Psychotherapists' outcome expectations: How are they established?

Therapists' outcome expectations influence the psychotherapy process and outcomes, but little is known about the factors influencing their development. This study explored therapists' experiences with establishing outcome expectations for their patients. The participants were 35 therapists from a public mental health setting, who were interviewed in five different focus groups. Interviews were transcribed and analyzed using thematic analysis. Three themes and 10 subthemes were identified. In Theme 1 (understanding the problem), participants' expectations were influenced by (a) their patients' diagnoses and the diagnostic process, (b) their perceptions of the complexity of the presenting problem, (c) how stable the patients' symptoms and situations were, and (d) whether they experienced familiarity with the patient or the patients' situation. In Theme 2 (the patient's openness to change), participants' expectations were influenced by (a) the patient's stated reason for seeking treatment, (b) the patient's conceptualization of their problem/situation, and (c) their perception of the patient's willingness to invest in the treatment. In Theme 3 (the fit between the therapist and patient), the participants discussed the factors that influenced whether they felt they were a good fit for working with an individual patient and how this perception of personal and professional fit influenced their expectations. We identify several ways that therapists' situational factors and their recognition of the patient through their own past experiences can influence their expectations. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Case report: A dual case study of how clinical feedback can be a communication aide and influence therapeutic work.

Background: While routine outcome monitoring and clinical feedback may improve outcomes after psychotherapy, results from efficiency studies have been mixed. Moreover, how clinical feedback is implemented influences how it works for patients and clinicians, and working mechanisms are hitherto not thoroughly explored. Researchers have argued that inviting and using feedback from patients is best conceived of as a clinical skill. In this paper, we use case study methodology to explore and describe feedback's functions within three clinical skill themes: actualizing alliance work, concretizing change and stagnation and verbalizing the non-verbal. Case presentation: Sonja is a young adult patient with a trauma background. She has a history of serious suicide attempts and distrust in relationships. She attended psychotherapy for eight months. Harald is a middle-aged man with a stable family. Traumatic events in his past has made him conceal own needs and developing depression. He attended psychotherapy for 19 months. Case material include the patient's clinical feedback over a range of life areas, medical health notes and the therapist's process notes. Conclusion: Clinical feedback can be a positive supplement to the therapeutic work and process. The importance of making this as a joint tool between the client and the therapist is significant.

Cost structure in specialist mental healthcare: what are the main drivers of the most expensive episodes?

BACKGROUND: Mental disorders are one of the costliest conditions to treat in Norway, and research into the costs of specialist mental healthcare are needed. The purpose of this article is to present a cost structure and to investigate the variables that have the greatest impact on high-cost episodes. METHODS: Patient-level cost data and clinic information during 2018-2021 were analyzed (N = 180,220). Cost structure was examined using two accounting approaches. A generalized linear model was used to explain major cost drivers of the 1%, 5%, and 10% most expensive episodes, adjusting for patients' demographic characteristics [gender, age], clinical factors [length of stay (LOS), admission type, care type, diagnosis], and administrative information [number of planned consultations, first hospital visits, interval between two hospital episode]. RESULTS: One percent of episodes utilized 57% of total resources. Labor costs accounted for 87% of total costs. The more expensive an episode was, the greater the ratio of the inpatient (ward) cost was. Among the top-10%, 5%, and 1% most expensive groups, ward costs accounted for, respectively, 89%, 93%, and 99% of the total cost, whereas the overall average was 67%. Longer LOS, ambulatory services, surgical interventions, organic disorders, and schizophrenia were identified as the major cost drivers of the total cost, in general. In particular, LOS, ambulatory services, and schizophrenia were the factors that increased costs in expensive subgroups. The "first hospital visit" and "a very short hospital re-visit" were associated with a cost increase, whereas "the number of planned consultations" was associated with a cost decrease. CONCLUSIONS: The specialist mental healthcare division has a unique cost structure. Given that resources are utilized intensively at the early stage of care, improving the initial flow of hospital care can contribute to efficient resource utilization. Our study found empirical evidence that planned outpatient consultations may be associated with a reduced health care burden in the long-term.

Relationship and Alliance Formation Processes in Psychotherapy: A Dual-Perspective Qualitative Study.

Objective: To explore how therapists and clients act dyadically to establish a therapeutic relationship during the first five sessions of psychotherapy. The study aimed to identify both relational facilitative and hindering processes occurring in routine care. Methods: Using the method 'interpersonal process recall' (IPR), we videotaped the third and fifth session of 12 psychotherapy dyads, and conducted video-assisted interviews with each therapist and client separately. In total, the data material consist of 47 IPR interviews. Data were analyzed using a thematic approach. Results: The analysis process revealed two main groups. The first group consisted of dyads with a positive relational outcome, and the second group consisted of dyads with a troubled or frail relational outcome. During the initial phase of therapy, clients described feeling overwhelmed by fear and shame. Positive relational development occurred when these emotions were successfully accommodated and replaced with a growing sense of safety with the therapist. However, the relationship became troubled when the client experienced an increase in shame and/or fear during the first sessions. When forming a therapeutic relationship, it is vital that the client experience the therapist as genuine and skilled, and that the therapist is able to engage and connect deeply with the client on a person-to-person level. The article further provides a discussion on how these dyadic experiences align with the working alliance and real relationship, and how the two consolidate during the first sessions of psychotherapy. Conclusion: The current study explored the complex relational processes underlying the formation of the therapeutic relationship. Core aspects of the real relationship are prerequisites to forming a collaborative working alliance in which both therapist and client are actively engaged. Facilitating a positive relationship is crucial in the early phase of psychotherapy, and therapists can actively identify and repair ruptures at this time.