Pål G. Ulvenes

Different processes for different therapies: therapist actions, therapeutic bond, and outcome.

Therapeutic bond, as a component of the alliance, is considered a common factor in psychotherapy; however, it may operate differently in various treatments. This article investigates therapist actions, particularly affect focus, in the formation of the bond and on reduction of symptoms in short-term dynamic psychotherapy (STDP) and cognitive therapy (CT) for cluster C patients. Forty-six cases (23 STDP and 23 CT) were assessed using the Psychotherapy Process Q-Sort, the Helping Alliance Questionnaire, and the Symptom Checklist 90. These scores were used to determine (a) therapist actions that predict formation of the bond, (b) the relation of the bond to symptom reduction, and (c) how therapist actions and bond interacted to reduce symptoms. Multiple regressions were applied to the total sample and to the STDP and CT cases. Psychotherapy Process Q-Sort items describing avoidance of affects were positively related to the bond in the total sample, STDP and CT. However, the relation between therapist actions, bond, and symptom reduction differed for the two treatments. For STDP, avoidance of affect suppressed the relation of bond to symptom reduction and also negatively influenced symptom reduction. On the other hand, in CT, avoidance of affect was positively related to both the formation of the bond and to symptom reduction. Although the bond is a common factor and important component of the alliance, it appears to operate differently in STDP and CT. A focus on affect is important to the benefits of STDP but interferes with the benefits of CT.

Learning how to rate video-recorded therapy sessions: a practical guide for trainees and advanced clinicians.

Watching and rating psychotherapy sessions is an important yet often overlooked component of psychotherapy training. This article provides a simple and straightforward guide for using one Website (www.ATOStrainer.com) that provides an automated training protocol for rating of psychotherapy sessions. By the end of the article, readers will be able to have the knowledge to go to the Website and begin using this training method as soon as they have a recorded session to view. This article presents, (a) an overview of the Achievement of Therapeutic Objectives Scale (ATOS; McCullough et al., 2003a), a research tool used to rate psychotherapy sessions; (b) a description of APA training tapes, available for purchase from APA Books, that have been rated and scored by ATOS trained clinicians and posted on the Website; (c) step-by-step procedures on how ratings can be done; (d) an introduction to www.ATOStrainer.com where ratings can be entered and compared with expert ratings; and (e) first-hand personal experiences of the authors using this training method and the benefits it affords both trainees and experienced therapists. This psychotherapy training Website has the potential to be a key resource tool for graduate students, researchers, and clinicians. Our long-range goal is to promote the growth of our understanding of psychotherapy and to improve the quality of psychotherapy provided for patients.

Properties of the Achievement of Therapeutic Objectives Scale (ATOS): A Generalizability Theory study

Abstract The psychometric properties of the process instrument Achievement of Therapeutic Objectives Scale (ATOS) were examined in this study. Generalizability Theory (GT) was used to evaluate variability attached to several possible sources of error. A random sample of 24 psychotherapy sessions was selected from a larger RCT trial including Cluster C patients and rated in different rating conditions (rating all scales versus rating a subgroup of the scales). Two G-study designs were used to compute variance components and generalizability coefficients. The results provided evidence that the ATOS is sensitive to differences among patients and to differences among subscales within patients (i.e., to different constructs within the ATOS). Rating condition contributed much to variability in scores when the ATOS scales were examined separately, but this variability was negligible when all scales were included in the same analysis. There was little variability due to raters, which indicates that adequately trained raters are able to apply the ATOS without contributing to measurement error.

Growth in sense of self and sense of others predicts reduction in interpersonal problems in short-term dynamic but not in cognitive therapy

Abstract Objectives: We investigated relationships between sense of self (SoS) and sense of others (SoO) and specific interpersonal problems in short-term dynamic and cognitive therapy. Method: 40 patients with Cluster C personality disorders from a RCT were included. The Achievement of Therapeutic Objective Scales (ATOS) was used to perform ratings of videotaped sessions. The Inventory of Interpersonal Problems Circumplex version was used as the outcome measure. Results: There were significant relationships between growth in SoS and SoO and reductions of hostile-dominant and hostile-submissive behaviors, as well as cold, social-avoidant and vindictive behaviors. Increase in SoO was also related to reductions in non-assertive and domineering behaviors. However, the results were only present in the STDP treatment group.

