| 1. |
- Alexandersson, Klas, et al.
(author)
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Session-to-session effects of therapist adherence and facilitative conditions on symptom change in CBT and IPT for depression
- 2023
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In: Psychotherapy Research. - : Taylor & Francis Group. - 1050-3307 .- 1468-4381. ; 33:1, s. 57-69
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Journal article (peer-reviewed)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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| 2. |
- Ekeblad, Annika, 1955-, et al.
(author)
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"What shall we focus on?" - A thematic analysis of what characterizes cognitive-behavior therapy sessions with high or low quality of working alliance
- 2022
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In: Psychotherapy Research. - : Taylor & Francis Group. - 1050-3307 .- 1468-4381. ; 32:8, s. 1003-1015
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Journal article (peer-reviewed)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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| 3. |
- Falkenström, Fredrik, 1972-, et al.
(author)
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How to Model and Interpret Cross-Lagged Effects in Psychotherapy Mechanisms of Change Research : A Comparison of Multilevel and Structural Equation Models
- 2022
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In: Journal of Consulting and Clinical Psychology. - : American Psychological Association (APA). - 0022-006X .- 1939-2117. ; 90:5, s. 446-458
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Journal article (peer-reviewed)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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| 4. |
- Falkenström, Fredrik, Professor, 1972-, et al.
(author)
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Patient Attachment and Reflective Functioning as Predictors for Therapist In-Session Feelings
- 2024
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In: Journal of counseling psychology. - : American Psychological Association (APA). - 0022-0167 .- 1939-2168. ; 71:3, s. 190-201
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Journal article (peer-reviewed)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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| 5. |
- Falkenström, Fredrik, 1972-, et al.
(author)
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Therapist in-session feelings predict change in depressive symptoms in interpersonal and brief relational psychotherapy
- 2022
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In: Psychotherapy Research. - : Taylor & Francis Group. - 1050-3307 .- 1468-4381. ; 32:5, s. 571-584
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Journal article (peer-reviewed)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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| 6. |
- Falkenström, Fredrik, 1972-, et al.
(author)
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Using Copulas to Enable Causal Inference from Non-Experimental Data : Tutorial and Simulation Studies
- 2023
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In: Psychological methods. - : American Psychological Association (APA). - 1082-989X .- 1939-1463. ; 28:2, s. 301-321
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Journal article (peer-reviewed)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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| 7. |
- Holmqvist Larsson, Kristina, et al.
(author)
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"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
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In: BMC Psychiatry. - : BioMed Central (BMC). - 1471-244X. ; 23:1
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Journal article (peer-reviewed)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.
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| 8. |
- Lindqvist, Karin, et al.
(author)
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Therapeutic alliance is calming and curing - The interplay between alliance and emotion regulation as predictors of outcome in Internet-based treatments for adolescent depression
- 2023
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In: Journal of Consulting and Clinical Psychology. - : American Psychological Association (APA). - 0022-006X .- 1939-2117. ; 91:7, s. 426-437
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Journal article (peer-reviewed)abstract
- Objective: Therapeutic alliance is one of the most stable predictors of outcome in psychotherapy, regardless of theoretical orientation. The alliance–outcome relationship in internet-based treatments has been investigated with mixed results. There is preliminary evidence that emotion regulation can work as a mediator for the alliance–outcome relationship. The present study aimed to investigate whether alliance predicted outcome session by session in two internet-based treatments for adolescent depression, and whether this relationship was mediated by emotion regulation.Method: Two hundred and seventy-two participants aged 15–19 years and diagnosed with depression were randomized to 10 weeks of internet-based psychodynamic or cognitive behavioral treatment. Both therapists and patients rated the alliance weekly. Patients also rated depressive symptoms and emotion regulation weekly. Analyses were made using cross-lagged panel modeling.Results: Alliance, as rated by both therapist and patient, predicted depression scores the following week. Emotion regulation rated by the patient also predicted depression scores the following week. Furthermore, alliance scores predicted emotion regulation scores the following week, which in turn predicted depression scores the week after, supporting the hypothesis that alliance influences outcome partly through emotion regulation. There were no group differences in any of these relationships.Conclusion: Alliance seems to play an important role in internet-based treatments, partly through emotion regulation. Clinicians working with text-based treatments should pay attention to the working alliance.
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| 9. |
- Mechler, Jakob, et al.
