The Effectiveness of Dialectical Behavior Therapy Compared to Schema Therapy for Borderline Personality Disorder: A Randomized Clinical Trial.

INTRODUCTION: In the treatment of borderline personality disorder (BPD), there is empirical support for both dialectical behavior therapy (DBT) and schema therapy (ST); these treatments have never been compared directly. This study examines whether either of them is more effective than the other in treating patients with BPD. METHODS: In this randomized, parallel-group, rater-blind clinical trial, outpatients aged between 18 and 65 years with a primary diagnosis of BPD were recruited in a tertiary outpatient treatment center (Lübeck, Germany). Participants were randomized to DBT or ST with one individual and one group session per week over 1.5 years. The primary outcome was the BPD symptom severity assessed with the mean score of the Borderline Personality Disorder Severity Index at 1-year naturalistic follow-up. RESULTS: Between November 26, 2014, and December 14, 2018, we enrolled 164 patients (mean age = 33.7 [SD = 10.61] years). Of these, 81 (49.4%) were treated with ST and 83 (50.6%) with DBT, overall, 130 (79.3%) were female. Intention-to-treat analysis with generalized linear mixed models did not show a significant difference at 1-year naturalistic follow-up between DBT and ST for the BPDSI total score (mean difference 3.32 [95% CI: -0.58-7.22], p = 0.094, d = -24 [-0.69; 0.20]) with lower scores for DBT. Pre-to-follow-up effect sizes were large in both groups (DBT: d = 2.45 [1.88-3.02], ST: d = 1.78 [1.26-2.29]). CONCLUSION: Patients in both treatment groups showed substantial improvements indicating that even severely affected patients with BPD and various comorbid disorders can be treated successfully with DBT and ST. An additional non-inferiority trial is needed to show if both treatments are equally effective. The trial was retrospectively registered on the German Clinical Trials Register, DRKS00011534 without protocol changes.

Good-Enough Therapy: A Review of the Empirical Basis of Good Psychiatric Management.

In this review, the question of whether good psychiatric management (GPM) has a sufficient, or good-enough, evidence base is examined from two complementary perspectives. First, the author reviews research that has investigated whether GPM reduces symptoms of borderline personality disorder. Analyses at the group and individual levels have indicated that symptoms may decrease among patients receiving GPM. Second, the author reviews research that has investigated the processes through which change occurs in GPM. Studies that have shown process changes toward emotional balance, interpersonally effective functioning, and a more coherent and reality-based autobiographical narrative are discussed. To fully answer the question of whether GPM is good enough, more controlled trials are needed to demonstrate effectiveness, mechanisms of change, and broad implementation in culturally diverse populations.

Does Researcher Allegiance Bias Outcomes in Psychotherapy Research? A Quasi-Experimental Secondary Analysis.

Researchers who conduct studies comparing the efficacy of two treatments often find that their preferred treatment outperforms the comparison treatment. This finding has been labelled the allegiance association. Although this association is robust, it is unclear whether it reflects an allegiance bias on the part of the researchers or whether it is noncausal, with researchers being allied to the more effective treatments. This study applied a quasi-experimental method proposed by a previous study to 19 pairs of treatment comparison studies. Each member of a pair had used the same two psychotherapies to treat clients with the same disorder, but the researchers in each of the two studies had opposing allegiances. If the authors of one study in the pair concluded that their preferred treatment was superior and the authors of the other study concluded that their preferred treatment was superior or that the two treatments were equivalent, these patterns would suggest allegiance bias. In 10 of the 19 pairs, the patterns were consistent with the operation of an allegiance bias, indicating that although allegiance biases are not inevitable, they are ubiquitous. Practitioners and other psychotherapy research consumers should use caution when interpreting the findings from treatment comparison studies.

Online psychotherapy as a first clinical experience during the Covid-19 pandemic: A new generation of psychotherapists in the digital age.

