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1.
  • Falkenström, Fredrik, Professor, 1972-, et al. (författare)
  • Patient Attachment and Reflective Functioning as Predictors for Therapist In-Session Feelings
  • 2024
  • Ingår i: Journal of counseling psychology. - : American Psychological Association (APA). - 0022-0167 .- 1939-2168. ; 71:3, s. 190-201
  • Tidskriftsartikel (refereegranskat)abstract
    • 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.
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2.
  • Falkenström, Fredrik, et al. (författare)
  • Therapeutic Alliance Predicts Symptomatic Improvement Session by Session
  • 2013
  • Ingår i: Journal of counseling psychology. - : American Psychological Association. - 0022-0167 .- 1939-2168. ; 60:3, s. 317-328
  • Tidskriftsartikel (refereegranskat)abstract
    • The therapeutic alliance has been found to predict psychotherapy outcome in numerous studies. However, critics maintain that the therapeutic alliance is a by-product of prior symptomatic improvements. Moreover, almost all alliance research to date has used differences between patients in alliance as predictor of outcome, and results of such analyses do not necessarily mean that improving the alliance with a given patient will improve outcome (i.e., a within-patient effect). In a sample of 646 patients (76% women, 24% men) in primary care psychotherapy, the effect of working alliance on next session symptom level was analyzed using multilevel models. The Clinical Outcomes in Routine Evaluation–Outcome Measure was used to measure symptom level, and the patient version of the Working Alliance Inventory–Short form revised (Hatcher & Gillaspy, 2006) was used to measure alliance. There was evidence for a reciprocal causal model, in which the alliance predicted subsequent change in symptoms while prior symptom change also affected the alliance. The alliance effect varied considerably between patients. This variation was partially explained by patients with personality problems showing stronger alliance effect. These results indicate that the alliance is not just a by-product of prior symptomatic improvements, even though improvement in symptoms is likely to enhance the alliance. Results also point to the importance of therapists paying attention to ruptures and repair of the therapy alliance. Generalization of results may be limited to relatively brief primary care psychotherapy.
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3.
  • Falkenström, Fredrik, et al. (författare)
  • Working alliance predicts psychotherapy outcome even while controlling for prior symptom improvement
  • 2014
  • Ingår i: Psychotherapy Research. - : Routledge. - 1050-3307 .- 1468-4381. ; 24:2, s. 146-159
  • Tidskriftsartikel (refereegranskat)abstract
    • 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.
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4.
  • Aafjes-van Doorn, Katie, et al. (författare)
  • Patients’ Affective Processes Within Initial Experiential Dynamic Therapy Sessions
  • 2017
  • Ingår i: Psychotherapy. - : American Psychological Association (APA). - 0033-3204 .- 1939-1536. ; 54:2, s. 175-183
  • Tidskriftsartikel (refereegranskat)abstract
    • Research has indicated that patients’ in-session experience of previously avoided affects may be important for effective psychotherapy. The aim of this study was to investigate patients’ in-session levels of affect experiencing in relation to their corresponding levels of insight, motivation, and inhibitory affects in initial Experiential Dynamic Therapy (EDT) sessions. Four hundred sixty-six 10-min video segments from 31 initial sessions were rated using the Achievement of Therapeutic Objectives Scale. A series of multilevel growth models, controlling for between-therapist variability, were estimated to predict patients’ adaptive affect experiencing (Activating Affects) across session segments. In line with our expectations, higher within-person levels of Insight and Motivation related to higher levels of Activating Affects per segment. Contrary to expectations, however, lower levels of Inhibition were not associated with higher levels of Activating Affects. Further, using a time-lagged model, we did not find that the levels of Insight, Motivation, or Inhibition during one session segment predicted Activating Affects in the next, possibly indicating that 10-min segments may be suboptimal for testing temporal relationships in affective processes. Our results suggest that, to intensify patients’ immediate affect experiencing in initial EDT sessions, therapists should focus on increasing insight into defensive patterns and, in particular, motivation to give them up. Future research should examine the impact of specific inhibitory affects more closely, as well as between-therapist variability in patients’ in-session adaptive affect experiencing.
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5.
  • Alexandersson, Klas, et al. (författare)
  • Session-to-session effects of therapist adherence and facilitative conditions on symptom change in CBT and IPT for depression
  • 2023
  • Ingår i: Psychotherapy Research. - : Taylor & Francis Group. - 1050-3307 .- 1468-4381. ; 33:1, s. 57-69
  • Tidskriftsartikel (refereegranskat)abstract
    • Objective: The objective of this study was to analyze the effect of adherence to both specific technique factors and facilitative condition variables (e.g., therapists' involvement, understanding and support) in Cognitive Behavior Therapy (CBT) and Interpersonal Psychotherapy (IPT). In addition, we were interested in whether the effect of therapist adherence would depend on the level of the working alliance. Method: Three sessions each from 74 patients diagnosed with Major Depressive Disorder who were randomized to 14 sessions of IPT or CBT were rated for adherence using a modified version of The Collaborative Study Psychotherapy Rating Scale-6 (CSPRS-6). Data was analyzed using Multilevel Modeling. Results: No effects of adherence to specific factors on outcome were found in neither CBT nor IPT. Facilitative conditions were associated with better outcome in CBT but not in IPT, even after adjustment for the quality of the working alliance. No interaction effects were found. Conclusions: Our findings highlight the importance of relational factors in CBT, but do not support the need for specific adherence to any of the two treatments. Possible explanations of the findings and directions for future research are discussed.
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6.
  • Ankarberg, Peter, et al. (författare)
  • Socialstyrelsens riktlinjer är partiska och ovetenskapliga!
  • 2017
  • Ingår i: Psykoterapi. - 2001-5836. ; 26:2, s. 30-34
  • Tidskriftsartikel (populärvet., debatt m.m.)abstract
    • Denna artikel är ett remissvar med synpunkter på de nationella riktlinjerna för ångest och depression, som vi publicerar i sin helhet i tidskriften. Vi gör det på grund av den ingående kunskap om processerna i riktlinjearbetet som några av författarna har kunnat få genom egen medverkan och närvaro i det arbetet.
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7.
  • Ankarberg, Peter, et al. (författare)
  • Treatment of depression with antidepressants is primarily a psychological treatment
  • 2008
  • Ingår i: Psychotherapy. - : American Psychological Association (APA). - 0033-3204 .- 1939-1536. ; 45:3, s. 329-339
  • Tidskriftsartikel (refereegranskat)abstract
    • Depression treatment with antidepressants is generally described as evidence-based. However, generalizations to practice recommendations seem to us to rest on the tacit assumption that treatment outcome in research trials is the sum of three factors: specific effects of the drug, expectancy effects (placebo), and spontaneous recovery. Because randomization isolates the specific effects of the drug, trials showing significant drug effects are used as evidence for prescribing the drug regardless of context. Drawing on Wampold's (2001) description of two metamodels of psychotherapy, the authors argue that available empirical evidence indicates that depression treatment with antidepressants is primarily a psychological treatment. This conclusion has far-reaching consequences for the scientific status of contemporary treatments for depression. It also affects what the doctor should focus on in a treatment with antidepressants and how to act when the patient is treatment resistant. In order to achieve the results obtained in clinical trials, the quantity and quality of support from the doctor is more important than pharmacological concerns, such as adequate doses of medicine. When faced with a treatment resistant patient, relationship factors rather than pharmacological factors should be in focus
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8.
