The Impact of Mental Imagery Instructions on Patients' and Therapists' Positive Affect and Strength-Based Behaviours Within Psychotherapy Sessions: A Randomized Controlled Process Study.

OBJECTIVE: Increased attention has recently been paid to the well-being and flourishing of patients in psychotherapy. This study investigated the occurrence of positive affect (PA) and strength-based behaviours within psychotherapy sessions contrasting positive versus neutral imagery instructions. METHODS: This is a secondary analysis of a randomized controlled trial. Seventy-eight sessions of cognitive behavioural therapy involving 26 patients (69.23% female; Mage = 40.31) treated by 13 therapists were selected. PA and strength-based behaviours of patients and therapists were coded on a minute-by-minute basis with the Resource-Oriented Microprocess Analysis. Each session started with a brief mental imagery instruction. Data were analysed using multilevel modelling. RESULTS: Mild levels of PA were very common, whereas stronger expressions were occasional, especially at the beginning and end of sessions. Strength-based behaviours were employed in one-fifth of the videos analysed. Therapists in the positive imagery instruction showed more strength-based behaviours in the beginning phase of sessions, p < 0.05. The two imagery instructions significantly differed in the session trajectories of PA, p < 0.05. A quadratic trend with higher initial values and a sharper decline in PA were found in the positive instruction, whereas the neutral instruction showed a flatter trend. CONCLUSION: Patients and therapists experience PA and discuss strengths in psychotherapy sessions despite patients' distress. The positive imagery instructions potentially induced a positive focus at baseline for therapists but had a negligible effect on the subsequent session progression. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03767101 (registered December 6, 2018).

Love yourself as a therapist, doubt yourself as an institution? Therapist and institution effects on outcome, treatment length, and dropout.

OBJECTIVE: Research suggests that some therapists achieve better outcomes than others. However, an overlooked area of study is how institution differences impact patient outcomes independent of therapist variance. This study aimed to examine the role of institution and therapist differences in adult outpatient psychotherapy. METHOD: The study included 1428 patients who were treated by 196 therapists at 10 clinics. Two- and three-level hierarchical linear regression models were employed to investigate the effects of therapists and institutions on three dependent patient variables: (1) symptom change, (2) treatment duration, and (3) dropout. Level three explanatory variables were tested. RESULTS: The results showed that therapist effects (TE) were significant for all three types of treatment outcome (7.8%-18.2%). When a third level (institution) was added to the model, the differences between therapists decreased, and significant institution effects (IE) were found: 6.3% for symptom change, 10.6% for treatment duration, and 6.5% for dropout. The exploratory analyses found no predictors able to explain the systematic variation at the institution level. DISCUSSION: TE on psychotherapy outcomes remain a relevant factor but may have been overestimated in previous studies due to not properly distinguishing them from differences at the institution level.

A Mental Imagery Micro-Intervention to Increase Positive Affect in Outpatient CBT Sessions (PACIfIC): Study Protocol of a Randomized Controlled Implementation Trial.

Background: Recent findings indicated that mental disorders are associated with both an up-regulation of negative affect and a down-regulation of positive affect (PA) as distinct processes. Established treatment approaches focus on the modification of problems and negative affect only. Experimental paradigms in healthy samples and research on strengths-based approaches showed that fostering PA may improve psychotherapy process and outcome. Specific and easily implementable interventions targeting PA in treatment sessions are scarce. Mental imagery was shown to be a promising strategy for boosting positive emotional experiences. Method: The PACIfIC-study is planned as a longitudinal randomized-controlled trial in the context of cognitive behavioral therapy, implemented at a German outpatient training and research center. In the process analysis, trajectories of PA over the first twelve treatment sessions will be examined with weekly questionnaires. In the intervention analysis, a six-minute positive mental imagery intervention to enhance PA will be developed and tested. The intervention is implemented with loudspeakers at the beginning of each session for a standardized induction of PA. The experimental group will be compared to an active control group (neutral mental imagery) and treatment as usual. Procedures in all treatment arms are parallelized. Main outcomes after twelve sessions of psychotherapy will be psychosocial resources, resilience and self-esteem (theory-driven), as well as psychopathology and working alliance (secondary outcome). Multilevel modeling will be conducted to address the nested data structure. Conclusion: Study results may have implications on the consideration of positive constructs in mental disorders and the implementation of strengths-based interventions in psychotherapy.

An exploratory study of patients' sudden losses during outpatient CBT and therapists' experience of difficulties.

OBJECTIVE: Patients' sudden deterioration in symptomatology, also called sudden losses, is a rarely explored phenomenon. METHOD: Psychological distress of 1,763 patients treated by 140 therapists was monitored after every therapy session. Patient-reported outcome measures and patients' therapy satisfaction was assessed. Therapists rated their experience of difficulties for every patient repeatedly over the course of therapy. RESULTS: More than one-quarter of patients (26.5%) experienced at least one sudden loss during therapy. Patients with sudden losses did not differ significantly in psychotherapy outcome and therapy satisfaction from patients without sudden shifts. Therapists did not experience professional self-doubt more often when working with sudden loss patients. CONCLUSION: Sudden losses were not necessarily harmful for the outcome of psychotherapy and patients' global therapy satisfaction. The results suggest that sudden losses can be compensated over the course of treatment.

Psychotherapist trainees' professional self-doubt and negative personal reaction: Changes during cognitive behavioral therapy and association with patient progress.

OBJECTIVE: This study examined psychotherapist trainees' experiences of "professional self-doubt" (PSD) and "negative personal reaction" (NPR) during cognitive behavioral therapy (CBT) and their associations with patients' symptoms and interpersonal problems. METHOD: Forty therapists treating 621 patients were analyzed. Patients' symptoms and interpersonal problems were collected repeatedly during therapy. Data about patients' interpersonal problems were available only for 106 patients and 18 therapists. Therapists' difficulties were assessed as trait-based (one assessment across all patients) and as state-based (repeated assessments for each individual patient) difficulties. Multilevel models were performed. RESULTS: None of the trait-based difficulties correlated with the change of the patients' symptoms. Yet, more NPR at the trait-level predicted a more favorable change, whereas higher PSD at the trait-level showed an opposite effect on change of patients' interpersonal problems. Regarding state-based difficulties, PSD as well as NPR decreased significantly over the course of CBT. Patients whose therapists' experienced PSD to increase during CBT were at risk of a less favorable patient progress regarding symptoms, whereas the change of interpersonal problems was not significantly associated with changes in therapists' difficulties. CONCLUSION: Patients' progress is associated with therapists' experiences of difficulties. Yet, trait- and state-based difficulties lead to different results.