The temporary closure of the Outpatient Psychotherapy Clinic at the Sigmund Freud Private University in Vienna during the Covid-19 pandemic demanded an immediate and unexpected reaction to assure further psychotherapeutic services. Both psychotherapists and patients were forced into a rapid transition to online psychotherapy. While Covid-19 research has comprehensively described challenges of online psychotherapies, we were interested in learning specifically how early stage psychotherapists-in-training, who started their clinical work with patients exclusively in the online setting, experienced this unprecedented clinical situation. Sixteen in-depth interviews were conducted with psychotherapists in training. The data were analyzed using a thematic analysis. The analysis revealed how psychotherapists in training were able to cultivate a set of early-training resources and competencies in the online therapy setting without evidence-based guidelines from supervisors and the institution. This study highlighted the necessity of incorporating specific and novel educational input that is necessary for achieving specific online skills in the early training phase. Recognizing that the therapeutic landscape has undergone an irreversible transformation, the data suggest that distinct techniques are necessary to equip early-training psychotherapists for the now commonly practiced alternation between online setting and in-person setting in psychotherapeutic processes.

Implementation of an Ecological Momentary Assessment (EMA) in Naturalistic Psychotherapy Settings: Qualitative Insights from Patients, Therapists, and Supervisors Perspectives.

Ecological momentary assessment (EMA) allows measuring intra-individual processes moment by moment, identifying and modeling, in a naturalistic way, individual levels and changes in different psychological processes. However, active EMA requires a high degree of adherence, as it implies a significant burden for patients. Moreover, there is still no consensus on standardized procedures for implementation. There have been few results in detecting desirable characteristics for the design and implementation of an EMA device. Studies that address these issues from the perspectives of participants in psychotherapeutic processes are needed. To analyze the perspectives of patients, therapists and supervisors on the implementation of an EMA device in a psychotherapeutic treatment for depression. The sample will include eight patients, eleven therapists and five supervisors, taken from a research project that implemented an EMA system for monitoring the dynamics of affectivity at the beginning of psychotherapies for depression. Semi-structured interviews specific to each group are being conducted and analyzed from a qualitative approach based on consensual qualitative research (CQR). Participants reported having a positive evaluation of the study's informational resources and implementation. Difficulties were expressed in responding in the morning hours and the importance of having a customized EMA that is tailored to the needs of the patients was expressed. Furthermore, patients and therapists agreed that the impact of the use of the monitoring system on treatment was neutral or positive. In contrast, patients considered the EMA to be positive for their daily life.

Measuring Alliance and Symptom Severity in Psychotherapy Transcripts Using Bert Topic Modeling.

We aim to use topic modeling, an approach for discovering clusters of related words ("topics"), to predict symptom severity and therapeutic alliance in psychotherapy transcripts, while also identifying the most important topics and overarching themes for prediction. We analyzed 552 psychotherapy transcripts from 124 patients. Using BERTopic (Grootendorst, 2022), we extracted 250 topics each for patient and therapist speech. These topics were used to predict symptom severity and alliance with various competing machine-learning methods. Sensitivity analyses were calculated for a model based on 50 topics, LDA-based topic modeling, and a bigram model. Additionally, we grouped topics into themes using qualitative analysis and identified key topics and themes with eXplainable Artificial Intelligence (XAI). Symptom severity could be predicted with highest accuracy by patient topics ( r =0.45, 95%-CI 0.40, 0.51), whereas alliance was better predicted by therapist topics ( r =0.20, 95%-CI 0.16, 0.24). Drivers for symptom severity were themes related to health and negative experiences. Lower alliance was correlated with various themes, especially psychotherapy framework, income, and everyday life. This analysis shows the potential of using topic modeling in psychotherapy research allowing to predict several treatment-relevant metrics with reasonable accuracy. Further, the use of XAI allows for an analysis of the individual predictive value of topics and themes. Limitations entail heterogeneity across different topic modeling hyperparameters and a relatively small sample size.

Effectiveness of Schema Therapy versus Cognitive Behavioral Therapy versus Supportive Therapy for Depression in Inpatient and Day Clinic Settings: A Randomized Clinical Trial.

