Routine monitoring of therapeutic alliance to predict treatment engagement in a Veterans Affairs substance use disorders clinic.

Measurement-based care (MBC) can improve mental health treatment outcomes and is a priority within the Department of Veterans Affairs (VA). However, to date, MBC efforts within the VA have focused on assessment of psychological symptoms to the exclusion of psychotherapy process variables such as the therapeutic alliance that may predict treatment response. This quality improvement project involved the implementation of routine monitoring of alliance within a VA substance use disorder (SUD) clinic predominantly serving veterans with serious mental illness. Alliance ratings were provided by 98 veterans following group therapy sessions. Low alliance ratings were used by the clinicians (n = 4) leading the groups (n = 9) as opportunities to discuss veterans' treatment experience and increase engagement. Using multilevel models that accounted for the nested nature of the data and veteran demographics, alliance ratings showed a small increase over time (B = 0.075, p < .001, f2 = 0.033). In addition, maximum alliance rating (i.e., patients' highest rating of alliance across all observations) was significantly but modestly associated with attendance at both MBC group sessions and all SUD-related visits in the 3 months following the initial alliance rating (Bs = 0.96 and 1.79; ps = .006 and .004; f2s = 0.079 and 0.088, respectively). Average alliance rating, however, was not associated with treatment attendance (ps > .050). Findings suggest that assessment of alliance is feasible within a VA SUD clinic and may provide information signaling risk for disengagement that could be used for increasing treatment engagement. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Computer-Assisted Cognitive-Behavior Therapy for Depression: A Systematic Review and Meta-Analysis.

OBJECTIVE: To evaluate the efficacy of computer-assisted forms of cognitive-behavior therapy for major depressive disorder (MDD) and examine the role of clinician support and other factors that might affect outcomes. DATA SOURCES: Ovid MEDLINE, PsycINFO, PubMed, and Scopus from their beginnings to July 18, 2016. Keywords were "randomized, controlled trials of computer-assisted cognitive-behavior therapy for depression" and "randomized, controlled trials of mobile apps for cognitive-behavior therapy of depression." STUDY SELECTION: Of 223 studies identified in the search, 183 were excluded yielding a sample of 40 randomized, controlled investigations of computer-assisted cognitive-behavior therapy (CCBT) for depression. DATA EXTRACTION: Data were abstracted independently by two authors, and consensus was reached by discussion with a third author. RESULTS: The overall mean effect size for CCBT compared to control conditions was g = 0.502, a moderately large effect. Studies that provided support from a clinician or other person yielded significantly larger effects (g = 0.673) than studies in which no support was provided (g = 0.239). Completion rate and study setting also influenced outcomes. Lower mean effect sizes were observed in studies with lower completion rates and in studies conducted in primary care practices. CONCLUSIONS: CCBT with a modest amount of support from a clinician or other helping person was found to be efficacious with relatively large mean effect sizes on measures of depressive symptoms. Self-guided CCBT for depression was considerably less effective. Future research should focus on enhancing the implementation of CCBT, including evaluating the amount and type of support needed for effective delivery, methods to improve engagement with computer-assisted therapies, and ways to improve treatment outcome in primary care settings.

Dissemination of computer-assisted cognitive-behavior therapy for depression in primary care.

Computer-assisted cognitive-behavior therapy (CCBT) for depression in primary care will be evaluated in a trial with 240 patients randomly assigned to CCBT or treatment as usual (TAU). The study will disseminate a therapy method found to be effective in psychiatric settings into primary care - a setting in which there have been significant problems in the delivery of adequate, evidence-based treatment for depression. The study will include a high percentage of disadvantaged (low-income) patients - a population that has been largely ignored in previous research in CCBT. There have been no previous studies of CCBT for depression in primary care that have enrolled large numbers of disadvantaged patients. The form of CCBT used in this study is designed to increase access to effective therapy, provide a cost-effective method, and be a sustainable model for wide-spread use in primary care. In order to deliver therapy in a practical manner that can be replicated in other primary care practices, patients with significant symptoms of depression will receive treatment with an empirically supported computer program that builds cognitive-behavior therapy skills. Support for CCBT will be provided by telephone and/or e-mail contact with a care coordinator (CC) instead of face-to-face treatment with a cognitive-behavior therapist. Outcome will be assessed by measuring CCBT completion rate, comprehension of CBT concepts, and satisfaction with treatment, in addition to ratings of depressive symptoms, negative thoughts, and quality of life. The cost-effectiveness analysis and exploration of possible predictors of outcome should help clinicians, health care organizations, and others plan further dissemination of CCBT in primary care.

