Associations between therapists' verbal techniques and patient-rated therapeutic alliance, insight, and problem solving.

OBJECTIVE: To investigate associations between common factors (alliance, insight, problem solving) and therapists' techniques. We expected a positive association between (1) supportive techniques and the alliance, (2) interpretative techniques and insight, and (3) a stronger association between interpretative techniques and insight for patients with more severe baseline symptoms. Other associations were analyzed in an exploratory way. METHOD: Sixty sessions from 15 adult female patients diagnosed with personality disorder were analyzed using the Psychodynamic Interventions List (verbal techniques, observer-rated transcripts), and the Session Questionnaire for General and Differential Individual Psychotherapy (common factors, patient-rated after each session). Multilevel modeling was applied. RESULTS: A greater use of supportive techniques was related to a higher therapeutic alliance (b = .28, 95% CI: .01-.55, p = .042). Neither the positive association between interpretative techniques and insight nor the moderating effect of baseline symptom severity could be confirmed. Exploratory analyses revealed associations between problem-solving and different verbal techniques. CONCLUSION: Therapists' use of supportive techniques seems to influence the therapeutic alliance positively in patients with personality disorders. The effect of interpretative techniques might depend on other factors like patient characteristics. In general, there seem to be differential and specific associations between different therapists' verbal techniques and common factors.

Prospective psychotherapists' bias and accuracy in assessing their own facilitative interpersonal skills.

We aimed to investigate prospective psychotherapists' bias in assessing their own facilitative interpersonal skills (FIS) and predictors of high self-assessments. In this cross-sectional observational study, we examined 132 psychology students and trainee psychotherapists. Therapists' demographic variables and self-concepts were assessed through self-report questionnaires, and their therapeutic skills were assessed with the German version of the "FIS" task. A truth-and-bias model approach was applied in three different hierarchical linear models to test self-assessment bias of FIS, and to identify factors associated with overly positive self-assessments of therapeutic skills. Significantly higher self-assessments of skills were found in comparison to observer ratings for overall FIS and for the FIS dimensions hope, emotional expression, warmth, acceptance, and understanding, empathy, alliance bond capacity, and rupture-repair responsiveness. Despite this discrepancy, there was a significant congruence between self- and observer ratings. A greater self-assessed ego-strength and attractiveness were associated with self-assessments of skills that were higher than the observer-rated average. Age, gender, experience, and other self-concept variables showed no significant association with self-assessments. This present study demonstrates self-assessment bias in prospective therapists. However, when participants rated their own FIS to be high, observers also tended to rate participants' skills higher. Especially therapists who generally feel more confident and attractive tend to estimate themselves positively. Supervisors and trainees should be aware of the ubiquity of self-assessment bias. Future research is necessary to test the effect of self-assessment bias on patient outcomes and process variables. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Factors influencing the duration of untreated illness among patients with anorexia nervosa: A multicenter and multi-informant study.

INTRODUCTION: The duration of untreated illness (DUI), that is, the interval between the onset of anorexia nervosa (AN) symptoms and start of specialized treatments, has a strong influence on the prognosis. OBJECTIVE: To quantify modifiable predictors of the DUI and to derive recommendations for secondary prevention strategies. METHODS: Within a multicenter, multi-informant study, DUI was assessed in interviews with patients undergoing first specialized AN treatment. Modifiable factors were assessed perspectives of AN-patients, their relatives, and primary care practitioners [PCPs]) with the FABIANA-checklist (Facilitators and barriers in anorexia nervosa treatment initiation). The effect of FABIANA-items on the DUI for each perspective was calculated using Cox Regression (control variables: age, eating disorder pathology, health care status, migration background, body mass index [BMI]). RESULTS: We included data from N = 125 female patients with AN (72 adults, 53 adolescents, Mage = 19.2 years, SD = 4.2, MBMI = 15.7 kg/m2 , SD = 1.9), N = 89 relatives (81.8% female, 18.2% male, Mage = 46.0 years, SD = 11.0) and N = 40 PCPs (Mage = 49.7 years, SD = 9.0). Average DUI was 12.0 months. Watching or reading articles about the successful treatment of other individuals with AN (patients' perspective) and regular appointments with a PCP (PCPs' perspective) were related to a shorter DUI (HR = 0.145, p = .046/ HR = 0.395, p = .018). Patients whose relatives rated that PCPs trivialized patients' difficulties had a longer DUI (HR = -0.147, p = .037). PCPs and relatives rated PCPs' competence higher than patients did. DISCUSSION: It is recommended (a) to incorporate treatment success stories in prevention strategies, (b) to inform PCPs about potential benefits of regular appointments during the transition to specialized care, and (c) to train PCPs in dealing with patients' complaints. PUBLIC SIGNIFICANCE: Many individuals with AN seek treatment very late. Our study shows that a promising approach to facilitate earlier AN treatment is to inform patients about successful treatments of affected peers, to foster regular appointments with a PCP and, to motivate these PCPs to take individuals' with AN difficulties seriously. Thus, our study provides important suggestions for interventions that aim to improve early treatment in AN.

