Emotional reactions are a vital part of the therapeutic relationship. The Feeling Word Checklist-24 (FWC-24) is an instrument asking the clinician (or the patient) to report to what degree he or she has experienced various feelings during a therapeutic interaction. The aim of this study was to assess the factor structure of the clinician-rated FWC-24 when taking dependencies in the data into account. The sample was deliberately heterogeneous and consisted of 4,443 ratings made by 101 psychotherapists working with different psychotherapy methods in relation to 191 patients of different ages, genders, and with different primary diagnoses. A random intercept-only model revealed large intraclass correlation coefficients at the therapist level, indicating that a multilevel analysis was warranted. A two-level exploratory factor analysis with therapists as the between level and patients plus sessions as the within level was conducted. The items from FWC-24 were found to be best represented by four factors on the between level and four factors on the within level. The factor structures were largely similar on the two levels and were labeled Engaged, Inadequate, Relaxed, and Moved. The different factors explained different amounts of variance on different levels, indicating that some factors are more therapist dependent and some more patient dependent.
As established in several studies, therapists differ in effectiveness. A vital research task now is to understand what characterizes more or less effective therapists, and investigate whether this differential effectiveness systematically depends on client factors, such as the type of mental health problem. The purpose of the current study was to examine whether therapists are universally effective across patient outcome domains reflecting different areas of mental health functioning. Data were obtained from 2 sites: the Research Consortium of Counseling and Psychological Services in Higher Education (N = 5,828) in the United States and from primary and secondary care units (N = 616) in Sweden. Outcome domains were assessed via the Outcome Questionnaire-45 (Lambert et al., 2004) and the CORE-OM (Evans et al., 2002). Multilevel models with observations nested within patients were used to derive a reliable estimate for each patient's change (which we call a multilevel growth d) based on all reported assessment points. Next, 2 multilevel confirmatory factor analytic models were fit in which these effect sizes (multilevel ds) for the 3 subscales of the OQ-45 (Study 1) and 6 subscales of CORE-OM (Study 2) were indicators of 1 common latent factor at the therapist level. In both data sets, such a model, reflecting a global therapist effectiveness factor, yielded large factor loadings and excellent model fit. Results suggest that therapists effective (or ineffective) within one outcome domain are also effective within another outcome domain. Tentatively, therapist effectiveness can thus be conceived of as a global construct. (PsycINFO Database Record
Despite substantial effect sizes for psychological therapy among different diagnosis groups and in different treatment contexts, many studies show that a large proportion of patients do not attain reliable improvement and a substantial portion are worse off after treatment. Previous studies suggest that patients in psychiatry may have worse outcome than patients in primary care.
In this practice-based study of psychological treatment in Swedish primary care and adult psychiatry, the proportions of patients who did not improve and who deteriorated were assessed.
Proportions of reliably improved, unchanged, and reliably deteriorated patients among 840 patients in primary care and 317 patients in specialist psychiatry were assessed by self-ratings using the Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM).
More than half of the patients did not change reliably. About 2% of the patients in primary care and 7% in psychiatry deteriorated. Multilevel analyses of the data from primary care indicated that there were no therapist effects.
The results emphasize the importance of monitoring treatment continuously in order to increase results for patients who do not improve.
Practice-based studies have found substantial effects of psychological treatment in routine care, often equivalent between treatment methods. Factors that moderate treatment outcome may be important to assess.
The purpose of this study was to evaluate treatment outcome in psychological treatment in primary care, and to compare outcome between the most frequently used methods. An additional aim was to study factors that might moderate outcome differences.
The Clinical Outcome in Routine Evaluation (CORE) system was used to evaluate psychological treatment at Swedish primary care centers. Treatment methods were coded by the therapists after treatment. Three major treatment orientations-directive (cognitive, behavioral and CBT), reflective (psychodynamic and relational) and supportive therapy were compared. Patient and therapist variables were studied as treatment moderating factors.
Analyses of 733 therapies, delivered by 70 therapists, showed good results in short psychological treatments (median session number = 6). Forty-three percent of the patients were remitted, 34% recovered. For patients receiving at least five sessions, the figures were 50% and 40%. Directive therapy and reflective therapy had comparable outcome, and better than supportive treatment. Patients in supportive therapy had higher age and received fewer therapy sessions. The patients' motivation, alliance capacity and reflective ability, as rated by the therapist after treatment, were lower for patients in supportive treatment.
Psychological treatment in primary care obtains god results. Supportive therapy should be studied more systematically, particularly with regard to variables that may moderate treatment outcome.
Interpersonal 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.
Ninety-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.
IPT 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
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.
To explore the associations between self-rated attachment style, psychological distress and substance use among substance use disorder (SUD) outpatients in psychological treatment.
In this practice-based study, 108 outpatients were asked to fill in the Experiences in Close Relationships - Short form, the Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM), the Alcohol Use Disorders Identification Test (AUDIT), and the Drug Use Disorders Identification Test (DUDIT) at treatment start and end. Patients were given psychological treatments with a directive, reflective or supportive orientation.
An insecure attachment style was more common among the SUD outpatients, compared to non-clinical groups. Patients with a fearful attachment style scored higher on psychological distress than patients with a secure attachment style. The associations between the attachment dimensions and psychological distress were stronger than those between attachment and SUD. Significantly more patients had a secure attachment style at treatment end.
This study shows significant relations between patients' attachment style and their initial psychological distress. The causal relationship between attachment style and psychological distress is, however, not clear and can likely go in both directions. The psychological treatment of patients with SUD contributed significantly to changes from insecure to secure attachment style.
We found among patients with SUD a strong relation between patients' attachment style and their psychological distress. Knowledge of the patient's attachment style may help the therapist to tailor the treatment to the patient's needs. A change from insecure to secure attachment style can be an important goal for a SUD treatment, as it may prevent the patient from using defence strategies involving substance use for regulating emotions and interpersonal relationships.
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.