Computer-Assisted Cognitive-Behavior Therapy for Depression in Primary Care: Systematic Review and Meta-Analysis.

OBJECTIVE: To examine evidence for the effectiveness of computer-assisted cognitive-behavior therapy (CCBT) for depression in primary care and assess the impact of therapist-supported CCBT versus self-guided CCBT. METHODS: A search for randomized studies of CCBT compared to control groups for treating depression in primary care settings was conducted using Ovid MEDLINE, PsycINFO, PubMed, and Scopus. We extracted the following information from the studies that met inclusion criteria: mean depression rating scale scores before and after treatment, number of patients, type of control group and CCBT program, therapist support time and method of support, and treatment completion rate. Meta-analyses compared differences between posttreatment mean scores in each condition, as well as mean scores at follow-up. Study quality and possible bias also were assessed. RESULTS: Eight studies of CCBT for depression in primary care met inclusion criteria. The overall effect size was g = 0.258, indicating a small but significant advantage for CCBT over control conditions. Therapist support was provided in 4 of the 8 studies. The effect size for therapist-supported CCBT was g = 0.372-a moderate effect. However, the effect size for self-guided CCBT was g = 0.038, indicating little effect. CONCLUSIONS: Implementation of therapist-supported CCBT in primary care settings could enhance treatment efficiency, reduce cost, and improve access to effective treatment for depression. However, evidence to date suggests that self-guided CCBT offers no benefits over usual primary care.

Good-enough level and dose-effect models: Variation among outcomes and therapists.

OBJECTIVE: The current study examined the good-enough level (GEL) and dose-effect model on three outcome variables: well-being, symptom distress, and life functioning, while accounting for therapist effects. The dose-effect model assumes the rate of change is consistent across clients, and the GEL model assumes that the rate of change will vary according to the total length of treatment. METHOD: The sample included 13,664 clients who completed 2-100 sessions of therapy. RESULTS: The GEL model was a better fit to the data compared to the dose-effect model for all outcomes. There were fewer changes in life functioning compared to well-being and symptom distress for clients. There were significant therapist effects for changes in symptom distress and life functioning, but not for the rates of change in well-being. CONCLUSION: Therapists should consider the rates of change for their own clients as well as by outcome.

Relationship between interpretation, alliance, and outcome in psychodynamic psychotherapy: control of therapist effects and assessment of moderator variable impact.

The current study examines the relationship between therapist interpretations in the early stages of psychodynamic psychotherapy and subsequent outcomes for 76 outpatients. Pre-treatment characteristics of global symptomatology, personality pathology, insight, and level of object relations were examined as possible significant patient characteristics. Independent clinicians reliably rated therapist use of interpretations over two early treatment sessions (third and ninth). Patient-rated alliance was also examined as a possible psychotherapy process predictor of change. Therapy outcomes were measured based on patients' changes in global symptomatology and estimates of improvement across a broad range of functioning at the end of treatment. An examination of the study independent variables revealed significant relationships between pre-treatment personality disorder symptomatology with patient object relations (OR), patient OR with pre-treatment insight, and pre-treatment insight with use of therapist interpretation. Pre-treatment symptomatology and early treatment interpretations predicted reliable change in global symptomatology. Patients' estimates of improvement across a broad band of functioning were most significantly impacted by quality of alliance. Analysis of these outcome relationships controlled for therapist effects. Statistical implications of therapist effects are discussed in regard to this area of research and future directions for investigation are explored.

Therapeutic alliance in the personal therapy of graduate clinicians: relationship to the alliance and outcomes of their patients.

UNLABELLED: This is the first study to explore the relationship between aspects of a therapists' personal therapy and the subsequent psychotherapy process and outcome they perform. The participants were 14 graduate clinicians with various experiences in personal therapy, who treated 54 outpatients engaged in short-term psychodynamic psychotherapy at a university-based community clinic. Results demonstrated non-significant relationships between the duration of personal therapy as well as a graduate clinician's overall alliance in their personal therapy with alliance ratings made by themselves as therapists and their patients, as well as the number of psychotherapy sessions attended by patients. However, the clinician's personal therapy alliance was significant and positively related to their patients' rating of outcome. Additionally, a significant negative correlation was observed between the degree of perceived helpfulness in their personal therapy and how these clinicians rated alliances, as the therapist, with their patients. The current findings suggest a relationship between a clinician's personal therapy alliance and the outcome of treatments they conduct. Implications for clinical training and practice as well as future research are discussed. KEY PRACTITIONER MESSAGE: While graduate clinician's personal therapy alliance was not significantly related to their patients' ratings of alliance, it was related to their patients' ratings of outcome. Trainee satisfaction with or quality of their personal therapy may be a more relevant than the amount or duration of their treatment in regard to the process and outcomes of their patients. The findings from retrospective clinician surveys on the helpfulness of their personal therapy may not be entirely consistent with empirical examination of these issues. The relation of personal therapy and outcome may work through improving the therapist's level of adaptive functioning (i.e., psychological-relational-emotional health) and future research should examine this simpler, more parsimonious, explanation for our findings.