  • Back, Malin, et al. (författare)
  • Reduction in depressive symptoms predicts improvement in eating disorder symptoms in interpersonal psychotherapy : results from a naturalistic study
  • 2020
  • Ingår i: Journal of Eating Disorders. - : BioMed Central. - 2050-2974. ; 8:1
  • Tidskriftsartikel (refereegranskat)abstract
    • 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 Åsberg 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.
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9.
  • Berg, Johan, et al. (författare)
  • Countertransference in Swedish psychotherapists: Testing the factor structure of the Therapist Response Questionnaire.
  • 2019
  • Ingår i: Research in Psychotherapy: Psychopathology, Process and Outcome. - : PAGEPress Publications. - 2499-7552 .- 2239-8031. ; 22:1, s. 99-112
  • Tidskriftsartikel (refereegranskat)abstract
    • Questionnaires need testing of reliability and factor structure before clinical use or research in new languages or cultures. The aim of this study was to evaluate the Therapist Response Questionnaire (TRQ) in Sweden compared to corresponding factor analyses in USA and Italy. A national sample of psychotherapists (N=242) registered their countertransference with a single client using TRQ. The data were analyzed with confirmatory factor analysis (CFA) to test factor structures from previous studies, and exploratory factor analysis (EFA). The CFA did not verify the factor structure from the previous studies. The EFA extracted seven factors as the best solution: Helpless/Inadequate, Overwhelmed/Disorganized, Hostile/Angry, Parental/Protective, Disengaged, Special/Overinvolved, Sexualized. Analysis of convergent validity indicated that five of these could be considered equivalent to factors in the previous studies, and the remaining two were conceptually related to corresponding factors. Even though the factor structure was not confirmed by the CFA, the concordance was large, indicating a reliable self-report instrument with promising validity for measurement of complex aspects of countertransference. Common countertransference themes can inform psychotherapy supervision and education, give feedback to the therapist, and lay ground for a taxonomy for therapist reactions and feelings.
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10.
  • Ekeblad, Annika, et al. (författare)
  • Change in reflective functioning in interpersonal psychotherapy and cognitive behavioral therapy for major depressive disorder
  • 2023
  • Ingår i: Psychotherapy Research. - : Routledge; Taylor & Francis. - 1050-3307 .- 1468-4381. ; 33:3, s. 342-349
  • Tidskriftsartikel (refereegranskat)abstract
    • Background Patients with Major Depressive Disorder (MDD) have been found to have restricted capacity for mentalization, and it is possible that this constitutes a vulnerability factor for developing depression. Due to its focus on linking depressive symptomatology to emotions and interpersonal relations, it was hypothesized that Interpersonal Psychotherapy (IPT) would improve mentalization more than Cognitive Behavioral Therapy (CBT). Methods In a randomized controlled trial of 90 patients undergoing IPT and CBT for MDD, Reflective Functioning (RF) was rated from Adult Attachment and from Depression-Specific Reflective Functioning (DSRF) Interviews before and after therapy. Treatment outcome was assessed using the Beck Depression Inventory-II. Results The interaction between time and treatment approach was statistically significant, with RF improving significantly more in IPT than in CBT. Change in RF was not correlated with change in depression. The difference in DSRF ratings before and after therapy was not statistically significant for any of the treatments. Conclusions IPT may improve mentalization more than CBT. However, although RF increased significantly in IPT, the mean level was still low after therapy. A limitation of the study is the large amount of post-treatment missing data. More research is needed to understand the potential role of mentalization in symptom reduction.
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11.
  • Ekeblad, Annika, et al. (författare)
  • Randomized Trial of Interpersonal Psychotherapy and Cognitive Behavioral Therapy for Major Depressive Disorder in a Community-Based Psychiatric Outpatient Clinic
  • 2016
  • Ingår i: Depression and anxiety (Print). - : WILEY-BLACKWELL. - 1091-4269 .- 1520-6394. ; 33:12, s. 1090-1098
  • Tidskriftsartikel (refereegranskat)abstract
    • 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.
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12.
  • Ekeblad, Annika, et al. (författare)
  • Reflective Functioning as Predictor of Working Alliance and Outcome in the Treatment of Depression
  • 2016
  • Ingår i: Journal of Consulting and Clinical Psychology. - : American Psychological Association (APA). - 0022-006X .- 1939-2117. ; 84:1, s. 67-78
  • Tidskriftsartikel (refereegranskat)abstract
    • 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.
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13.
  • Ekeblad, Annika, 1955-, et al. (författare)
  • "What shall we focus on?" - A thematic analysis of what characterizes cognitive-behavior therapy sessions with high or low quality of working alliance
  • 2022
  • Ingår i: Psychotherapy Research. - : Taylor & Francis Group. - 1050-3307 .- 1468-4381. ; 32:8, s. 1003-1015
  • Tidskriftsartikel (refereegranskat)abstract
    • Objective: Several studies have shown that the quality of the working alliance predicts symptomatic improvement sessionby-session, including in cognitive-behavioral therapy (CBT). We wanted to explore what characterizes CBT sessions with high and low alliances further using qualitative analysis. Method: Ten CBT-sessions were selected from eight patients' therapies in a larger research project on psychotherapy for patients with major depression. Five sessions were chosen from high- and five from low-alliance sessions, based on therapist- and patient-reported Working Alliance Inventory scores. Transcripts of these sessions were analyzed using thematic analysis. Results: The analysis yielded four themes, each structured into two sub-themes: Therapist style, Person in focus, Content focus, and Therapeutic direction. In contrast to low-alliance sessions, high-alliance sessions were characterized by a more exploring as opposed to expert therapist style; a focus on the patient's thoughts, feelings, and behavior, rather than a diffuse focus or a focus on other people's actions/external events; and a sense of moving forward rather than stagnation. Conclusion: Our qualitative analysis showed theoretically and clinically meaningful processes in CBT sessions of high- vs low working alliance. This method is a useful complement to quantitative within-patient analyses, to expand on the meaning of quantitative findings.
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14.