Who are the skilled therapists? Associations between personal characteristics and interpersonal skills of future psychotherapists.

OBJECTIVE: Facilitative interpersonal skills (FIS) are a promising variable to explain the so-called therapist effect. We aimed to investigate associations between observer-rated interpersonal skills and self-reported personal characteristics of future therapists. METHOD: In this cross-sectional observational study, psychology students and trainee therapists completed self-report personality and sociodemographic questionnaires as well as the FIS Performance Task (German version, observer-rated). Mixed multilevel model analysis was conducted with FIS total mean score (mean value of 312 individual ratings [13 video-clips, 8 FIS-items, 3 raters]) as dependent variable, therapist ID and FIS clip ID as random effects and 15 therapist variables as fixed effects. RESULTS: In the present sample consisting of 177 participants (age: M = 29.8 years (SD = 7.3), [18,59]; 79.1% female, 20.9% male) greater therapists' experience level, male gender and lower levels of alexithymia were predictive for higher FIS score when statistically controlling for other therapist variables in the model. Age, self-reported childhood maltreatment, attachment style, emotion regulation and self-concept variables turned out to be unrelated. CONCLUSION: The results can inform psychotherapy training programs. They specifically support the importance of addressing therapists' potential difficulties in recognizing and verbalizing emotions. This is in line with theoretical literature on alliance ruptures and premises of the Alliance-focused training.

The development and psychometric evaluation of FABIANA-checklist: a scale to assess factors influencing treatment initiation in anorexia nervosa.

BACKGROUND: A long duration of untreated illness (DUI) is an unfavorable prognostic factor in anorexia nervosa (AN) and is associated with chronic illness progression. Although previous preventive measures aimed at reducing DUI and thus improving short- and long-term treatment outcomes have been partially successful, a better understanding of the factors involved in the sensitive phase prior to treatment initiation is needed. To date, there is no validated instrument available to assess these factors specifically for patients with AN. The FABIANA-project (Facilitators and barriers in anorexia nervosa treatment initiation) aims at identifying predictors of the DUI in order to target preventive measures better in the future. As part of this project, the FABIANA-checklist was developed, based on a multi-informant perspective and a multimodal bottom-up approach. The present study focusses on the process of item generation, item selection and psychometric validation of the checklist. METHODS: Based upon a previous qualitative study, an initial set of 73 items was generated for the most frequently mentioned facilitators and barriers of treatment initiation in AN. After a process of consensual rating and cognitive pre-testing, the resulting 25-item version of the FABIANA-checklist was provided to a sample of female patients (N = 75), aged ≥ 14 years with AN that underwent their first psychotherapeutic treatment in the last 12 months. After item analysis, dimensionality of the final version of the FABIANA-checklist was tested by Principal Component Analysis (PCA). We evaluated construct validity assuming correlations with related constructs, such as perceived social support (F-SozU), support in the health care system (PACIC-5A), illness perception and coping (BIPQ). RESULTS: We included 54 adult and 21 adolescent patients with AN, aged on average 21.4 years. Average BMI was 15.5 kg/m2, age of onset was 19.2 years and average DUI was 2.25 years. After item analysis, 7 items were excluded. The PCA of the 18-item-FABIANA-checklist yielded six components explaining 62.64% of the total variance. Overall internal consistency was acceptable (Cronbach's α = .76) and construct validity was satisfactory for 14 out of 18 items. Two consistent components emerged: "primary care perceived as supportive and competent" (23.33%) and "emotional and practical support from relatives" (9.98%). With regard to the other components, the heterogeneity of the items led to unsatisfactory internal consistency, single item loading and in part ambiguous interpretability. CONCLUSIONS: The FABIANA-checklist is a valid instrument to assess factors involved in the process of treatment initiation of patients with AN. Psychometrics and dimensionality testing suggests that experienced emotional and practical support from the primary health care system and close relatives are main components. The results indicate that a differentiated assessment at item level is appropriate. In order to quantify the relative importance of the factors and to derive recommendations on early-intervention approaches, the predictive effect of the FABIANA-items on the DUI will be determined in a subsequent study which will further include the perspective of relatives and primary caregivers. Trial registration Clinical Trials.gov Identifier: NCT03713541: https://clinicaltrials.gov/ct2/show/NCT03713541 .