INTRODUCTION: Schema therapy (ST) reduces depressive symptoms, but clinical trials have not investigated its effectiveness for patients suffering from severe forms of depression and high rates of comorbidities. There is high demand for exploring and improving treatments for this patient group. The objective of the current study was to evaluate whether ST is more effective than individual supportive therapy (IST) and noninferior compared with cognitive behavioral therapy (CBT) in treating depression. METHODS: For this clinical trial, medicated patients were recruited in inpatient and day clinic settings. The major inclusion criteria were age between 18 and 75 years and primary diagnosis of depression without psychotic symptoms. A total of 292 participants were randomized to ST, CBT, or IST and received 7 weeks of psychotherapy (up to 14 individual and 14 group sessions). The primary outcome was change in depression severity after treatment measured by Beck Depression Inventory-II. Primary test for efficacy was superiority of ST over IST. Secondary test was noninferiority of ST compared with CBT. Multilevel modeling was conducted. The results at 6-month follow-up were explored. RESULTS: Across treatment, ST was not superior to IST. Secondary outcome analyses and completer analyses showed similar results. However, ST showed clinically relevant noninferiority compared with CBT. CONCLUSION: ST for depression as part of a psychiatric care program showed clinical noninferiority compared to CBT, without being superior to IST. ST represents a potentially useful addition to the therapeutic repertoire for the treatment of depression but its efficacy, including long-term efficacy, should be evaluated further.

The utility of completing adjuvant video lessons based on the unified protocol during psychotherapy: A retrospective study using a telehealth platform in routine clinical care.

Digital supplements to tele-psychotherapy are increasingly needed. The purpose of this retrospective study was to investigate the association between outcomes and the use of supplemental video lessons based on the Unified Protocol (UP), an empirically supported transdiagnostic treatment.Participants included 7,326 adults in psychotherapy for depression and/or anxiety. Partial correlations were calculated between number of UP video lessons completed and change in outcomes after 10 weeks, controlling for number of therapy sessions and baseline scores. Then, participants were divided into those who did not complete any UP video lessons (n = 2355) and those who completed at least 7/10 video lessons (n = 549), and propensity-matched on 14 covariates. Repeated measures analysis of variance compared these groups (n = 401 in each group) on outcomes.Among the entire sample, symptom severity decreased as the number of UP video lessons completed increased, with the exception of lessons on avoidance and exposure. Those watching at least 7 lessons showed significantly greater reduction in both depression and anxiety symptoms than those who did not watch any.Viewing supplemental UP video lessons in addition to tele-psychotherapy had a positive and significant association with symptom improvement and may provide an additional tool for clinicians to implement UP components virtually.

Predictors of Effects in Brief Psychiatric Treatment for Borderline Personality Disorder.

If evidence points to the equal efficacy of all bona fide treatments for borderline personality disorder (BPD) in general, it may not necessarily be true for a specific individual, nor do such general conclusions help in the triage of clients in clinical services. We investigated potential therapy outcome predictors for participants with a BPD diagnosis (N = 99). They were assessed on scales including the Outcome Questionnaire-45.2 (OQ-45), the Inventory of Interpersonal Problems-64, and the Borderline Symptom List. Our analyses revealed that individuals with low levels of symptom distress at intake had the smallest change in total OQ-45 score over the course of brief treatment, while the individuals with high levels of symptom distress had a mean large change in total score (-23). We observed that individuals with high symptom loads AND low levels of interpersonal problems at intake seemed to have the best progress.

Effects of a Web-Based Behavioral Activation Intervention on Depressive Symptoms, Activation, Motivation, and Volition: Results of a Randomized Controlled Trial.