  • Falkenström, Fredrik, 1972- (författare)
  • A Buddhist contribution to the psychoanalytic psychology of self
  • 2003
  • Ingår i: International Journal of Psychoanalysis. - : John Wiley & Sons. - 0020-7578 .- 1745-8315. ; 84:6, s. 1551-1568
  • Tidskriftsartikel (refereegranskat)abstract
    • The author attempts to integrate the concepts of self used in psychoanalytic theory with the understanding of the nature of self as explained within the Buddhist meditative tradition. He divides different concepts of self in psychoanalytic theory into three major levels of consciousness and abstraction: self as experience, representational self and self as system. The representational level is defined as consisting of unconscious organizing structures of interaction: the system level is a hierarchically higher organization of representations, while the experiential level consists of the moment-to-moment flow of consciousness. He argues that for the sake of theoretical clarity these levels should be differentiated in discussions of self. He then describes the Buddhist psychology of self and tries to show how this perspective can enrich psychoanalytic understanding of the experiential self and of narcissism, which in Buddhist language would be described as clinging to (seeking or avoiding) images of self that arise in the mind. Last, he describes a model of therapeutic development using different levels of self and the interrelationship between them, showing how psychoanalytic psychotherapy and Buddhist insight meditation emphasize different levels of self using complementary rather than mutually exclusive methods.
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15.
  • Falkenström, Fredrik, et al. (författare)
  • Can psychotherapists function as their own controls? Meta-analysis of the crossed therapist design in comparative psychotherapy trials
  • 2013
  • Ingår i: Journal of Clinical Psychiatry. - : Physicians Postgraduate Press. - 0160-6689 .- 1555-2101. ; 74:5, s. 482-491
  • Tidskriftsartikel (refereegranskat)abstract
    • 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.
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16.
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17.
  • Falkenström, Fredrik, et al. (författare)
  • Confirmatory Factor Analysis of the Patient Version of the Working Alliance Inventory-Short Form Revised
  • 2015
  • Ingår i: Assessment (Odessa, Fla.). - : SAGE PUBLICATIONS INC. - 1073-1911 .- 1552-3489. ; 22:5, s. 581-593
  • Tidskriftsartikel (refereegranskat)abstract
    • 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.
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18.
  • Falkenström, Fredrik, 1972- (författare)
  • Data Analytic Advances That Bridge the Scientist-Practitioner Gap
  • 2022
  • Ingår i: Cognitive and Behavioral Practice. - : Elsevier. - 1077-7229 .- 1878-187X. ; 29:3, s. 585-590
  • Tidskriftsartikel (refereegranskat)abstract
    • In this commentary, I advance the view that the scientist-practitioner gap is partly due to the research designs commonly used in psychotherapy research. Specifically, I believe that randomized controlled trials, which are important for establish-ing treatment efficacy and as leverage when making the case for the value of psychotherapy in relation to various stake-holders, are limited for further development of clinical theories. Instead, I find recent advances in cross-lagged panel modeling to be both clinically intuitive and stronger for causal inference than most other nonexperimental designs. In addi-tion to discussing causal inference and clinical interpretation of cross-lagged panel models, I discuss the potential of improving mediation analysis, personalization of research, and studying issues of clinical timing. Finally, I briefly discuss some limitations of cross-lagged panel models. It is my belief that the use of these data analytic advances can make empir-ical research better live up to the innovations in Beck's work.
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19.
  • Falkenström, Fredrik, et al. (författare)
  • Development and Validation of a 6-item Working Alliance Questionnaire for Repeated Administrations During Psychotherapy
  • 2015
  • Ingår i: Psychological Assessment. - : American Psychological Association. - 1040-3590 .- 1939-134X. ; 27:1, s. 169-183
  • Tidskriftsartikel (refereegranskat)abstract
    • Recently, researchers have started to measure the working alliance repeatedly across sessions of psychotherapy, relating the working alliance to symptom change session by session. Responding to questionnaires after each session can become tedious, leading to careless responses and/or increasing levels of missing data. Therefore, assessment with the briefest possible instrument is desirable. Because previous research on the Working Alliance Inventory has found the separation of the Goal and Task factors problematic, the present study examined the psychometric properties of a 2-factor, 6-item working alliance measure, adapted from the Working Alliance Inventory, in 3 patient samples (ns = 1,095, 235, and 234). Results showed that a bifactor model fit the data well across the 3 samples, and the factor structure was stable across 10 sessions of primary care counseling/psychotherapy. Although the bifactor model with 1 general and 2 specific factors outperformed the 1-factor model in terms of model fit, dimensionality analyses based on the bifactor model results indicated that in practice the instrument is best treated as unidimensional. Results support the use of composite scores of all 6 items. The instrument was validated by replicating previous findings of session-by-session prediction of symptom reduction using the Autoregressive Latent Trajectory model. The 6-item working alliance scale, called the Session Alliance Inventory, is a promising alternative for researchers in search for a brief alliance measure to administer after every session.
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20.
  • Falkenström, Fredrik, et al. (författare)
  • Do therapist effects really impact estimates of within-patient mechanisms of change? A Monte Carlo simulation study
  • 2020
  • Ingår i: Psychotherapy Research. - : ROUTLEDGE JOURNALS, TAYLOR & FRANCIS LTD. - 1050-3307 .- 1468-4381. ; 30:7, s. 885-899
  • Tidskriftsartikel (refereegranskat)abstract
    • Objective:Existing evidence highlights the importance of modeling differential therapist effectiveness when studying psychotherapy outcome. However, no study to date examined whether this assertion applies to the study of within-patient effects in mechanisms of change. The study investigated whether therapist effects should be modeled when studying mechanisms of change on a within-patient level. Methods:We conducted a Monte Carlo simulation study, varying patient- and therapist level sample sizes, degree of therapist-level nesting (intra-class correlation), balanced vs. unbalanced assignment of patients to therapists, and fixed vs random within-patient coefficients. We estimated all models using longitudinal multilevel and structural equation models that ignored (2-level model) or modeled therapist effects (3-level model). Results:Across all conditions, 2-level models performed equally or were superior to 3-level models. Within-patient coefficients were unbiased in both 2- and 3-level models. In 3-level models, standard errors were biased when number of therapists was small, and this bias increased in unbalanced designs. Ignoring random slopes led to biased standard errors when slope variance was large; but 2-level models still outperformed 3-level models. Conclusions:In contrast to treatment outcome research, when studying mechanisms of change on a within-patient level, modeling therapist effects may even reduce model performance and increase bias.
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21.
  • Falkenström, Fredrik (författare)
  • Does psychotherapy for young adults in routine practice show similar results as therapy in randomized clinical trials?
  • 2010
  • Ingår i: Psychotherapy Research. - : Routledge. - 1050-3307 .- 1468-4381. ; 20:2, s. 181-192
  • Tidskriftsartikel (refereegranskat)abstract
    • Previous research indicates that patients treated with psychotherapy in the community do not stay in treatment long enough to achieve clinically significant change. Because the average patient seeking treatment at a community center may not be as informed and motivated for change as the average patient participating in a research trial, the authors compared outcome among all patients presenting to a mental health clinic (n=416) and a subgroup of patients who started psychotherapy at the same clinic (n=101). Outcome was assessing using the Symptom Checklist-90, Inventory of Interpersonal Problems, and Global Assessment of Functioning. Results confirmed that outcome among all patients seeking the centre was worse than in an average clinical trial. However, patients who started psychotherapy after assessment achieved results comparable to those in RCT studies.