Early treatment contributes to a more favorable illness course and an improved prognosis in patients with anorexia nervosa (AN). The current study presents the development of the FABIANA checklist, which aims to assess factors which influence duration of untreated illness. The FABIANA checklist was developed on the basis of interviews with patients, their relatives and primary care practitioners. It provides data from the first use of the checklist in a German sample of 75 patients with AN. The results of our study suggest that the FABIANA-checklist is a valid instrument to assess factors involved in the process of treatment initiation. Emotional and practical support from the primary health care system and close relatives were the most consistent components. A follow-up study will investigate the relationship between the FABIANA-items and the DUI in order to guide the conception of effective secondary prevention measures.

["Achieving closeness in video treatment despite distance"]. / "In Videobehandlungen trotz Distanz Nähe schaffen": Wie erlebten Psychotherapeuten die Durchführung von Videobehandlungen in Zeiten von COVID-19?

Background: As a result of the contact ban issued at the beginning of the coronavirus disease 2019 (COVID-19) outbreak in March 2020, psychotherapists provided significantly more video-based therapy (VBT) and most of them provided it the first time. To date, there is little research on how therapists experienced VBT during the pandemic and no studies are available that look at possible procedure-specific features. Objective: The aim was to analyze what subjective experiences therapists of different guideline procedures had with the implementation of VBT in times of the COVID 19 pandemic and what advantages and disadvantages they experienced. Methods: This was a mixed methods study with a cross-sectional online survey. In addition to quantitative data, seven open-ended questions were used to collect therapists' subjective experiences with conducting VBT and analyzed using qualitative content analysis. The identified categories were subjected to a frequency analysis. Data from 174 medical or psychological psychotherapists were included in the analysis. Results: Particularly frequently mentioned advantages were flexibility of location and time, continuity of contact during pandemic periods and avoidance of risk of infection. The most commonly cited disadvantage was the lack of sensory input, facial expressions, gestures, eye contact, and nonverbal communication. The VBT was well-accepted by most, but not all, patients. Technical problems made the implementation difficult. Conclusion: For many therapists VBT remained a stopgap solution that was not designed to last; however, VBT could help to solve known care problems (e.g., underprovision in rural areas) beyond the pandemic period. The results of the study make an important contribution to weighing up the opportunities and risks of VBT for psychotherapeutic care and for keeping an eye on possible dangers and difficulties.

[Online psychotherapy in times of coronavirus disease 2019]. / Onlinepsychotherapie in Zeiten der Corona-Pandemie: Querschnittsbefragung deutscher Psychotherapeuten.