Relationship education in community settings: effectiveness with distressed and non-distressed low-income racial minority couples.

Couple relationship education (CRE) programs are intended to prevent negative couple outcomes, however, some evidence suggests couples in greater distress may still benefit. The current study examined pre- and postchanges in relationship functioning of 362 low-income African American and Hispanic couples. Outcomes (dedication and communication) were assessed by examining differences between two distinct groupings of couples; distressed (both partners reporting clinically significant distress) and nondistressed (neither partner reporting clinically significant distress) couples. Distressed couples at predemonstrated large-sized gains in all outcome variables, as compared to nondistressed couples. Those who participated in the single-couple format demonstrated lower gains in positive communication as compared to those in the group format. Implications for distressed couples in CRE programs are offered.

Benchmarking outcomes in a public behavioral health setting: feedback as a quality improvement strategy.

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of a large public behavioral health (PBH) agency serving only clients at or below the federal poverty level that had implemented continuous outcome feedback as a quality improvement strategy. METHOD: The authors investigated the post treatment outcomes of 5,168 individuals seeking treatment for a broad range of diagnoses who completed at least 2 psychotherapy sessions. The Outcome Rating Scale (ORS; Duncan, 2011; Miller & Duncan, 2004) was used to measure outcomes. Clients had a mean age of 36.7 years and were predominantly female (60.7%) and White (67.8%), with 17.7% being Hispanic, 9.3% being African American, and 2.8% being Native American. Forty-six percent were diagnosed with depression, mood, and anxiety disorders; 18.8% were diagnosed with substance abuse disorders; and 14.4% were diagnosed with bipolar disorder and schizophrenia. A subset of clients with a primary diagnosis of a depressive disorder was compared to treatment efficacy benchmarks derived from clinical trials of major depression. Given that the PBH agency had also implemented an outcome management system, the total sample was also compared to benchmarks derived from clinical trials of continuous outcome feedback. RESULTS: Treatment effect sizes of psychotherapy delivered at the PBH agency were comparable to effect size estimates of clinical trials of depression and feedback. Observed effect sizes were smaller, however, when compared to feedback benchmarks that used the ORS. CONCLUSIONS: Services to the poor and disabled can be effective, and continuous outcome feedback may be a viable means both to improve outcomes and to narrow the gap between research and practice.

The influence of demand characteristics and social desirability on clients' ratings of the therapeutic alliance.

OBJECTIVE: To examine demand characteristics, social desirability on clients' rating of working alliance using the Session Rating Scale (SRS; Miller, Duncan, & Johnson, 2000). METHOD: Clients (N = 102) at two sites were randomly assigned to one of three alliance feedback conditions: (a) IF--SRS completed in presence of therapist and the results discussed immediately afterward; (b) Next Session Feedback--SRS completed alone and results discussed next session; or (c) No Feedback--SRS completed alone and results not available to therapist. Clients completed the SRS for the first three sessions of treatment. RESULTS: No statistically significant differences in SRS scores across the feedback conditions were found. Additionally, the analysis showed that SRS scores were not correlated with a measure of social desirability but were correlated with an established alliance measure. CONCLUSIONS: The results indicate that alliance scores were not inflated due to the presence of a therapist or knowing that the scores would be observed by the therapist.

Differences among trainees in client outcomes associated with the phase model of change.

This study investigated psychotherapy trainees' ability to facilitate change in outcomes (e.g., well-being, symptom reduction, and life functioning) specifically related to the phase model. Four different psychotherapist experience levels (beginning practicum, advanced practicum, intern/postdoc, and psychologist) were compared to determine whether there are training differences related to significant change for psychotherapy outcomes according to the phase model. A total of 1,318 clients from a university counseling center, treated by 64 psychotherapists, were included in the analysis for this study. Results indicate that interns/postdocs' clients achieve more significant change than psychologists' and advanced practicum students' clients related to life functioning. In addition, interns/postdocs' clients achieve more significant change related to symptom reduction, when compared with the clients of psychologists. Implications for these results, given the hypotheses of both the phase model and competency models, are discussed.

