Modeling therapist responses with structured practice enhances facilitative interpersonal skills.

OBJECTIVE: Facilitative interpersonal skills (FIS) video stimuli were used to develop and test a brief training component of observational modeling with repeated practice. Specifically, this study hypothesized that a brief training of video modeling therapeutic use of interpersonal skills, combined with repeated practice, would result in improved FIS responses (relative to control). METHOD: Undergraduates (n = 101) with expressed interest in the helping professions were randomly assigned to Modeled Practice or Control conditions. After a baseline, participants in Modeled Practice observed model responses and then repeatedly practiced different responses, while those in the Control group observed videos comparable in format, but nontherapeutic in content. Participants then gave responses to different simulated clients, which were used to assess hypotheses. RESULTS: FIS for Modeled Practice was significantly higher than controls in postpractice. CONCLUSIONS: Result provides empirical support for training in practice strategy components and has implications for therapeutic deliberate practice training.

Mindfulness practice predicts interleukin-6 responses to a mindfulness-based alcohol relapse prevention intervention.

Chronic alcohol misuse can result in chronically elevated interleukin (IL)-6, a pro-inflammatory cytokine, in the bloodstream. Given that Mindfulness-Based Relapse Prevention (MBRP) has been shown to reduce alcohol misuse, MBRP might also be effective in reducing IL-6 concentrations. Past research has found, however, that IL-6 does not respond consistently to mindfulness-based interventions. Building on prior studies, we examined whether between-person variability in engagement with mindfulness training (i.e., formal mindfulness practice time) is associated with between-person variability in changes in serum IL-6, using data from a randomized controlled trial evaluating MBRP for Alcohol Dependence (MBRP-A). Participants were 72 alcohol dependent adults (mean age = 43.4 years, 63.9% male, 93.1% White) who received a minimum dose (i.e., at least four sessions) of MBRP-A either at the start of the trial (n = 46) or after a 26-week delay (n = 26). IL-6 concentrations did not significantly change from pre- to post-intervention for the full sample. Nevertheless, greater mindfulness practice time was significantly associated with reduced IL-6 levels (r = -0.27). The association between practice time and IL-6 changes remained significant when controlling for intervention timing (i.e., immediate or after the 26-week delay), demographic characteristics, and changes in mindful awareness, obsessive-compulsive drinking, and depressive symptoms. The association between practice time and IL-6 changes was not significant when omitting the minimum treatment dose requirement. Overall, results suggest that the level of engagement in mindfulness training may predict changes in the inflammatory pathophysiology in adults with alcohol dependence.

Mindfulness-based relapse prevention for alcohol dependence: Findings from a randomized controlled trial.

OBJECTIVES: To assess the effects of mindfulness-based relapse prevention for alcohol dependence (MBRP-A) intervention on drinking and related consequences. METHODS: 123 alcohol-dependent adults in early recovery, recruited from outpatient treatment programs, were randomly assigned to MBRP-A (intervention plus usual-care; N = 64) or Control (usual-care-alone; N = 59) group. MBRP-A consisted of eight-weekly sessions and home practice. Outcomes were assessed at baseline, 8 weeks and 26 weeks (18 weeks post-intervention), and compared between groups using repeated measures analysis. RESULTS: Outcome analysis included 112 participants (57 MBRP-A; 55 Control) who provided follow-up data. Participants were 41.0 ±â€¯12.2 years old, 56.2% male, and 91% white. Prior to "quit date," they reported drinking on 59.4 ±â€¯34.8% (averaging 6.1 ±â€¯5.0 drinks/day) and heavy drinking (HD) on 50.4 ±â€¯35.5% of days. Their drinking reduced after the "quit date" (before enrollment) to 0.4 ±â€¯1.7% (HD: 0.1 ±â€¯0.7%) of days. At 26 weeks, the MBRP-A and control groups reported any drinking on 11.5 ±â€¯22.5% and 5.9 ±â€¯11.6% of days and HD on 4.5 ±â€¯9.3% and 3.2 ±â€¯8.7% of days, respectively, without between-group differences (ps ≥ 0.05) in drinking or related consequences during the follow-up period. Three MBRP-A participants reported "relapse," defined as three-consecutive HD days, during the study. Subgroup analysis indicated that greater adherence to session attendance and weekly home practice minutes were associated with improved outcomes. CONCLUSIONS: MBRP-A as an adjunct to usual-care did not show to improve outcomes in alcohol-dependent adults in early recovery compared to usual-care-alone; a return to drinking and relapse to HD were rare in both groups. However, greater adherence to MBRP-A intervention may improve long-term drinking-related outcomes.