INTRODUCTION: Behavioral activation (BA) is effective for the treatment of depression. The Health Action Process Approach (HAPA), which is derived from health psychology, can provide a motivational-volitional framework of BA. OBJECTIVE: This study investigated the efficacy of a HAPA-based internet-delivered BA intervention (iBA; called InterAKTIV) in individuals with depression, also assessing HAPA-based motivational and volitional outcomes. METHODS: In a two-arm randomized controlled efficacy trial with a parallel design, 128 participants with a major depressive episode were randomly allocated to the intervention group (IG; TAU + immediate access to iBA) or control group (CG; TAU + access to iBA after follow-up). The primary outcome of clinician-rated depressive symptoms and secondary outcomes were assessed at baseline (T1), 8 weeks (T2), 6-month after randomization (T3). Data were analyzed on an intention-to-treat basis. RESULTS: Linear mixed model analyses revealed a significant group*time interaction effect on clinician-rated depressive symptoms favoring the IG (F2, 156.0 = 7.40; p < 0.001, d = 0.79 at T2, d = 0.25 at T3). The IG was also superior regarding self-rated depressive symptoms, BA, most motivational, and all volitional outcomes. CONCLUSION: This study shows that HAPA-based iBA can significantly improve clinician-rated depressive symptoms, as well as outcomes used in the HAPA model in people with depression. Building on these efficacy results, in the next step, the relationship between BA interventions and activity levels should be investigated, taking into account motivation and volition as potential mediators.

Hair cortisol as outcome parameter for psychological and neuropsychiatric interventions-a literature review.

Background: Studies measuring hair cortisol concentration (HCC) have been increasingly conducted to document stress-related, endocrine changes aggregated over time. Previous studies have shown that HCC reflects abnormalities in the hypothalamic-pituitary-adrenocortical axis (HPA axis) in the context of somatic diseases, such as Cushing's syndrome. HCC variations also reveal a corresponding alteration in HPA-axis-function in mental disorders, highlighting its potential role as a biomarker for interventions targeting mental health problems. Aims: The aim of this study was to investigate the role of HCC in various psychological and neuropsychiatric interventions and to explore the extent to which HCC can serve as a predictive or outcome parameter in such interventions by conducting a PRISMA-compliant review of the literature. Methods: From May to July 2022, the databases Web of Science, Google Scholar, PsychINFO, and ResearchGate were systematically searched using different combinations of relevant keywords. Studies of different types that examined HCC in the context of a wide range of psychological and neuropsychiatric interventions were included. Studies in languages other than English or German and animal studies were excluded. The MMAT tool was used, to assesses the Risk of bias. Results: The initial search identified 334 studies. After applying the inclusion and exclusion criteria, 14 publications with a total number of 1,916 participants were identified. An association between HCC and PTSD, depressive disorders, and ongoing social and family stress can be documented. The effect of relaxation techniques, mental training, CBT, or PTSD therapy on HCC has been studied with equivocal results. Some studies found decreased HCC after treatment, while others did not show a clear effect. Baseline HCC appears to be of particular importance. In some studies, higher baseline HCC was associated with increased treatment response, providing a predictive value for HCC. Discussion: HCC is increasingly being used as a biomarker for the mapping of psychological and neuropsychiatric interventions. However, due to the wide range of study populations and interventions, results are still heterogeneous. Nevertheless, HCC seems to be an encouraging biological parameter to describe the trajectory of different interventions aimed at improving mental health.

Evaluating Change in Transference, Interpersonal Functioning, and Trust Processes in the Treatment of Borderline Personality Disorder: A Single-Case Study Using Ecological Momentary Assessment.

Transference-focused psychotherapy (TFP) is an empirically supported treatment for borderline personality disorder (BPD) that improves functioning via targeting representations of self affectively relating to others, particularly as evoked in the therapeutic relationship. If change in TFP operates as theorized, then shifts in patterns of "self affectively relating to others" should be observed in the transference prior to shifts in daily relationships. Using ecological momentary assessment (EMA), a patient with BPD rated daily interpersonal events for 2-week periods during 18 months of TFP; at 9 and 18 months these ratings included interactions with the therapist. Results suggest that positive perceptions of her therapist that ran counter to her negatively biased perception in other relationships preceded changes in her perceptions of others. EMA shifts corresponded to improvements in self-reported symptoms, interview-based personality functioning, and therapist assessments. Implications for assimilation of a trusting experience with the therapist as a mechanism of change in TFP are discussed.