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22.
  • Falkenström, Fredrik, et al. (författare)
  • Dynamic Models of Individual Change in Psychotherapy Process Research
  • 2017
  • Ingår i: Journal of Consulting and Clinical Psychology. - : AMER PSYCHOLOGICAL ASSOC. - 0022-006X .- 1939-2117. ; 85:6, s. 537-549
  • Tidskriftsartikel (refereegranskat)abstract
    • 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.
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23.
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24.
  • Falkenström, Fredrik, et al. (författare)
  • How Much Therapy Is Enough? : Comparing Dose-Effect and Good-Enough Models in Two Different Settings
  • 2016
  • Ingår i: Psychotherapy. - : American Psychological Association (APA). - 0033-3204 .- 1939-1536. ; 53:1, s. 130-139
  • Tidskriftsartikel (refereegranskat)abstract
    • 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.
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25.
  • Falkenström, Fredrik, 1972-, et al. (författare)
  • How to Model and Interpret Cross-Lagged Effects in Psychotherapy Mechanisms of Change Research : A Comparison of Multilevel and Structural Equation Models
  • 2022
  • Ingår i: Journal of Consulting and Clinical Psychology. - : American Psychological Association (APA). - 0022-006X .- 1939-2117. ; 90:5, s. 446-458
  • Tidskriftsartikel (refereegranskat)abstract
    • Objective: Modeling cross-lagged effects in psychotherapy mechanisms of change studies is complex and requires careful attention to model selection and interpretation. However, there is a lack of field-specific guidelines. We aimed to (a) describe the estimation and interpretation of cross lagged effects using multilevel models (MLM) and random-intercept cross lagged panel model (RI-CLPM); (b) compare these models' performance and risk of bias using simulations and an applied research example to formulate recommendations for practice. Method: Part 1 is a tutorial focused on introducing/describing dynamic effects in the form of autoregression and bidirectionality. In Part 2, we compare the estimation of cross-lagged effects in RI-CLPM, which takes dynamic effects into account, with three commonly used MLMs that cannot accommodate dynamics. In Part 3, we describe a Monte Carlo simulation study testing model performance of RI-CLPM and MLM under realistic conditions for psychotherapy mechanisms of change studies. Results: Our findings suggested that all three MLMs resulted in severely biased estimates of cross-lagged effects when dynamic effects were present in the data, with some experimental conditions generating statistically significant estimates in the wrong direction. MLMs performed comparably well only in conditions which are conceptually unrealistic for psychotherapy mechanisms of change research (i.e., no inertia in variables and no bidirectional effects). Discussion: Based on conceptual fit and our simulation results, we strongly recommend using fully dynamic structural equation modeling models, such as the RI-CLPM, rather than static, unidirectional regression models (e.g., MLM) to study cross-lagged effects in mechanisms of change research. What is the public health significance of this article? We describe the differences between multilevel and structural equation modeling in the study of mechanisms of change in psychotherapy research. We argue that the common application of multilevel modeling assumes that there is no within-patient inertia in predictor or outcome variable, and the outcome variable does not impact the predictor, both of which seem highly unrealistic in psychotherapy research. Moreover, we demonstrate that violations of these assumptions may lead to severe bias in estimated coefficients, resulting in inaccurate recommendations for clinical practice. Thus, we recommend researchers to use structural equation modeling to estimate the effects of proposed change mechanisms over time.
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26.
  • Falkenström, Fredrik, et al. (författare)
  • Improvement of the Working Alliance in One Treatment Session Predicts Improvement of Depressive Symptoms by the Next Session
  • 2016
  • Ingår i: Journal of Consulting and Clinical Psychology. - : American Psychological Association (APA). - 0022-006X .- 1939-2117. ; 84:8, s. 738-751
  • Tidskriftsartikel (refereegranskat)abstract
    • Objective: Developments in working alliance theory posit that the therapist's 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.
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27.
  • Falkenström, Fredrik, 1972- (författare)
  • Is the quality of the patient-therapist relationship a causal factor for therapy outcome?
  • 2021
  • Ingår i: Nordic Journal of Psychiatry. - : Taylor & Francis Group. - 0803-9488 .- 1502-4725. ; 75:1:Sup 1, s. 53-53
  • Tidskriftsartikel (refereegranskat)abstract
    • Background A good therapy relationship is viewed by many as a precondition for effective therapeutic work, and by some even a therapeutic factor in itself. In theory, the therapy relationship has been divided into the components working alliance, transference, and “real relationship”. Most empirical research has been conducted on the working alliance, which concerns the quality of collaboration between therapist and patient. Methods State-of-the-art position statement. Results Research on the working alliance has gone from fairly simple pre-post correlational designs to multi-level cross-lagged panel designs. Although almost all research is based on observational data, the “new generation” of alliance research takes account of temporal precedence and potential unobserved confounders that are stable over time. Research to date strongly suggests that patient-therapist dyads who establish a good-quality working alliance early in treatment are more likely to achieve good outcome. Moreover, the quality of the alliance in a given session is predictive of change in symptom distress by the following session. Conclusions Working alliance is predictive of psychotherapy outcome. Although later studies are stronger for drawing causal conclusions, none of the studies to date can conclusively rule out alternative explanations of alliance-outcome predictions. Whether alliance is facilitative of technical interventions or therapeutic in itself is also not clear. Future research should (1) find ways of ruling out alternative explanations of relationship variable findings, (2) study the interaction between relationship variables and technique, and (3) study the therapy relationship as a mediator of therapeutic interventions, and (4) study other relationship variables than alliance.
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28.
  • Falkenström, Fredrik, et al. (författare)
  • Patient Reflective Functioning as Predictor of Early Psychotherapy Process in the Treatment of Depression
  • Annan publikation (övrigt vetenskapligt/konstnärligt)abstract
    • 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.
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29.
  • Falkenström, Fredrik, et al. (författare)
  • Reflective Functioning, Affect Consciousness, and Mindfulness : Are These Different Functions?
  • 2014
  • Ingår i: Psychoanalytic psychology. - : American Psychological Association (APA). - 0736-9735 .- 1939-1331. ; 31:1, s. 26-40
  • Tidskriftsartikel (refereegranskat)abstract
    • 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. 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. 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. 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 the high end of the affect consciousness scale measures a mature capacity for mentalized affectivity, while RF is largely a buffer against trauma and adversity. Low or absent findings for the FFMQ are explained more in terms of different methods variance.
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30.
  • Falkenström, Fredrik, et al. (författare)
  • Review of organizational effects on the outcome of mental health treatments
  • 2018
  • Ingår i: Psychotherapy Research. - : Taylor & Francis Group. - 1050-3307 .- 1468-4381. ; 28:1, s. 76-90
  • Forskningsöversikt (refereegranskat)abstract
    • 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.
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31.