Lack of emotional clarity and diminished self-efficacy as core problems in functional dependency: A structural equation modeling analysis with a college student sample.

BACKGROUND: High levels of functional dependency appear to be deleterious to psychological and physical health. The goal of this research was to identify factors responsible for the association between functional dependency and negative health outcomes. METHODS: Self-report data were collected from 149 undergraduate students. Structural equation modeling was used to test a model in which functional dependency has indirect effects on three negative psychological outcomes (negative affect, functional impairment, and dissatisfaction with life) through two variables: lack of experiential awareness and diminished self-efficacy. RESULTS: The model provided a good fit to the data and five of the six indirect effects were statistically significant. LIMITATIONS: Limitations include self-report and cross-sectional nature of the data. CONCLUSIONS: These results help to shed light on the core pathology in functional dependency and implicate specific interventions in treating problems associated with this personality trait.

Brief Mindfulness-Based Interventions for Acute and Chronic Pain: A Systematic Review.

OBJECTIVES: Nonpharmacologic approaches have been characterized as the preferred means to treat chronic noncancer pain by the Centers for Disease Control and Prevention. There is evidence that mindfulness-based interventions (MBIs) are effective for pain management, yet the typical MBI may not be feasible across many clinical settings due to resource and time constraints. Brief MBIs (BMBIs) could prove to be more feasible and pragmatic for safe treatment of pain. The aim of the present article is to systematically review evidence of BMBI's effects on acute and chronic pain outcomes in humans. METHODS: A literature search was conducted using PubMed, PsycINFO, and Google Scholar and by examining the references of retrieved articles. Articles written in English, published up to August 16, 2017, and reporting on the effects of a BMBI (i.e., total contact time <1.5 h, with mindfulness as the primary therapeutic technique) on a pain-related outcome (i.e., pain outcome, pain affect, pain-related function/quality of life, or medication-related outcome) were eligible for inclusion. Two authors independently extracted the data and assessed risk of bias. RESULTS: Twenty studies meeting eligibility criteria were identified. Studies used qualitative (n = 1), within-group (n = 3), or randomized controlled trial (n = 16) designs and were conducted with clinical (n = 6) or nonclinical (i.e., experimentally-induced pain; n = 14) samples. Of the 25 BMBIs tested across the 20 studies, 13 were delivered with audio/video recording only, and 12 were delivered by a provider (participant-provider contact ranged from 3 to 80 min). Existing evidence was limited and inconclusive overall. Nevertheless, BMBIs delivered in a particular format-by a provider and lasting more than 5 min-showed some promise in the management of acute pain. CONCLUSIONS: More rigorous large scale studies conducted with pain populations are needed before unequivocally recommending BMBI as a first-line treatment for acute or chronic pain.

Early psychotherapeutic empathy, alliance, and client outcome: Preliminary evidence of indirect effects.

The association between psychotherapeutic empathy and client outcome is well established, yet the mechanisms underlying this association remain poorly understood. We hypothesized that early experiences of empathy influence outcome through the working alliance. To test this hypothesis, we used archival data collected from 56 clients (mean [M] age = 19.5 years, 83.9% female, 76.8% White) who reported mild, moderate, or severe depressive symptoms at screening and pretreatment assessments and then received five sessions of evidence-based psychotherapy. Therapists (M age = 26.0 years, 50% female, 100% White) were six students in a clinical psychology PhD program. Results of bootstrap analyses were consistent with the idea that early experiences of empathy strengthen the alliance (specifically the goals and tasks facets), which in turn facilitates improvements in depressive symptoms and psychological well-being. While preliminary, these results implicate a specific pathway of change in the treatment of depression.

