjective distress, and the initial measure of clinical distress were significant predictors of the trajectories of OQ-30, whereas unemployment, sociocultural status and reactance were not significant. The results regarding social support network are in line with the literature, while results of socioeconomic status (unemployment and sociocultural level) move in an opposite direction in comparison to the available evidence. Moreover, the mental health findings (initial OQ-30 and subjective distress) confirm the contradictory body of literature produced in this domain. Finally, reactance seems to be a significant predictor in previous study in contradiction of our results. Overall, this endeavor constitutes important but preliminary evidence to enhance the production of bottom-up science within practice research networks in the global south.

Sexual minority clients report experiencing frequent microaggressions during therapy, however, therapists may not recognize those microaggressions or may be reluctant to self-report them. The main aim of the present study was thus to develop an observational measure of in-session therapist-committed microaggressions related to the sexual orientation of sexual minority individuals (e.g., those who identify as lesbian, gay, bisexual, or queer). The present study further examined the association between therapist-committed sexual orientation microaggressions and ruptures in the therapeutic alliance. We hypothesized that clinically significant microaggressions would be positively associated with withdrawal ruptures in the alliance. The sample consisted of 44 gay and bisexual men who participated in a cognitive behavioral treatment designed to reduce depression, anxiety, human immunodeficiency virus-transmission-risk behaviors, and substance use. An observer-based coding measure designed for this study, the Sexual Orientation Microaggression Rating Scale (SOMRS), was utilized to capture sexual minority microaggressions in the initial sessions of treatment. Good interrater reliability was achieved for the SOMRS. Microaggressions were coded in 34% of the sessions. Within the subset of sessions with coded microaggressions, a significant association was found between withdrawal ruptures and microaggression significance ratings. The SOMRS holds potential for supporting research on microaggression as well as future efforts to help clinicians recognize and repair in-session behaviors that negatively impact sexual minority clients. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Objective: The aim of this study was to disaggregate the between-patient and within-patient effects of emotion regulation (ER) on treatment outcome and explore relevant trait-like moderators of the within-patient effects. Method: Three hundred thirty-nine patients with heterogenous clinical conditions were admitted to psychotherapy at a clinical center. During the intake evaluation, patients completed the Inventory of Interpersonal Problems, the Outcome Questionnaire 30, and the State Difficulties of Emotion Regulation Scale. Subsequently, patients responded to the Outcome Questionnaire 30 and State Difficulties of Emotion Regulation Scale every session for the initial five sessions, followed by assessments every two sessions until the 15th session and then every four sessions until the end of treatment. Results: Multilevel models revealed significant between- and within-patient effects of ER on clinical distress. That is, patients with lower average levels of ER difficulties showed greater benefit from treatment, and lower ER difficulties over the course of treatment were associated with lower clinical distress. Furthermore, interactive models demonstrated that lower average levels of ER throughout treatment and fewer interpersonal problems at the beginning of treatment were associated with better treatment outcome. Conclusion: These findings provide evidence supporting the role of ER as a mechanism of change. The interaction between trait-like components and state-like fluctuations of ER suggests a capitalization model for the role of ER in psychotherapy.

ZusammenfassungObwohl die meisten Psychotherapeuten einen integrativen und prozessorientierten Ansatz verfolgen, sind transtheoretische Ansätze in der Psychotherapieausbildung selten. Um angehende Therapeuten besser auf die Komplexität der Praxis vorzubereiten, bedarf es eines solchen Ansatzes. Ein vielversprechender Weg ist die Berücksichtigung von Änderungsprinzipien, die über verschiedene Therapieschulen hinweg gelten. Über das Änderungsprinzip der therapeutischen Allianz sind sich die Therapieschulen am meisten einig. Im Folgenden wird daher ein Allianz-Fokussiertes Training vorgestellt, bei dem Therapeuten lernen Brüche in der Allianz zu erkennen und mit Strategien zur Resolution darauf zu reagieren. Gegenwärtige Lehrmethoden wie Rollenspiele und Supervision haben ihre Grenzen, da sie nur posteriori und auf einen kleinen Teil der Fälle angewandt werden können. Ein zukunftsweisender Ansatz könnte daher ein online-Training sein, das Änderungsprinzipien wie die Allianz und Marker für Handlungsbedarf integriert, bewährte Methoden des gezielten Übens und Expertentrainings nutzt und das Potential der Technologie ausschöpft.