(author)
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Therapist-guided internet-based psychodynamic therapy versus cognitive behavioural therapy for adolescent depression in Sweden : a randomised, clinical, non-inferiority trial
- 2022
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In: The Lancet Digital Health. - : Elsevier. - 2589-7500. ; 4:8, s. E594-E603
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Journal article (peer-reviewed)abstract
- Background Adolescent major depressive disorder (MDD) is highly prevalent and associated with lifelong adversity. Evidence-based treatments exist, but accessible treatment alternatives are needed. We aimed to compare internet-based psychodynamic therapy (IPDT) with an established evidence-based treatment (internet-based cognitive behavioural therapy [ICBT]) for the treatment of adolescents with depression. Methods In this randomised, clinical trial, we tested whether IPDT was non-inferior to ICBT in the treatment of adolescent MDD. Eligible participants were 15-19 years old, presenting with a primary diagnosis of MDD according to DSM-5. Participants were recruited nationwide in Sweden through advertisements on social media, as well as contacts with junior and senior high schools, youth associations, social workers, and health-care providers. Adolescents who scored 9 or higher on the Quick Inventory of Depressive Symptomatology for Adolescents (QIDS-A17-SR) in an initial online screening were contacted by telephone for a diagnostic assessment using the Mini International Neuropsychiatric Interview. Participants were randomly assigned to ICBT or IPDT. Both interventions comprised eight self-help modules delivered over 10 weeks on a secure online platform. The primary outcome was change in depression severity measured weekly by the QIDS-A17-SR. Primary analyses were based on an intention -to-treat sample including all participants randomly assigned. A non-inferiority margin of Cohen's d=0.30 was predefined. The study is registered at ISRCTN, ISRCTN12552584. Findings Between Aug 19, 2019, and Oct 7, 2020, 996 young people completed screening; 516 (52%) were contacted for a diagnostic interview. 272 participants were eligible and randomly assigned to ICBT (n=136) or IPDT (n=136). In the ICBT group, 51 (38%) of 136 participants were classified as remitted, and 54 (40%) of 136 participants were classified as remitted in the IPDT group. Within-group effects were large (ICBT: within-group d=1.75, 95% CI 1.49 to 2.01; IPDT: within-group d=1.93, 1.67 to 2.20; both p<0.0001). No statistically significant treatment difference was found in the intention-to-treat analysis. Non-inferiority for IPDT was shown for the estimated change in depression during treatment (d=-0.18, 90% CI -0.49 to 0.13; p=0.34). All secondary outcomes showed non-significant between-group differences. Interpretation IPDT was non-inferior to ICBT in terms of change in depression for the treatment of adolescents with MDD. This finding increases the range of accessible and effective treatment alternatives for adolescents with depression. Copyright (C) 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.
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| 10. |
- Nilsson, Thomas, et al.
(author)
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Exploring termination setback in a psychodynamic therapy for panic disorder
- 2021
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In: Journal of Consulting and Clinical Psychology. - : American Psychological Association (APA). - 0022-006X .- 1939-2117. ; 89:9, s. 762-772
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Journal article (peer-reviewed)abstract
- Objective: Termination in psychodynamic therapy (PDT) is a potentially conflictual and turbulent phase for patients, with a risk for increases in symptoms. However, few studies of PDT have assessed symptoms frequently enough during treatment to determine whether such setbacks are in fact common in PDT. Methods: In a doubly randomized clinical preference trial, 217 adults (female = 163; M age = 34.8 (12.6)) with panic disorder with or without agoraphobia were treated with panic-focused psychodynamic psychotherapy (PFPP) or panic control treatment (PCT), a form of cognitive behavioral therapy. Participants completed the Panic Disorder Severity Scale-Self Report (PDSS-SR) weekly during treatment (weeks 1-12), and 6, 12 and 24 months after treatment. Using piecewise latent growth curve modeling we tested the trajectories of change focusing on the termination phase in PFPP. Results: Week-to-week improvement on the PDSS-SR stopped (a termination setback [TS]) in PFPP during weeks 10-12, whereas PCT participants continued to improve. Larger symptom reductions up to week 10 in PFPP predicted a more severe TS. Less avoidant attachment and less severe interpersonal problems also predicted more severe TS. The TSs tended to last, as evidenced by inferior outcomes, up to the 12-month follow-up. Conclusions: This study provides evidence of a TS in PDT. Resurgence of symptoms as termination approached was more common in PFPP than in PCT. Studies involving weekly assessment of primary and comorbid symptoms, as well as qualitative analyses of the patient experiences of the therapeutic process during termination, in different forms of PDT, are warranted.
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