Theoretical background: As a reaction to the coronavirus diseases 2019 (COVID-19) pandemic, in individual settings psychotherapy could be conducted online to an unlimited extent in Germany. The attitudes and experiences of psychotherapists with respect to online therapy (OT) have so far been generally poorly studied and particularly with a view to the situation during the pandemic. Objective: The aim of the study was to examine 1) the frequency of utilization of OT during the first lockdown, 2) the satisfaction with OT versus face-to-face therapy and 3) the technology acceptance experience overall and with respect to the guideline procedures. Material and methods: German psychotherapists licensed and in training, cognitive-behavioral (CB 45.6%), analytic (AP 14%), depth-psychological (DP 34.5%), systemic (SYS 5.8%), were invited to participate in an online survey on demographic and therapeutic data, use of OT, satisfaction with OT vs. face-to-face therapy (Zufriedenheitsfragebogen für Therapeuten, ZUF-THERA) and technology acceptance (Unified Theory of Acceptance and Use of Technology 2 Questionnaire, UTAUT). Results: The 174 participating psychotherapists (mean age = 44.73 years, SD ±â€¯12.79; female 81.6%) reported that the average proportion of OT in the total therapeutic activity during the lockdown was 43.09%, with significant differences between guideline procedures (DP, CB > AP). The satisfaction with OT proved to be significantly lower than with face-to-face therapy and did not differ between the procedures. Prior experience with OT was reported by 23.6% of therapists overall and was higher among those working systemically compared to CB or AP therapists. Therapists working in CB experienced more enjoyment with OT than those working in DP and AP as well as perceived a stronger social influence (e.g. through colleagues) in the use of OT than therapists working in DP. Conclusion: The frequency of use of OT soared during the first lockdown (March-May 2020, 43% in comparison to the former limit covered by health insurances of 20%). In principle, therapists were highly satisfied with OT but significantly lower than with face-to-face therapy. Further studies analyzing the reasons for this in detail are urgently recommended.

Facilitators and barriers in anorexia nervosa treatment initiation: a qualitative study on the perspectives of patients, carers and professionals.

BACKGROUND: An early psychotherapeutic treatment of anorexia nervosa (AN) is crucial for a good prognosis. In order to improve treatment initiation, knowledge about facilitators and barriers to treatment is needed. OBJECTIVE: Against this background, we aimed to identify facilitators and barriers from the perspectives of patients, carers and professionals using a qualitative approach. METHOD: To this end, semi-structured interviews were conducted in triads of female patients with AN aged 14 years and older at the beginning of their first psychotherapeutic treatment, their carers, and referring health care professionals. A modified Grounded Theory approach was used for analysis. RESULTS: In total, 22 interviews were conducted (n = 6 adults, n = 4 adolescents, 4 full triads). The duration of untreated AN ranged between 30 days and 25.85 years (M = 3.06 ± 8.01 years). A wide spectrum of facilitators and barriers within the patient, the social environment, the health care system and the society were identified. Most prominent factors were 'recognizing and addressing' by close others, 'waiting times and availability' and 'recommendations and referrals' by health care professionals. 'Positive role models for treatment' were perceived as a specific facilitative social influence. Facilitators were more frequently mentioned than barriers and most of the factors seem to hold potential for modifiability. CONCLUSION: Overall, the findings suggest that early intervention approaches for AN should not only address patients and the health care system, but may also involve carers and successfully treated former patients. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03713541 .

Facilitators and barriers in anorexia nervosa treatment initiation (FABIANA): study protocol for a mixed-methods and multicentre study.

BACKGROUND: Anorexia nervosa is a serious disorder, which often takes a chronic course. Early treatment leads to a significantly better prognosis and prevents chronicity. However, existing evidence on facilitators and barriers in anorexia nervosa treatment initiation is scarce. AIMS: Against this background, the FABIANA study (ClinicalTrials.gov Identifier: NCT03713541) aims to (a) identify potentially modifiable facilitators and barriers from the perspectives of adolescent and adult patients with anorexia nervosa, carers and physicians, (b) develop and test an instrument for the combined assessment of multiple key facilitators and barriers, and (c) quantify the effect of potentially modifiable versus non-modifiable key facilitators and barriers on the duration of untreated illness (DUI) in patients with anorexia nervosa. METHOD: FABIANA is an observational, mixed-method-study divided into three consecutive substudies each corresponding to one of the study aims. All three substudies will include female patients with anorexia nervosa aged 14 years and older at the beginning of their first psychotherapeutic anorexia nervosa treatment. The qualitative substudy I and the quantitative substudy III will additionally include carers and involved physicians. The recruitment will take place at 20 cooperating study centres throughout Germany, which provide in-patient or out-patient anorexia nervosa specialist care. The DUI will be calculated based on the month of illness onset as determined in validated interviews on lifetime anorexia nervosa symptoms and the therapist-reported date of treatment initiation. CONCLUSIONS: Strengths and limitations of the retrospective assessment of the DUI will be discussed. The findings of the FABIANA study will contribute to the development of evidence-based early-intervention approaches and the prevention of a chronic course of illness. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03713541. DECLARATION OF INTEREST: None.