Although most psychotherapists adopt an integrative and process-oriented approach, transtheoretical approaches to psychotherapy training are rare. To better prepare future therapists for the complexities of clinical practice, such an approach is needed. A promising way forward is to consider principles of change that cut across different schools of therapy. The principle of the therapeutic alliance is where different therapy schools agree most. Therefore, an alliance-focused training is presented below, where therapists learn to recognize ruptures in the therapeutic alliance and respond to them with resolution strategies. Current teaching methods like role-playing and supervision have their limitations, as they can only be applied post hoc and to a small number of cases. A new approach could be an online training that integrates principles of change, such as the alliance and markers for interventions, utilizes proven methods of deliberate practice and expert training, and makes use of the potential of technology.

This study explored therapeutic foci’s structural change and its interaction with clinical severity in a young adult patient receiving psychodynamic therapy. We conducted a systematized single-case time-series analysis for a complete focused psychodynamic treatment (54 sessions). To assess clinical severity, the patient completed the Outcome Questionnaire 45.2 every session. Two external raters established a psychodynamic profile with five therapeutic foci for the case, using Operationalized Psychodynamic Diagnosis. These foci included one relational focus, two conflict foci and two structure foci. Raters estimated patient’s structural change by means of Heidelberg Structural Change Scale, assessing the evolution of such foci. Raters used this measure to code every session. We conducted a vector autoregressive analysis to explore therapeutic foci’s structural change and its interaction with clinical severity. Time-series analysis showed predictive effects of foci’s structural change throughout the entire treatment. Greater structural change in the relational focus predicted greater clinical severity and less structural change in conflict foci. Also, greater structural change in conflict foci predicted greater structural change in structure foci. Results support the hypothesis of structural modifications as a mechanism of change for psychodynamic therapy. We discuss results to better understand how patients may benefit from psychodynamic therapy.

Objective Histrionic personality disorder (HPD) with a lifetime prevalence rate of 1.8% is an under-researched psychiatric diagnosis. The present study therefore aimed to investigate both the processes and outcomes of psychotherapy for HPD in a non-controlled study. Methods A total of 159 patients diagnosed with HPD were recruited and received clarification-oriented psychotherapy. Sessions 15, 20, and 25 were video-recorded and analysed using the Process-Content-Relationship Scale. Therapy outcome was assessed with symptom measures at intake and discharge. Hierarchical linear modelling was applied to estimate the changes in the psychotherapeutic outcome and associations with patient and therapist process developments. Results Improvements in relationship processes of patients and therapists were systematically related to outcome while only partial relationships were found on the levels of process and content. Conclusion The present study represents the first systematic insight into core changes in patients with HPD undergoing psychotherapy.

IntroductionRoutine Outcome Monitoring (ROM) has emerged as a strong candidate to improve psychotherapy processes and outcome. However, its use and implementation are greatly understudied in Latin-America. Therefore, the aim of the present pilot study conducted in Argentina was to implement a ROM and feedback system grounded on a psychometrically sound instrument to measure session by session outcome in psychotherapy. MethodsThe sample consisted of 40 patients and 13 therapists. At baseline, the patients completed the Patient Health Questionnaire-9 and the Generalized Anxiety Disorder-7, and they also completed the Hopkins Symptom Checklist-11 before each of the first five sessions. To estimate patient change during the first sessions, we conducted a quantitative analysis using Hierarchical Linear Models. Furthermore, we conducted a qualitative analysis using Consensual Qualitative Research to analyze therapist perception regarding the ROM and feedback system. ResultsResults showed a significant reduction in patients' symptomatic severity during the first five sessions. Additionally, baseline depression significantly predicted the estimated severity at the end of the fifth session. Feedback was given to the therapists after the first four sessions based on these analyses. With regard to the perception of the feedback system, clinicians underlined its usefulness and user-friendly nature. They also mentioned that there was a match between the information provided and their clinical judgment. Furthermore, they provided suggestions to enhance the system that was incorporated in a new and improved version. DiscussionLimitations and clinical implications are discussed.