Leveraging Novel Technologies and Artificial Intelligence to Advance Practice-Oriented Research.

Mental health services are experiencing notable transformations as innovative technologies and artificial intelligence (AI) are increasingly utilized in a growing number of studies and services.These cutting-edge technologies carry the promise of substantial improvements in the field of mental health. Nevertheless, questions emerge about the alignment of novel technologies and AI systems with human needs, especially in the context of vulnerable populations receiving mental healthcare. The practice-oriented research (POR) model is pivotal in seamlessly integrating these emerging technologies into clinical research and practice. It underscores the importance of tight collaboration between clinicians and researchers, all driven by the central goal of ensuring and elevating client well-being. This paper focuses on how novel technologies can enhance the POR model and highlights its pivotal role in integrating these technologies into clinical research and practice. We discuss two key phases: pre-treatment, and during treatment. For each phase, we describe the challenges, present the major technological innovations, describe recent studies exemplifying technology use, and suggest future directions. Ethical concerns and the importance of aligning humans and technology are also considered, in addition to implications for practice and training.

Short-term intervention complemented by wearable technology improves Trichotillomania - A naturalistic single-case report.

There is a growing interest in using wearable technology for the treatment of body-focused repetitive behaviors (BFRBs), such as Trichotillomania. Yet, to our knowledge, few studies address the applicability and use of wearable technology as a therapeutic element in more naturalistic situations. Here we would like to introduce its potential use combined with a Habit-Reversal Training in a single-case experimental design. In practice, individuals with BFRBs frequently show complex constellations of psychiatric disorders. Accordingly, the here presented participant was diagnosed with Trichotillomania as well as comorbid ADHD and examination phobia. The participant was offered to wear an unobtrusive and user-friendly vibration device that sent an alarm when her critical hairpulling behaviors occurred. The complementing Habit-Reversal Training included an Awareness Training supported by the vibration alarm of the wearable device. It further included a Competing Response Training by learning benign behaviors that could replace the hairpulling behavior. The frequency of hairpulling episodes was assessed using daily self-reports and by using the monitoring function of the wearable device. The intervention procedure was implemented into the participant's everyday life and evaluated over the course of 214 days. The results indicated a significant reduction in the daily episodes of hair pulling. Our preliminary findings suggest that the here applied intervention has the potential to effectively treat Trichotillomania in individuals with comorbid disorders in psychotherapeutic outpatient care. Certainly, group-studies will need to further validate the approach's effectiveness.

The Silent Treatment?: Changes in patient emotional expression after silence.

Psychotherapy can be an emotionally laden conversation, where both verbal and non-verbal interventions may impact the therapeutic process. Prior research has postulated mixed results in how clients emotionally react following a silence after the therapist is finished talking, potentially due to studying a limited range of silences with primarily qualitative and self-report methodologies. A quantitative exploration may illuminate new findings. Utilizing research and automatic data processing from the field of linguistics, we analysed the full range of silence lengths (0.2 to 24.01 seconds), and measures of emotional expression - vocally encoded arousal and emotional valence from the works spoken - of 84 audio recordings Motivational Interviewing sessions. We hypothesized that both the level and the variance of client emotional expression would change as a function of silence length, however, due to the mixed results in the literature the direction of emotional change was unclear. We conducted a multilevel linear regression to examine how the level of client emotional expression changed across silence length, and an ANOVA to examine the variability of client emotional expression across silence lengths. Results indicated in both analyses that as silence length increased, emotional expression largely remained the same. Broadly, we demonstrated a weak connection between silence length and emotional expression, indicating no persuasive evidence that silence leads to client emotional processing and expression.

Teamwork solutions for complex problems in psychotherapy: A systems thinking-based commentary.