The role of self-esteem in the treatment of patients with anorexia nervosa - A systematic review and meta-analysis.

OBJECTIVE: We aimed to provide a comprehensive overview of the role of self-esteem in the treatment of patients with anorexia nervosa (AN). Specifically, our objectives were to investigate the differences in self-esteem between individuals with AN and healthy controls, or individuals with other eating disorders, and to examine self-esteem as an outcome, predictor, moderator, and mediator in AN treatment. METHOD: The databases PsycINFO, PSYNDEXplus, Ovid MEDLINE®, and ProQuest were searched for studies published from 1990 to 2018. To estimate aggregated effect sizes, we performed random-effects meta-analyses. RESULTS: A screening of 1,596 abstracts and 203 full-texts identified 68 relevant publications. Results suggest a significantly lower global self-esteem in individuals with AN than in healthy controls (d = -1.90, p < .001). In contrast, global self-esteem of AN and bulimia nervosa (BN) patients was found to be comparable (d = 0.05, p = .529). It might be specific to AN patients that negative self-evaluations may not affect scholastic and professional abilities. Significantly moderate self-esteem increases were observed in treated AN patients at the end of treatment (d = 0.56, p < .001), short-term (d = 0.50, p < .001), and long-term (d = 0.75, p < .001) follow-up. Self-esteem did not predict end of treatment remission-or weight-related outcome and treatment dropout. However, small to moderate predictive effects were detected on short-term (r = .15, p = .007) and long-term remission or weight (r = .33, p = .017). Finally, first indications point to self-esteem as a mediator in adult AN inpatient treatment. DISCUSSION: The review provides insights relevant for theory, research, and practice. Implications concern the overall support for transdiagnostic approaches and the recommendation to consider low initial self-esteem for decisions on after-care.

The change process in adult anorexia nervosa inpatient treatment: a path model.

PURPOSE: Knowledge on the change process in the treatment of anorexia nervosa (AN) is an important starting point for the improvement of treatment, yet very little evidence exists. In an exploratory analysis, we aimed to investigate the interdependencies between higher-rank change process factors, BMI and AN-specific cognitions and behaviours over the course of inpatient treatment. METHODS: We included 176 female adult AN inpatients from three specialized centres. The temporal interdependencies between the change factors and the outcome variables over the course of treatment (t0: beginning, t1: mid-treatment, t2: end) were investigated using a path model. RESULTS: The sample had a mean age of 27.1 years (SD = 8.9 years) and a mean BMI at admission of 15.0 kg/m2 (SD = 1.6 kg/m2). A greater basic need satisfaction and a greater emotional involvement and commitment to treatment at t0 positively influenced the BMI at t1. Furthermore, greater basic need satisfaction at t0 led to less AN-specific cognitions and behaviours at t2. CONCLUSIONS: The results are discussed with respect to the self-determination theory and the consistency theory. Further research on the change process in AN treatment is recommended.

A bottom-up approach to assess verbal therapeutic techniques. Development of the Psychodynamic Interventions List (PIL).