The Inventory of Interpersonal Problems (IIP) is a widely studied instrument in the mental health field. While there have been some applications of this tool in adolescents, the majority of research has focused on the adult population. This study aims to examine the psychometric properties of the Inventory of Interpersonal Problems-32 (IIP-32) specifically in Argentinian adolescents. A total of 557 participants completed the IIP-32 alongside an additional assessment of interpersonal traits. To evaluate reliability, we analyzed internal consistency and item homogeneity. We analyzed the construct validity of IIP-32 through confirmatory factor analysis and the concurrent validity through correlations between the IIP-32 and other measures of interpersonal traits. The findings of this study indicate adequate internal consistency and homogeneity of the items, as well as construct, concurrent and criterion validity. Overall, the results of this paper establish the IIP-32 as a reliable and valid instrument with significant clinical implications for assessing interpersonal difficulties in adolescents from Argentina.

This study aimed to develop and test algorithms to determine the individual relevance of two psychotherapeutic change processes (i.e., mastery and clarification) for outcome prediction. We measured process and outcome variables in a naturalistic outpatient sample treated with an integrative treatment for a variety of diagnoses (n = 608) during the first 10 sessions. We estimated individual within-patient effects of each therapist-evaluated process of change on patient-evaluated subsequent outcomes on a session-by-session basis. Using patients' baseline characteristics, we trained machine learning algorithms on a randomly selected subsample (n = 407) to predict the effects of patients' process variables on outcome. We subsequently tested the predictive capacity of the best algorithm for each process on a holdout subsample (n = 201). We found significant within-patient effects of therapist perceived mastery and clarification on subsequent outcome. In the holdout subsample, the best-performing algorithms resulted in significant but small-to-medium correlations between the predicted and observed relevance of therapist perceived mastery (r = .18) and clarification (r = .16). Using the algorithms to create criteria for individual recommendations, in the holdout sample, we identified patients for whom mastery (14%) or clarification (18%) were indicated. In the mastery-indicated group, a greater focus on mastery was moderately associated with better outcome (r = .33, d = .70), while in the clarification-indicated group, the focus was not related to outcome (r = -.05, d = .10). Results support the feasibility of performing individual predictions regarding mastery process relevance that can be useful for therapist feedback and treatment recommendations. However, results will need to be replicated with prospective experimental designs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

AIM:The therapeutic alliance is a robust predictor of treatment outcome. However, little is known about the way alliance negotiation contributes to psychotherapy outcome. The aim of the present study was to analyze the effects of alliance negotiation on treatment outcome in the first four sessions of psychotherapy.METHODS:Ninety-six patients diagnosed with emotional disorders received weekly Solution-Focused Brief Therapy. Each patient completed both the Alliance Negotiation Scale (ANS) and the Outcome Questionnaire 45 (OQ.45) after each of the first four sessions. Both between- and within-patients effects of alliance negotiation on symptom severity were analyzed using Hierarchical Linear Models.RESULTS:Results showed significant between and within patient effects of alliance negotiation on symptom severity. Patients with higher levels of alliance negotiation across treatment showed lower levels of symptom severity (between-patient effect). Also, in a session with higher alliance negotiation compared to the average session of this patient, symptom severity was lower than in the average session (within-patient effect).DISCUSSION:The results indicate that therapies characterized by higher alliance negotiation and sessions with higher alliance negotiation are beneficial for early outcome.CONCLUSION:From a clinical point of view, the results suggest that alliance negotiation is a meaningful factor for therapy outcome and that therapists may benefit from training and monitoring alliance negotiation during the early stages of treatment.

OBJECTIVE:In process-outcome research, there is a growing body of literature investigating the therapeutic mechanisms underlying the promotion of positive change. This study investigated the between- and within-patient effects of problem mastery and motivational clarification on outcome in patients receiving two variations of cognitive therapies for depression.METHODS:This study drew on data of a randomized controlled trial conducted at an outpatient clinic and included 140 patients randomly assigned to 22 sessions of either cognitive-behavioral therapy or exposure-based cognitive therapy. To address the nested structure of the data and analyze mechanism effects, we used multilevel dynamic structural equations models.RESULTS:We found significant within-patient effects of both problem mastery and motivational clarification on subsequent outcome.CONCLUSION:The results suggest that changes in problem mastery and motivational clarification precede symptom improvement during cognitive therapy for depressed patients and thus there may be benefit in fostering these putative mechanisms during psychotherapy.