Working Alliance, Interpersonal Problems, and Depressive Symptoms in Tele-Interpersonal Psychotherapy for HIV-infected Rural Persons: Evidence for Indirect Effects.

OBJECTIVE: Interpersonal psychotherapy (IPT) has demonstrated efficacy for the treatment of depression, yet little is known about its therapeutic mechanisms. As a specific treatment, IPT has been shown to directly reduce depressive symptoms, although it is unclear whether these reductions occur via interpersonal changes. Within IPT, the potential role of the working alliance, a common factor, as a predictor of depression and interpersonal changes is also unclear. METHOD: Participants were 147 depressed persons living with HIV in rural communities of 28 U.S. states enrolled in a randomized clinical trial. Seventy-five patients received up to 9 sessions of telephone-administered IPT (tele-IPT) plus standard care and 72 patients received standard care only. Two models were tested; one included treatment condition (tele-IPT vs. control) and another included the working alliance as independent variables. RESULTS: The first model found an indirect effect whereby tele-IPT reduced depression via decreased social avoidance. There was a direct effect between tele-IPT and reduced depression. In the second model, the working alliance influenced depressive symptom relief via reductions in social avoidance. Both goal and task working alliance subscales were indirectly associated with reductions in depressive symptoms, also through reductions in social avoidance. There were no direct effects involving the working alliance. Tele-IPT's influence on depressive symptom reduction was primarily through a direct effect, whereas the influence of working alliance depression was almost entirely via an indirect effect through interpersonal problems. CONCLUSION: Study findings have implications for IPT when intervening with depressed rural people living with HIV/AIDS over the telephone.

Enhancing psychotherapy process with common factors feedback: A randomized, clinical trial.

In this study, we developed and tested a common factors feedback (CFF) system. The CFF system was designed to provide ongoing feedback to clients and therapists about client ratings of three common factors: (a) outcome expectations, (b) empathy, and (c) the therapeutic alliance. We evaluated the CFF system using randomized, clinical trial (RCT) methodology. PARTICIPANTS: Clients were 79 undergraduates who reported mild, moderate, or severe depressive symptoms at screening and pretreatment assessments. These clients were randomized to either: (a) treatment as usual (TAU) or (b) treatment as usual plus the CFF system (TAU + CFF). Both conditions entailed 5 weekly sessions of evidence-based therapy delivered by doctoral students in clinical psychology. Clients completed measures of common factors (i.e., outcome expectations, empathy, therapeutic alliance) and outcome at each session. Clients and therapists in TAU + CFF received feedback on client ratings of common factors at the beginning of Sessions 2 through 5. When surveyed, clients and therapists indicated that that they were satisfied with the CFF system and found it useful. Multilevel modeling revealed that TAU + CFF clients reported larger gains in perceived empathy and alliance over the course of treatment compared with TAU clients. No between-groups effects were found for outcome expectations or treatment outcome. These results imply that our CFF system was well received and has the potential to improve therapy process for clients with depressive symptoms. (PsycINFO Database Record

Development and Validation of a Six-Item Version of the Interpersonal Dependency Inventory.

The Interpersonal Dependency Inventory (IDI) is a frequently used, 48-item measure of maladaptive dependency. Our goal was to develop and psychometrically evaluate a very brief version of the IDI. An exploratory factor analysis of the IDI in Study 1 ( N = 838) yielded a six-item IDI (IDI-6), with three items loading on an emotional dependency factor (IDI-6-ED), and the other three items loading on a functional dependency factor (IDI-6-FD). This factor solution was validated by confirmatory factor analysis in Study 2 ( N = 916). The IDI-6-ED and IDI-6-FD demonstrated good convergent and divergent validity in Study 3 ( N = 100). In Study 4 ( N = 22-43), the IDI-6-ED and IDI-6-FD were generally stable over 4-week and 8-week intervals and were found to be responsive to the effects of psychological treatment. These results have implications for dependency conceptualizations and support the IDI-6 as a brief, psychometrically sound instrument.