INTRODUCTION: Most psychological treatments are administered in a one-to-one therapy format, which has proven effective but has limitations in complex clinical situations. Teamwork can help address these limitations by going beyond the one-to-one therapy approach and involving the client's professional and relational network in therapy interventions to promote and secure change. In this issue of Journal of Clinical Psychology: In Session five effective teamwork practices are presented illustrating how clinicians integrate teamwork into treatment delivery to improve outcomes in an array of cases presenting high complexity. PURPOSE: In this commentary section, we describe the role and essence of these teamwork practices from a systems thinking approach as a theoretical umbrella to understand the diversity of processes hindering and facilitating effective teamwork CONCLUSSION: From this approach we discuss the core skills that psychotherapists should train to master team working and interprofessional collaboration. The basic professional competence consists in the ability to foster and coordinate shared frames of understanding in case formulation. An advanced systemic skill is based on the ability to formulate and change relational patterns, given that interpersonal processes are the main key factor to understand barriers and facilitators of effective teamwork to overcome stalemated complex clinical situations.

Synchrony in psychotherapy: High physiological positive concordance predicts symptom reduction and negative concordance predicts symptom aggravation.

OBJECTIVE: Therapeutic alliance is often considered as a predictor for therapeutic success. This study explored dyadic synchrony of skin conductance response (SCR) during naturalistic therapeutic interactions and investigated its potential as an objective biomarker for predicting therapy effectiveness. METHODS: In this proof-of-concept study, skin conductance from both dyad members was continuously measured via wristbands during psychotherapy. Patients and therapists completed post-session reports capturing their subjective appraisal of therapeutic alliance. Additionally, patients completed symptom questionnaires. Each therapeutic dyad was recorded twice in a follow-up design. The first session of the follow-up group was assessed for physiological synchrony (Single Session Index (SSI)). Therapy outcome was captured by the difference between symptom severity scores over time. RESULTS: SCR synchrony significantly predicted the outcome variable of change in patients' global severity index (GSI). High positive SCR concordance was linked to a reduction in patients' GSI, while negative or small positive SSI values were linked to an increase in patients' GSI. CONCLUSION: The results demonstrate the presence of SCR synchrony in clinical interactions. Skin conductance response synchrony was a significant predictor for change in patients' symptom severity index, emphasizing its potential as an objective biomarker in the context of evidence-based psychotherapy.

Virtual Reality Exposure to a Healthy Weight Body Is a Promising Adjunct Treatment for Anorexia Nervosa.

INTRODUCTION/OBJECTIVE: Treatment results of anorexia nervosa (AN) are modest, with fear of weight gain being a strong predictor of treatment outcome and relapse. Here, we present a virtual reality (VR) setup for exposure to healthy weight and evaluate its potential as an adjunct treatment for AN. METHODS: In two studies, we investigate VR experience and clinical effects of VR exposure to higher weight in 20 women with high weight concern or shape concern and in 20 women with AN. RESULTS: In study 1, 90% of participants (18/20) reported symptoms of high arousal but verbalized low to medium levels of fear. Study 2 demonstrated that VR exposure to healthy weight induced high arousal in patients with AN and yielded a trend that four sessions of exposure improved fear of weight gain. Explorative analyses revealed three clusters of individual reactions to exposure, which need further exploration. CONCLUSIONS: VR exposure is a well-accepted and powerful tool for evoking fear of weight gain in patients with AN. We observed a statistical trend that repeated virtual exposure to healthy weight improved fear of weight gain with large effect sizes. Further studies are needed to determine the mechanisms and differential effects.

Research evidence on psychotherapist skills and methods: Foreword and afterword.

This article serves as both the foreword and the afterword to the special section of Psychotherapy Research devoted to research reviews of psychotherapist skills and methods: it introduces the interorganizational Task Force that guided the reviews and then features its conclusions. We begin by operationally defining therapist skills and methods and then contrasting them with other components of psychotherapy. Next, we consider the typical assessment of skills and methods and how they are linked with outcomes (immediate in-session, intermediate, and distal) in the research literature. We summarize the strength of the research evidence on the skills and methods reviewed in the 8 articles in this special section and in the companion special issue in Psychotherapy. We end with diversity considerations, research limitations, and the formal conclusions of the interorganizational Task Force on Psychotherapy Skills and Methods that Work.