OBJECTIVE: Knowing which specific verbal techniques "good" therapists use in their daily work is important for training and evaluation purposes. In order to systematize what is being practiced in the field, our aim was to empirically identify verbal techniques applied in psychodynamic sessions and to differentiate them according to their basic semantic features using a bottom-up, qualitative approach. METHOD: Mixed-Method-Design: In a comprehensive qualitative study, types of techniques were identified at the level of utterances based on transcribed psychodynamic therapy sessions using Qualitative Content Analysis (4211 utterances). The definitions of the identified categories were successively refined and modified until saturation was achieved. In a subsequent quantitative study, inter-rater reliability was assessed both at the level of utterances (n = 8717) and at the session level (n = 38). The convergent validity of the categories was investigated by analyzing associations with the Interpretive and Supportive Technique Scale (ISTS). RESULTS: The inductive approach resulted in a classification system with 37 categories (Psychodynamic Interventions List, PIL). According to their semantic content, the categories can be allocated to three dimensions: form (24 categories), thematic content (9) and temporal focus (4). Most categories showed good or excellent inter-rater reliability and expected associations with the ISTS were predominantly confirmed. The rare use of the residual category "Other" suggests that the identified categories might comprehensively describe the breadth of applied techniques. CONCLUSIONS: The atheoretical orientation and the clear focus on overt linguistic features should enable the PIL to be used without intensive training or prior theoretical knowledge. The PIL can be used to investigate the links between verbal techniques derived from practice and micro-outcomes (at the session level) as well as the overall therapeutic outcomes. This approach might enable us to determine to what extent the outcome of therapy is due to unintended or non-theoretically relevant techniques.

Hospital utilization outcome of an assertive outreach model for schizophrenic patients - results of a quasi-experimental study.

We assessed whether an Assertive Outreach (AO) program for patients with schizophrenia implemented in German routine care in rural areas reduces psychiatric hospital admissions and/or psychiatric hospital days. We conducted a quasi-experimental controlled study with 5 assessments in 12 months. Data collection included health care utilization (Client Sociodemographic and Service Receipt Inventory), and clinical parameters. The assessments took place in the practices of the psychiatrists. Admission incidence rates were calculated. For bivariate group comparison, we used U-tests, T-tests and Chi(2)-Tests, multivariate analysis was conducted using zero-inflated regression models. For hospital outcomes, data of 295 patients was analysed. No statistically significant differences between AO and TAU patients in terms of hospital admissions or hospital days were found. Overall hospital utilization was low (8%). Advantages of AO over TAU referring to hospital utilization were not found. However, a spill-over effect might have reduced hospital utilization in both groups. Further research should differentiate patient subgroups. These two appear to be key factors to explain effects or absence of effects and to draw conclusions for the mental health care delivery.

[Prevention and Treatment of Eating Disorders: The Health Care Network Anorexia and Bulimia nervosa]. / Prävention und Versorgung von Essstörungen: Das Gesundheitsnetz Magersucht und Bulimie.

The "Health care network anorexia and bulimia nervosa", a subproject of psychenet - the Hamburg network for mental health - aims to decrease the incidence of eating disorders as well as the risk for chronic illness courses. One focal project, therefore, evaluates a school-based prevention manual in a randomized controlled trial. The other one examines the impact of a systemic public health intervention on early treatment initiation in anorexia nervosa. The present article provides an overview about study design and interventions in both focal projects as well as preliminary results.

Aggregating factors of the change process in the treatment of anorexia nervosa.

PURPOSE: We aimed to reduce the large body of factors which may be associated with the change process in treatments for Anorexia Nervosa (AN) into a clinically and scientifically useful number of higher-rank dimensions. In addition, we examined the associations between the identified factors and eating disorder psychopathology and body mass index (BMI) in exploratory analyses. METHODS: Within a naturalistic multicenter study we administered the Change Process Questionnaire (CPQ-AN) to inpatients with AN upon admission. The factorial structure of the CPQ-AN was explored via factor analysis. Multiple regression analyses were performed to examine the associations with BMI and eating disorder symptomatology (EDI-2). RESULTS: In total 233 female inpatients with AN (mean BMI=14.9 kg/m(2), SD=1.7) participated. The factor analysis yielded four latent factors: basic need satisfaction, AN-specific cognitions and behavior, emotional involvement and commitment to treatment, and alliance and treatment confidence. Furthermore, greater basic need satisfaction and less AN-specific cognitions and behavior predicted lower EDI-2 scores. Higher alliance and treatment confidence were associated with higher BMI as well as a lower EDI-2 score. CONCLUSION: The associations between the newly derived dimensions and BMI and AN-psychopathology provide evidence to support the clinical relevance of the identified change process dimensions. Future investigations could provide further insights to deepen our understanding of the change process in AN.