Empathy from the client's perspective: A grounded theory analysis.

Although empathy is one of most robust predictors of client outcome, there is little consensus about how best to conceptualize this construct. OBJECTIVE: The aim of the present research was to investigate clients' perceptions and in-session experiences of empathy. METHOD: Semi-structured, video-assisted interpersonal process recall interviews were used to collect data from nine clients receiving individual psychotherapy at a university psychology clinic. RESULTS: Grounded theory analysis yielded a model consisting of three clusters: (1) relational context of empathy (i.e., personal relationship and professional relationship), (2) types of empathy (i.e., psychotherapists' cognitive empathy, psychotherapists' emotional empathy, and client attunement to psychotherapist), and (3) utility of empathy (i.e., process-related benefits and client-related benefits). CONCLUSIONS: These results suggest that empathy is a multi-dimensional, interactional process that affects-and is affected by-the broader relationship between client and psychotherapist.

A prospective study of therapist facilitative interpersonal skills as a predictor of treatment outcome.

OBJECTIVE: This study examined whether therapists' facilitative interpersonal skills (FIS) would prospectively predict the outcomes of therapies that occurred more than one year later. METHOD: Therapists were 44 clinical psychology trainees who completed the FIS performance task and a self-reported measure of social skills in the initial weeks of their training. In the FIS task, prospective therapists were presented with a standard set of videos portraying clients in therapy. Verbal responses to these therapeutic simulations were recorded and then rated by trained coders. More than one year later, the therapists began providing psychotherapy to clients in a psychology clinic. Clients completed a symptom measure before each therapy session. RESULTS: Using multilevel modeling, it was found that therapist FIS significantly predicted client symptom change. That is, higher FIS therapists were more effective than lower FIS therapists. However, subsequent analyses showed that this FIS effect was not uniform across all therapy durations; specifically, higher FIS therapists were more effective than lower FIS therapists over shorter durations (e.g., ≤8 sessions) but did not differ from lower FIS therapists in effectiveness for the small percentage of therapies that were longer-term (e.g., >16 sessions). CONCLUSIONS: Therapists' interpersonal characteristics may influence client progress in therapy.

An investigation of client mood in the initial and final sessions of cognitive-behavioral therapy and psychodynamic-interpersonal therapy.

OBJECTIVE: Our aim was to examine client mood in the initial and final sessions of cognitive-behavioral therapy (CBT) and psychodynamic-interpersonal therapy (PIT) and to determine how client mood is related to therapy outcomes. METHODS: Hierarchical linear modeling was applied to data from a clinical trial comparing CBT with PIT. In this trial, client mood was assessed before and after sessions with the Session Evaluation Questionnaire-Positivity Subscale (SEQ-P). RESULTS: In the initial sessions, CBT clients had higher pre-session and post-session SEQ-P ratings and greater pre-to-post session mood change than did clients in PIT. In the final sessions, these pre, post, and change scores were generally equivalent across CBT and PIT. CBT outcome was predicted by pre- and post-session SEQ-P ratings from both the initial sessions and the final sessions of CBT. However, PIT outcome was predicted by pre- and post-session SEQ-P ratings from the final sessions only. Pre-to-post session mood change was unrelated to outcome in both treatments. CONCLUSIONS: These results suggest different change processes are at work in CBT and PIT.

Mindfulness Therapy for Maladaptive Interpersonal Dependency: A Preliminary Randomized Controlled Trial.