  • Falkenström, Fredrik, et al. (författare)
  • Self-analysis and post-termination improvement after psychoanalysis and long-term psychotherapy
  • 2007
  • Ingår i: Journal of the American Psychoanalytic Association. - 0003-0651 .- 1941-2460. ; 55:2, s. 629-674
  • Tidskriftsartikel (refereegranskat)abstract
    • Long-term follow-up studies of long-term psychoanalytically oriented psychotherapy or psychoanalysis are extremely rare, and few have focused on the post-treatment process itself. In the Stockholm Outcome of Psychoanalysis and Psychotherapy project, one of the results was that patients in psychoanalysis continued to improve after termination to a higher degree than patients in long-term psychotherapy. In this study 20 patients selected from the project were interviewed on two occas ions, one and two years after termination, in order to explore how they described their post-treatment processes. The interviews were studied qualitatively using a multiple case study design, and categories of different types of post-treatment development were created from these case studies. Results indicate that the variation within treatment groups is large, and that development may continue in several ways after termination. The most striking difference between psychoanalysis and psychotherapy was not, as hypothesized, in the self-analytic function, but in various self-supporting strategies described by former analysands but not by former psychotherapy patients. However, only self-analysis was significantly correlated with post-termination improvement across both treatments. Three patients improving after termination and three deteriorating are described in detail as illustrations. Some methodological constraints of the design limit the generalizeability of results.
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32.
  • Falkenström, Fredrik (författare)
  • Studying mindfulness in experienced meditators: A quasi-experimental approach
  • 2010
  • Ingår i: PERSONALITY AND INDIVIDUAL DIFFERENCES. - : Elsevier BV. - 0191-8869. ; 48:3, s. 305-310
  • Tidskriftsartikel (refereegranskat)abstract
    • Self-report measures were used to study mindfulness and well-being in experienced meditators in a quasi-experimental intervention study. Seventy-six experienced meditators were studied, 48 who were participating in an intensive meditation retreat in the Vipassana (insight meditation) tradition and 28 who did not. Retreat participants had scheduled meditation practice from early morning to late at night, and were encouraged to practice mindfulness throughout the whole day. The Kentucky Inventory of Mindfulness Skills (KIMS) and the Five Facet Mindfulness Questionnaire (FFMQ) were used to measure mindfulness, and the General Population version of the Clinical Outcomes in Routine Evaluation (GP-CORE) was used to measure well-being. Correlation analyses in the pre-intervention data showed that self-reported mindfulness was strongly related to well-being, with the exception for the observe subscale of FFMQ, Only the acceptance subscales were associated with meditation experience. Mindfulness increased after the retreat, but the increase was not significantly larger for retreat participants than for the control group. However. well-being increased more in the retreat group than the control group, and increase in mindfulness was associated with increase in well-being across both groups. Results are discussed in relation to previous research and methodological aspects.
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33.
  • Falkenström, Fredrik (författare)
  • The Capacity for Self-Observation in Psychotherapy
  • 2012
  • Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
    • The phenomena of self-awareness and self-observation are thought by many to be uniquely human qualities, and questions about how they develop have engaged philosophers and spiritual thinkers throughout history. More recently these issues have come to interest psychologists, psychotherapists, and researchers of diverse clinical psychology orientations as well. This dissertation explored conceptual issues and empirical measurement methods related to self-awareness and self-observation capacities. The four studies approached this from different angles: Study I used mainly qualitative methods to study post-treatment processes related to continuing clinical improvement after termination of long-term psychotherapeutic treatments. The main finding was that self-analysis seemed to be related to continued improvement after ending of therapy, but contrary to our hypothesis there was no difference between psychotherapy and the more intensive psychoanalysis in this regard. Study II tested the measurement of mindfulness by self report in a sample of experienced Buddhist meditators. The findings confirmed relationships between mindfulness and psychological well-being, but raised doubt about the instruments’ sensitivity to change. Study III compared different methods for measuring theoretically related concepts of self-observation: mindfulness, mentalization, and affect consciousness. This study showed surprisingly little common variance between affect consciousness and mentalization/mindfulness. Finally, the results of Study IV showed that in patients diagnosed with clinical depression, mentalization about depressive symptoms predicted aspects of the initial psychotherapy process better than mentalization about attachment. Taken together, these studies show the complexity of the phenomenon of self-observation and the corresponding complexity of research on it. The relationships between variables related to self-observation, their measurements, and their relationships to the psychotherapy process seem more complex than would be expected from current theories. A model for types of self-observation in the process of change in psychotherapy is tentatively proposed.
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34.
  • Falkenström, Fredrik (författare)
  • The psychodynamics of self-observation
  • 2007
  • Ingår i: Psychoanalytic dialogues. - : Informa UK Limited. - 1048-1885 .- 1940-9222. ; 17:4, s. 551-574
  • Tidskriftsartikel (refereegranskat)abstract
    • A framework for thinking about self-observation in relational psychoanalytic terms is described, in which three different levels of self-observation are distinguished. These levels are differentiated according to the kind of intrapsychic relationship enacted (monadic, dyadic, or triangular). Each level of observation is discussed separately with focus on the dynamic forces inhibiting or facilitating self-observation within each level. Dyadic and triangular levels of self-observation are well known in psychoanalytic theories, but a monadic, or one-dimensional level in which the ego is not split, is also described. This form of observation and the psychodynamics involved is discussed in relation to Bion's concept "O" and theory from Buddhist psychology. Finally, the interrelatedness of levels is described, and a brief case description from a session of psychoanalytic psychotherapy is used to illustrate how the three levels of observation interact. © 2007 The Analytic Press, Inc.
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35.
  • Falkenström, Fredrik, et al. (författare)
  • The Working Alliance: From Global Outcome Prediction to Micro-Analyses of Within-Session Fluctuations
  • 2017
  • Ingår i: Psychoanalytic inquiry. - : ROUTLEDGE JOURNALS, TAYLOR & FRANCIS LTD. - 0735-1690 .- 1940-9133. ; 37:3, s. 167-178
  • Tidskriftsartikel (refereegranskat)abstract
    • The working alliance, originally a psychoanalytic concept, is probably the most empirically studied psychotherapy process variable. There are many studies showing that a better alliance predicts better outcomes (e.g., Horvath et al., 2011), although the causal direction of this relationship is still debated (Barber et al., 2000; DeRubeis, Brotman, and Gibbons, 2005; Falkenstrom, Granstrom, and Holmqvist, 2013). Additionally, most of the empirical research on the working alliance is limited in clinical utility because of the relative simplicity of the research. Specifically, most empirical research on the working alliance has aimed to link patient-therapist dyads overall level of working alliance with global treatment outcomes. In actual clinical practice, therapists may be most interested in the fluctuations in the alliance from one session to the next, or even from one moment to the next within a session. There is a rich tradition in psychoanalysis of evaluating the results of therapeutic interventions by examining the patients responses. With the help of modern statistical methods, we believe the impact of a single intervention or series of interventions on factors such as working alliance, symptomatic improvement, or emotional experiences can be studied. Although this research is still in its infancy, we believe it is the future of scientific investigation of the talking cure.