Patient early session experience and treatment outcome.

Patient Session Evaluation Questionnaire (SEQ: Stiles, 1980) ratings from early in treatment were examined in relation to outcomes during psychodynamic psychotherapy. Twenty-eight therapists treated 73 patients at a university-based clinic. A relationship between Smoothness ratings and symptom improvement approached statistical significance using bivariate correlations and multilevel analyses. A significant relationship was found between Positivity ratings and a broad scale of patient-rated functional improvement across many domains (i.e., psychopathology, interpersonal, occupational, and social) before and after accounting for therapist effects.

Clients' perceptions of their psychotherapists' multicultural orientation.

The current retrospective study examined whether clients' (N = 176) perceptions of their psychotherapists' multicultural orientation (MCO) were associated with their psychological functioning, working alliance, and real relationship scores. Moreover, we tested whether clients' perceptions of the working alliance and the real relationship mediated the relationship between clients' perceptions of their psychotherapists' MCO and psychological functioning. The results showed that clients' perceptions of their psychotherapists' MCO were positively related to working alliance, real relationship, and psychological functioning. Only clients' ratings of the working alliance mediated the relationship between clients' perceptions of their psychotherapists' MCO and psychological functioning. Thus, because clients perceive their psychotherapists as being more oriented toward cultural issues, they may view the therapist as being more credible and may gain a sense of comfort in the therapeutic process. In turn, clients' strong alliance facilitates improvement in psychological well-being.

The role of leaders' working alliance in premarital education.

Premarital (and general relationship) education programs, as a prevention method, have been shown to have a positive effect on marital quality and can prevent divorce. However, it is unclear whether these positive effects are consistent across leaders who conduct premarital education programs. Examining the variability in relationship outcomes attributed to the leaders of premarital education programs, and the role of general therapeutic factors such as working alliance in explaining relationship outcomes, may help increase the effectiveness of these programs. Accordingly, this study examined 31 leaders who trained 118 couples (236 attendees) in a randomized clinical trial of the Prevention and Relationship Enhancement Program (PREP), a research-based and empirically supported premarital education program being compared with a treatment as usual track. The results demonstrated that couples' relationship outcomes from pre- to post-training varied on the basis of the leader who provided the premarital education training. Both training in PREP and aggregated leader working alliance quality (as rated by attendees) explained variability between leaders in change in attendees' observed negative and positive communication. Leaders' aggregated working alliance quality also explained change in relationship satisfaction. In addition, attendees' ratings of their leaders' working alliance predicted change in their relationship satisfaction and confidence, and attendees had higher positive communication when they reported better working alliance with their leader.

The relationship between therapist and client hope with therapy outcomes.

The current study examined whether clients' perceptions of hope and therapists' hope in their clients were associated with therapy outcomes. The authors conducted a naturalistic study of brief therapy with 10 therapists and 43 adult clients. Client-rated hope significantly increased after one session of therapy. However, no significant relationship was found between pretherapy client-rated hope and first-session symptom change. Further, client-rated hope at any point in therapy was not significantly related to therapy outcomes. Therapists' hope in their clients after the first and last sessions was significantly related to client outcomes. Implications for therapy practice and research are offered.

"Hooking up" among college students: demographic and psychosocial correlates.

This study investigated 832 college students' experiences with hooking up, a term that refers to a range of physically intimate behavior (e.g., passionate kissing, oral sex, and intercourse) that occurs outside of a committed relationship. Specifically, we examined how five demographic variables (sex, ethnicity, parental income, parental divorce, and religiosity) and six psychosocial factors (e.g., attachment styles, alcohol use, psychological well-being, attitudes about hooking up, and perceptions of the family environment) related to whether individuals had hooked up in the past year. Results showed that similar proportions of men and women had hooked up but students of color were less likely to hook up than Caucasian students. More alcohol use, more favorable attitudes toward hooking up, and higher parental income were associated with a higher likelihood of having hooked up at least once in the past year. Positive, ambivalent, and negative emotional reactions to the hooking up experience(s) were also examined. Women were less likely to report that hooking up was a positive emotional experience than men. Young adults who reported negative and ambivalent emotional reactions to hooking up also reported lower psychological well-being and less favorable attitudes toward hooking up as compared to students who reported a positive hooking up experience. Based on these findings, suggestions for psychoeducational programming are offered. Additionally, directions for future research are provided.