[The techniques of the psychodynamic therapist: verbal interventions from a theoretical and practice-oriented perspective ]. / Das Werkzeug des psychodynamischen Psychotherapeuten - verbale Interventionstypen aus theoretischer und aus der Praxis abgeleiteter Perspektive.

OBJECTIVES: To date we have only a limited understanding of the concrete verbal intervention techniques used in psychodynamic psychotherapy. In particular, there is no standard classification of these techniques. METHODS AND RESULTS: We analyzed the various types of verbal psychodynamic interventions from a theoretical perspective and looked at the issues relating to the definition and operationalization of these techniques. A list of different intervention types described in the theoretical literature was compiled and the varying definitions were compared. In addition, we developed a classification system to reflect the use of intervention types employed in psychodynamic practice. Qualitatively analyzed session transcripts formed the basis of this new classification system. The interventions were classified in terms of conversational technique (24 categories), thematic content (9 categories), and temporal focus (4 categories). CONCLUSIONS: Empirical research in this field necessitates clear operational definitions and the unambiguous use of related terms. We developed a classification system in order to systematize and operationalize different types of interventions. It can be used for process research and to summarize specific techniques used in psychotherapy training.

Effectiveness and efficiency of assertive outreach for Schizophrenia in Germany: study protocol on a pragmatic quasi-experimental controlled trial.

BACKGROUND: A model of assertive outreach (AO) in which office-based psychiatrists collaborate with ambulatory nursing services for providing intensive home-treatment is currently being implemented in rural areas of Lower Saxony, Germany. The costs of the model are reimbursed by some of the statutory health insurance companies active in Lower Saxony. Effectiveness and efficiency of this model for patients suffering from schizophrenia is evaluated in a pragmatic and prospective trial. METHODS: Quasi-experimental controlled trial: patients receiving the intervention are all those receiving AO; controls are patients not eligible for AO based on their health insurance affiliation. ELIGIBILITY CRITERIA: clinical diagnosis of schizophrenia (ICD-10 F.20), aged at least 18 years and being moderately to severely impaired in global functioning. PRIMARY OUTCOME: admission and days spent in psychiatric inpatient care; secondary outcomes: clinical and functional status; patient satisfaction with chronic care; health care costs. Follow-up time: 6 and 12 months. DISCUSSION: The study faces many challenges typical to pragmatic trials such as the rejection of randomisation by service providers, the quality of treatment as usual (TAU) to which the intervention will be compared, and the impairment of the study subjects. Solutions of how to deal with these challenges are presented and discussed in detail. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number: http://ISRCTN34900108, German Clinical Trial Register: http://DRKS00003351.

[A literature- and expert-based analysis of the outpatient treatment of depressive ill people in Germany]. / Eine literatur- und expertengestützte Analyse der Versorgungspraxis von depressiv erkrankten Menschen in Deutschland.

OBJECTIVE: This study analyses deficits in outpatient care for depressed persons in Germany and seeks to identify possibilities for improvement. METHOD: Literature search and expert interviews. RESULTS: The outpatient depression care does not consider guidelines. A numerous possibilities to optimise outpatient treatment of depressive ill people were identified. CONCLUSIONS: Incentives should be systematically set to encourage services that are specific for treating chronic disorders. Systematic incentive for the improvement of the outpatient depression care should be given for example in particular for the achievements, which are important for the care of chronic disorders.

Instability and discontinuous change in the experience of therapeutic interaction: an extended single-case study of psychodynamic therapy processes.

The authors developed a concept that applies self-organization theory to psychodynamic principles. According to this concept, episodes of temporary destabilization represent a precondition for abrupt changes within the therapeutic process. The authors examined six courses of therapy (patients diagnosed with depression and personality disorder). After each therapy session, patients rated their experience of the therapeutic interaction. A measure of instability was used to identify episodes of destabilization with respect to patients' interaction experience throughout the process. Episodes of pronounced destabilization occurred in the four courses of therapy that showed better therapy outcomes. These episodes were characterized by temporary strong deteriorations in interaction experience (negative peaks). Three of the four courses showed subsequent discontinuous improvements to a higher level of interaction. Results indicate that the systematic inclusion of a measure of instability is worthwhile in investigations of discontinuous changes. This method allows the theoretical assumptions of the psychodynamic approach to be tested.