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36.
  • Falkenström, Fredrik, 1972-, et al. (författare)
  • Therapist in-session feelings predict change in depressive symptoms in interpersonal and brief relational psychotherapy
  • 2022
  • Ingår i: Psychotherapy Research. - : Taylor & Francis Group. - 1050-3307 .- 1468-4381. ; 32:5, s. 571-584
  • Tidskriftsartikel (refereegranskat)abstract
    • 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 patient's depressive symptoms may improve. Findings need replication in a larger sample.
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37.
  • Falkenström, Fredrik, Professor, 1972- (författare)
  • Time-lagged panel models in psychotherapy process and mechanisms of change research : Methodological challenges and advances
  • 2024
  • Ingår i: Clinical Psychology Review. - : Elsevier. - 0272-7358 .- 1873-7811. ; 110
  • Tidskriftsartikel (refereegranskat)abstract
    • In recent years, there has been increasing interest in utilizing time-lagged panel models to study mechanisms of change in psychotherapy. These models offer valuable insights into the dynamic relationships between variables over time and offer stronger causal inference capabilities than cross-sectional analyses. Therefore, they are wellsuited for modeling the intricate relationships between mechanisms of change and outcomes in psychotherapy studies, which are typically beyond experimental control. However, their complexity, coupled with the fact that detailed explanations are often embedded in dense statistical or econometric texts, poses challenges. This paper provides a background on cross-lagged panel models and delves deeper into explaining the issues of 1) dynamic panel bias, 2) long-run effects, and 3) testing whether different treatments work by different mechanisms. Using data from a psychotherapy study on treatment of adolescent depression, I demonstrate how these issues manifest in real data. In conclusion, I recommend using structural equation modeling to circumvent dynamic panel bias, reporting long-run effects to reveal the long-term impact of sustained therapeutic work on mechanisms of change, and carefully considering whether mediation, moderation, or a combination of both, best describes differential effects of mechanisms between treatments.
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38.
  • Falkenström, Fredrik, Professor, 1972-, et al. (författare)
  • To Detrend, or Not to Detrend, That Is the Question? : The Effects of Detrending on Cross-Lagged Effects in Panel Models
  • 2023
  • Ingår i: Psychological methods. - : American Psychological Association (APA). - 1082-989X .- 1939-1463.
  • Tidskriftsartikel (refereegranskat)abstract
    • Intervention studies in psychology often focus on identifying mechanisms that explain change over time. Cross-lagged panel models (CLPMs) are well suited to study mechanisms, but there is a controversy regarding the importance of detrending-defined here as separating longer-term time trends from cross-lagged effects-when modeling these change processes. The aim of this study was to present and test the arguments for and against detrending CLPMs in the presence of an intervention effect. We conducted Monte Carlo simulations to examine the impact of trends on estimates of cross-lagged effects from several longitudinal structural equation models. Our simulations suggested that ignoring time trends led to biased estimates of auto- and cross-lagged effects in some conditions, while detrending did not introduce bias in any of the models. We used real data from an intervention study to illustrate how detrending may affect results. This example showed that models that separated trends from cross-lagged effects fit better to the data and showed nonsignificant effect of the mechanism on outcome, while models that ignored trends showed significant effects. We conclude that ignoring trends increases the risk of bias in estimates of auto- and cross-lagged parameters and may lead to spurious findings. Researchers can test for the presence of trends by comparing model fit of models that take into account individual differences in trends (e.g., autoregressive latent trajectory model, the latent curve model with structured residuals, or the general cross-lagged model).
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39.
  • Falkenström, Fredrik, 1972-, et al. (författare)
  • Using Copulas to Enable Causal Inference from Non-Experimental Data : Tutorial and Simulation Studies
  • 2023
  • Ingår i: Psychological methods. - : American Psychological Association (APA). - 1082-989X .- 1939-1463. ; 28:2, s. 301-321
  • Tidskriftsartikel (refereegranskat)abstract
    • Causal inference in psychological research is typically hampered by unobserved confounding. A copula-based method can be used to statistically control for this problem without the need for instruments or covariates, given relatively lenient distributional assumptions on independent variables and error terms. The current study aims to: (1) provide a user-friendly introduction to the copula method for psychology researchers; and (2) examine the degree of non-normality in the independent variables required for satisfactory performance. A Monte Carlo simulation study was used to assess the behavior of the copula method under various combinations of conditions (sample size, skewness of independent variables, effect size, and magnitude of confounding). In addition, an applied example from research on the effects of parental rearing on adult personality and life satisfaction was used to illustrate the method. Simulations revealed that the copula method performed better at higher levels of skewness in the independent variables, and that the impacts of lower skewness can be offset to some extent by larger sample size. When skewness and/or sample size is too small, the copula method is biased towards the uncorrected model. In the applied example, parental rejection/punishment predicted less adaptive personality and life satisfaction, with no evidence of confounding. For parental control/overprotection, there was evidence that confounding attenuated the estimated relationship with personality/life satisfaction. Copula adjustment is a promising method for handling unobserved confounding. The discussion focuses on how to proceed when assumptions are not quite met, and outlines potential avenues for future research.
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40.
  • Falkenström, Fredrik, 1972-, et al. (författare)
  • Using time-lagged panel data analysis to study mechanisms of change in psychotherapy research: Methodological recommendations
  • 2020
  • Ingår i: Counselling and Psychotherapy Research. - : WILEY. - 1473-3145 .- 1746-1405. ; 20:3, s. 435-441
  • Tidskriftsartikel (refereegranskat)abstract
    • The introduction of novel methodologies in the past decade has advanced research on mechanisms of change in observational studies. Time-lagged panel models allow us to track session-by-session changes and focus on within-patient associations between predictors and outcomes. This shift is crucial as change in mechanisms inherently takes place at a within-patient level. These models also enable preliminary casual inferences, which can guide the development of effective personalised interventions that target mechanisms of change, used at specific treatment phases for optimal effect. Given their complexity, panel models need to be implemented with caution, as different modelling choices can significantly affect results and reduce replicability. We outline three central methodological recommendations for use of time-lagged panel analysis to study mechanisms of change: (a) taking patient-specific effects into account, separating out stable between-person differences from within-person fluctuations over time; (b) properly controlling for autoregressive effects; and (c) considering long-term time trends. We demonstrate these recommendations in an applied example examining the session-by-session alliance-outcome association in a naturalistic psychotherapy study. We present limitations of time-lagged panel analysis and future directions.
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41.