Existing treatments for maladaptive interpersonal dependency and dependent personality disorder do not meet basic scientific standards for effectiveness. The present investigation tested the efficacy of a mindfulness-based approach: mindfulness therapy for maladaptive interpersonal dependency (MT-MID). Forty-eight participants who reported consistently high levels of maladaptive dependency (i.e., scored higher than 1 standard deviation above the mean on the Interpersonal Dependency Inventory at two separate assessments) were randomized to either 5 sessions of MT-MID or a minimal contact control. Five self-reported outcomes (mindfulness, maladaptive interpersonal dependency, helplessness, fears of negative evaluation, and excessive reassurance seeking) were assessed at pretreatment, posttreatment, and a 4-week follow-up. Intent-to-treat analyses indicated that MT-MID yielded greater improvements than the control on all 5 outcomes at posttreatment (median d=1.61) and follow-up (median d=1.51). Participants assigned to MT-MID were more likely than control participants to meet criteria for clinically significant change at posttreatment (56.5% vs. 0%) and follow-up (42.9% vs. 0%). There was also evidence that increases in mindfulness mediated the dependency-related improvements. These results provide preliminary support for the efficacy of a mindfulness-based approach for treating the symptoms of maladaptive dependency.

The early formation of the working alliance from the client's perspective: A qualitative study.

This research used qualitative methods and archival data to examine clients' perceptions of the early formation of the working alliance. Following their first and second sessions of individual psychotherapy, 54 clients responded to structured written assignments that were rooted in Bordin's (1979) model of the alliance. Analysis yielded 884 recording units, which were organized into 4 main clusters: (a) clients' initial misgivings about psychotherapy; (b) organization and meaning-making; (c) psychotherapist supportive activities; and (d) client appreciation of techniques. Clients' perceived contributions to alliance development and their experiences of the initial interactions with their psychotherapists are explored in the context of existing theory and research.

Treatment expectations, alliance, session positivity, and outcome: an investigation of a three-path mediation model.

OBJECTIVE: The aim of this study was to test a 3-path mediation model, in which the effect of treatment expectations on outcome is mediated first by the alliance and then by session positivity. METHOD: Archival process and outcome data were used for this investigation. These data had been collected from 116 clients (70% female, 81% White, mean age = 24.1 years), who sought psychotherapy for a variety of reasons at a university-based clinic. RESULTS: Correlation analyses established that clients' treatment expectations, the therapeutic alliance, session positivity, and outcome were significantly related to each other. A bootstrap (data resampling) procedure was employed to test the hypothesized 3-path mediated effect. The results of this analysis were consistent with the hypothesis that high treatment expectations enhance the therapeutic alliance, which contributes to clients feeling positive at the end of sessions and in turn facilitates improvements in symptoms and functioning. CONCLUSION: The current research is the first to provide evidence for this particular model, and thus helps to shed light on the intricacies and underlying dynamics of psychotherapy.

Factorial and predictive validity of the expectations about counseling-brief (EAC-B) with clients seeking counseling.

Our goals in this study were to define the factorial structure of treatment expectations for a sample of treatment-seeking clients and to understand the predictive validity of those expectations. A sample of 353 clients who were about to begin counseling at a university counseling center or at a psychology clinic completed the Expectations About Counseling-Brief form (EAC-B) and then completed measures of the working alliance, session quality, and symptom distress throughout the treatment. Principal components analysis resulted in a 3-factor solution of EAC-B treatment expectations, which accounted for 48.0% of the total variance. Consistent with previous research, the 3 factors were labeled client involvement, counselor expertise, and facilitative conditions. Among clients with prior treatment experience, a meaningful 4-factor solution was achieved; it involved the counselor expertise factor being split into 2 subgroups labeled "counselor directive helping" and "counselor subjective expertise." The predictive validity of these 3 factors found that each of the 3 EAC-B factor-derived scales, as well the total EAC-B score, was predictive of clients' (but not therapists') ratings of the therapeutic alliance as well as ratings of session depth, smoothness, and positivity. Client involvement, facilitative conditions, and EAC-B Total score (but not counselor expertise) predicted therapy outcome.