  • Falkenström, Fredrik, et al. (författare)
  • Working Alliance Predicts Symptomatic Improvement in Public Hospital-Delivered Psychotherapy in Nairobi, Kenya
  • 2019
  • Ingår i: Journal of Consulting and Clinical Psychology. - : AMER PSYCHOLOGICAL ASSOC. - 0022-006X .- 1939-2117. ; 87:1, s. 46-55
  • Tidskriftsartikel (refereegranskat)abstract
    • Objective: Although patient-therapist collaboration (working alliance) has been studied extensively in Europe and America, it is unknown to what extent the importance of working alliance for psychotherapy outcome generalizes to lower-and middle-income countries. Additionally, there is a need for more studies on the alliance using methods that are robust to confounders of its effect on outcome. Method: In this study, 345 outpatients seeking care at the 2 public psychiatric hospitals in Nairobi, Kenya, filled out the Session Alliance Inventory (SAI) and the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) during each session. The effect of alliance on next-session psychological distress was modeled using the random intercept cross-lagged panel model, which estimates a cross-lagged panel model on within- and between-subjects disaggregated data. Results: Changes in the working alliance from session to session significantly predicted change in psychological distress by the next session, with an increase of 1 point of the SAI in a given session resulting in a decrease of 1.27 points on the CORE-OM by the next session (SE = 60, 95% confidence interval [-2.44, -.10]). This finding represents a medium-sized standardized regression coefficient of between.16 and.21. Results were generally robust to sensitivity tests for stationarity, missing data assumptions, and measurement error. Conclusion: Results affirm cross-cultural stability of the session-by-session reciprocal effects model of alliance and psychological distress-symptoms as seen in a Kenyan psychiatric outpatient sample, using the latest developments in cross-lagged panel modeling. A limitation of the study is its naturalistic design and lack of control over several variables.
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42.
  • Fisher, Hadar, et al. (författare)
  • Therapists' oxytocin response mediates the association between patients' negative emotions and psychotherapy outcomes
  • 2023
  • Ingår i: Journal of Affective Disorders. - : Elsevier. - 0165-0327 .- 1573-2517. ; 338, s. 163-170
  • Tidskriftsartikel (refereegranskat)abstract
    • Background: Existing literature suggests that patients' experiences of emotions, especially negative emotions, predict outcomes in psychotherapies for major depressive disorder. However, the specific mechanisms underlying this effect remain unclear. Based on studies pointing to the role of oxytocin (OT) in attachment relationships, we proposed and tested a mediation model where the therapists' hormonal responses, as represented by increases in their OT levels, mediates the association between negative emotions and symptomatic change. Method: OT saliva samples (pre- and post-session, N = 435) were collected on a fixed schedule over 16 sessions from the therapists of 62 patients receiving psychotherapy for major depression. The Hamilton Rating Scale for Depression was administered to the patients before the sessions, and the patients reported their in-session emotions after the sessions. Results: The findings support the proposed within-person mediation model: (a) higher levels of negative emotions in patients predicted greater increases in therapist OT levels pre- to post-session throughout treatment; (b) greater OT levels in therapists, in turn, predicted reduction in patients' depressive symptoms on the subsequent assessment; and (c) the therapists' OT levels significantly mediated the association between patients' negative emotions and reduction in their depressive symptoms. Limitations: This design precluded establishing a time sequence between patients' negative emotions and therapists' OT; thus, causality could not be inferred. Conclusion: These findings point to a possible biological mechanism underlying the effects of patients' experiences of negative emotions on treatment outcomes. The findings suggest that therapists' OT responses could potentially serve as a biomarker of an effective therapeutic processes.
  •  
43.
  • Fitzpatrick, Olivia M., et al. (författare)
  • Who Benefits the Most From Cognitive Change in Cognitive Therapy of Depression? A Study of Interpersonal Factors
  • 2020
  • Ingår i: Journal of Consulting and Clinical Psychology. - : AMER PSYCHOLOGICAL ASSOC. - 0022-006X .- 1939-2117. ; 88:2, s. 128-136
  • Tidskriftsartikel (refereegranskat)abstract
    • Objective: Research suggests that decreases in negative cognitions coincide with symptom improvements over the course of cognitive therapy (CT) of depression, but the role cognitive change (CC) plays in reducing symptoms remains controversial. Method: A total of 126 adults (mean age = 31.7, SD = 13.35; 60% female; 83% Caucasian) participated in CT for depression. Patients completed the Beck Depression Inventory-II and the Immediate Cognitive Change Scale at each session. At intake evaluation, maladaptive personality traits (Personality Inventory for DSM-5, Brief Form) and interpersonal problems (Inventory of Interpersonal Problems, Short Version) were assessed via self-report, and social skills were assessed through patients evaluation of their performance following a series of behavioral role-plays (standardized interaction task). To rule out between-patient differences as potential confounds, our model disaggregated within- and between-patient components of CC and depression scores. Results: Within-patient CC significantly predicted within-patient change in depressive symptoms. This relation was moderated by patients evaluations of their social skills and patients level of interpersonal problems, with CC predicting symptoms more robustly for patients with fewer perceived social skills and for those with greater interpersonal problems. Maladaptive personality traits did not emerge as a moderator. Additional analyses showed the relation of CC and symptom change was particularly strong among those with social anxiety disorder and among those observers rated as having lower social skills. Conclusions: CC in CT sessions appears to foster subsequent depressive symptom reduction, especially among patients with lower levels of self-evaluated social skills and greater interpersonal problems.
  •  
44.
  • Fluckiger, Christoph, et al. (författare)
  • The Reciprocal Relationship Between Alliance and Early Treatment Symptoms: A Two-Stage Individual Participant Data Meta-Analysis
  • 2020
  • Ingår i: Journal of Consulting and Clinical Psychology. - : AMER PSYCHOLOGICAL ASSOC. - 0022-006X .- 1939-2117. ; 88:9, s. 829-843
  • Tidskriftsartikel (refereegranskat)abstract
    • Objective: Even though the early alliance has been shown to robustly predict posttreatment outcomes, the question whether alliance leads to symptom reduction or symptom reduction leads to a better alliance remains unresolved. To better understand the relation between alliance and symptoms early in therapy, we meta-analyzed the lagged session-by-session within-patient effects of alliance and symptoms from Sessions I to 7. Method: We applied a 2-stage individual participant data meta-analytic approach. Based on the data sets of 17 primary studies from 9 countries that comprised 5,350 participants, we first calculated standardized session-by-session within-patient coefficients. Second, we meta-analyzed these coefficients by using random-effects models to calculate omnibus effects across the studies. Results: In line with previous meta-analyses, we found that early alliance predicted posttreatment outcome. We identified significant reciprocal within-patient effects between alliance and symptoms within the first 7 sessions. Cross-level interactions indicated that higher alliances and lower symptoms positively impacted the relation between alliance and symptoms in the subsequent session. Conclusion: The findings provide empirical evidence that in the early phase of therapy. symptoms and alliance were reciprocally related to one other, often resulting in a positive upward spiral of higher alliance/lower symptoms that predicted higher alliances/lower symptoms in the subsequent sessions. Two-stage individual participant data meta-analyses have the potential to move the field forward by generating and interlinking well-replicable process-based knowledge.
  •  
45.
  • Hatcher, Robert L., et al. (författare)
  • Psychometric evaluation of the Working Alliance Inventory—Therapist version : Current and new short forms
  • 2020
  • Ingår i: Psychotherapy Research. - : Informa UK Limited. - 1050-3307 .- 1468-4381. ; 30:6, s. 706-717
  • Tidskriftsartikel (refereegranskat)abstract
    • Background: The Working Alliance Inventory (WAI) and its short forms are widely used, although the properties of the therapists? versions have been little studied. Method: We examined the psychometric properties of two short forms (WAI-S-T, WAI-SR-T), and explored the creation of a psychometrically stronger short form using contemporary measure development techniques. Well-fitting items from the full 36-item WAI were identified in a development sample (131 therapists, 688 patients) using multi-level Bayesian Structural Equation Modeling, accounting for therapist rated effects. Multi-level Item Response Theory (IRT) methods aided creation of a revised short form (WAI-S-T-IRT). Factor structures of the three forms were assessed using multi-level ML estimation with robust standard errors. Results: Collinearity problems for the Goal and Task dimensions led to testing a two-factor model (Goal?Task, Bond). All three measures showed satisfactory fit; the WAI-S-T-IRT fit slightly better but differences were minor. Testing the structures in an independent sample (N?=?1117) yielded essentially the same results. No version showed strong measurement invariance. Discussion: Continued use of current therapist forms is supported; differentiation of theoretical dimensions is difficult with current measures, and may not be possible with self-report forms.
  •  
46.
  • Holmqvist Larsson, Kristina, et al. (författare)
  • "It's ok that I feel like this" : a qualitative study of adolescents' and parents' experiences of facilitators, mechanisms of change and outcomes in a joint emotion regulation group skills training
  • 2023
  • Ingår i: BMC Psychiatry. - : BioMed Central (BMC). - 1471-244X. ; 23:1
  • Tidskriftsartikel (refereegranskat)abstract
    • BackgroundEmotion regulation difficulties underlie several psychiatric conditions, and treatments that focus on improving emotion regulation can have an effect on a broad range of symptoms. However, participants' in-depth experiences of participating in emotion regulation treatments have not been much studied. In this qualitative study, we investigated participants' experiences of a joint emotion regulation group skills training in a child and adolescent psychiatric outpatient setting.MethodsTwenty-one participants (10 adolescents and 11 parents) were interviewed about their experiences after they had participated in a seven-session transdiagnostic emotion regulation skills training for adolescents and parents. The aim of the skills training was to decrease emotion regulation difficulties, increase emotional awareness, reduce psychiatric symptoms, and enhance quality of life. The skills training consisted of psychoeducation about emotions and skills for regulating emotions. The interviews were transcribed and analysed using reflexive thematic analysis.ResultsThe analysis resulted in three overarching themes: Parent - Child processes, Individual processes, and Group processes. The result showed that participants considered an improved parent-child relationship to be the main outcome. Increased knowledge, emotion regulation skills and behavioural change were conceptualised as both mechanisms of change and outcomes. The group format, and the fact that parents and adolescents participated together, were seen as facilitators. Furthermore, the participants experienced targeting emotions in skills training as meaningful and helpful.ConclusionThe results highlight the potential benefits of providing emotion regulation skills training for adolescents and parents together in a group format to improve the parent-child relationship and enable the opportunity to learn skills.
  •  
47.
  • Holmqvist Larsson, Mattias, 1977-, et al. (författare)
  • Alliance ruptures and repairs in psychotherapy in primary care
  • 2018
  • Ingår i: Psychotherapy Research. - : Routledge. - 1050-3307 .- 1468-4381. ; 28:1, s. 123-136
  • Tidskriftsartikel (refereegranskat)abstract
    • 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.
  •  
48.
  • Holmqvist Larsson, Mattias, 1977- (författare)
  • Rupture and Repair in the Working Alliance : Relation to Psychotherapy Outcome and Within-Session Interaction
  • 2019
  • Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
    • Ruptures and repairs are processes related to shifts in the collaborative relationship Cthe working allianceJ between patient and therapist in psychotherapy. Ta study ruptures and repairs is one way ta disentangle mechanisms that might underlie the association between the working alliance and psychotherapy outcome. The overarching aim af this thesis was ta analyze the clinical relevance af the rupture and repair concepts at different process levels. The same three alliance patterns were investigated in the three empirical studies: the rupture pattern, the repair pattern, and the no-rupture/stable pattern. The analyses af the alliance patterns moved fromwhole treatments ta session segments. In Study I ruptures were found ta be associated with worse outcomes than treatments without ruptures. Repairs were, in longer therapies, shown ta be related ta better outcomes than norupture treatments. In Study Il it was found that the three alliance patterns could be discerned within sessions. Ruptures and repairs within sessions were found ta be associated with patient-ratings af the working alliance. In Study 111 the alliance patterns were found ta be related ta different  interaction patterns within sessions. In these analyses, importont patient contributions ta repairs af ruptures were found.
  •  
49.
  • Holmqvist Larsson, Mattias, 1977-, et al. (författare)
  • The Alliance and Rupture Observation Scale (AROS) : Development and validation of an alliance and rupture measure for repeated observations within psychotherapy sessions
  • 2019
  • Ingår i: Journal of Clinical Psychology. - : John Wiley & Sons. - 0021-9762 .- 1097-4679. ; 75:3, s. 404-417
  • Tidskriftsartikel (refereegranskat)abstract
    • 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.
  •  
50.
  • Katznelson, Hannah, et al. (författare)
  • Reflective Functioning, Psychotherapeutic Alliance, and Outcome in Two Psychotherapies for Bulimia Nervosa
  • 2020
  • Ingår i: Psychotherapy. - : American Psychological Association (APA). - 0033-3204 .- 1939-1536. ; 57:2, s. 129-140
  • Tidskriftsartikel (refereegranskat)abstract
    • Mentalization is a developmental achievement defined as the capacity to understand behavior in terms of mental states. This study investigated mentalization in psychoanalytic psychotherapy (PPT) and cognitive behavior therapy (CBT) through a secondary data analysis of findings from a randomized controlled trial for bulimia nervosa. It was hypothesized that mentalization would predict alliance and outcome in both treatments, whereas increase in mentalization was only expected after PPT. Furthermore, it was investigated whether change in mentalization predicted symptom change. A total of 70 participants with bulimia nervosa were randomized to PPT or CBT. Participants were assessed at 3 time points with the Eating Disorder Examination and the Adult Attachment Interview (rated for reflective functioning [RF]). Therapy sessions were rated with the Vanderbilt Therapeutic Alliance Scale. Higher intake RF significantly predicted better alliance, whereas no association was observed between RF and outcome. A significant interaction between time, therapy type, and RF found RF improving more in PPT than in CBT. There was a significant association between RF change and symptom change in the PPT group. The study suggests a relation between RF and psychotherapy process, whereas the relation between RF and outcome is more complex. Furthermore, PPT seems to enhance mentalization, which seems related to symptomatic improvement, suggesting that mentalization might serve as a specific mechanism of change in PPT.
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