How and when feedback works in psychotherapy: Is it the signal?

Abstract Objective: Monitoring of ongoing psychotherapy is of crucial importance in improving the quality of mental health care, and feedback (FB) about patients’ progress has been established as a viable means. The essential feature of FB models is that patient progress is measured continuously through therapy. Aim: This study investigated the effect of receiving a warning signal when a patient is not achieving expected improvement (not-on-track), monitored with the Norwegian version of the patient FB system OQ®-Analyst. Method: Patients from six psychiatric clinics in Southern Norway (N = 259) were randomized to FB or no feedback (NFB). Results: For the total sample, the FB effects appeared early (session three). Receiving a warning signal did not change the slope of patients’ progress after the signal was given (FB versus NFB). FB seemed to be more effective with more severely distressed patients, although insignificant. Therapists indicated that the graphs imaging patient progress, and the accompanying discussion with the patient, were the most important aspects of FB. Conclusions: The use of OQ®-Analyst should be recommended in psychotherapeutic settings in Norway. Given the inconsistent results regarding the effect of warning signals, definitive conclusions about their effect may depend upon how and for whom it is used.

Metacognition and Cognition in Inpatient MCT and CBT for Comorbid Anxiety Disorders: A Study of Within-Person Effects.

Psychotherapists have long questioned what mediating processes are linked to outcome of psychotherapy. Few studies examining this question have assessed within-person changes in the process outcome relationship over time. The present study examined changes in cognition and metacognition over the course of therapy using a dataset from a randomized controlled trial comparing Metacognitive therapy (MCT) and Cognitive–behavioral therapy (CBT). The sample included 74 patients measured on process and symptom instruments weekly throughout therapy. Multilevel longitudinal models (sessions nested within patients) were used to examine the relationship between metacognition, cognition, and anxiety. Main effects of metacognition and cognition on anxiety and the interaction with treatment, as well as the reciprocal relationships, were investigated. The results indicate a main effect of both cognitions and metacognitions on predicting anxiety. However, there was no interaction with treatment condition. The reciprocal relationship of anxiety on metacognitions was larger in MCT compared with CBT. This is the first study documenting within-person effects of both cognitions and metacognitions on anxiety over the course of therapy. Implications for therapy are discussed.

Exposure and non-fear emotions: A randomized controlled study of exposure-based and rescripting-based imagery in PTSD treatment

Interventions involving rescripting-based imagery have been proposed as a better approach than exposure-based imagery when posttraumatic stress disorder (PTSD) is associated with emotions other than fear. Prior research led to the studys hypotheses that (a) higher pretreatment non-fear emotions would predict relatively better response to rescripting as compared to exposure, (b) rescripting would be associated with greater reduction in non-fear emotions, and (c) pretreatment non-fear emotions would predict poor response to exposure. A clinically representative sample of 65 patients presenting a wide range of traumas was recruited from patients seeking and being offered PTSD treatment in an inpatient setting. Subjects were randomly assigned to 10 weeks of treatment involving either rescripting-based imagery (Imagery Rescripting; IR) or exposure-based imagery (Prolonged Exposure; PE). Patients were assessed on outcome and emotion measures at pretreatment, posttreatment and 12 months follow-up. Comparison to control benchmarks indicated that both treatments were effective, but no outcome differences between them appeared. None of the initial hypotheses were supported. The results from this study challenge previous observations and hypotheses about exposure mainly being effective for fear-based PTSD and strengthen the notion that exposure-based treatment is a generally effective treatment for all types of PTSD.

The Mobility Inventory for Agoraphobia Avoidance Alone Scale Factor Structure and Psychometric Properties of Subscales

In this study, we investigated the factor structure of situational fears in agoraphobia by examining four models of the Avoidance Alone items in the Mobility Inventory for Agoraphobia. A main sample of 327 agoraphobic patients and an independent control sample of 64 agoraphobic patients were studied. A confirmatory factor analysis supported a four-factor model including a public places, an enclosed spaces, a public transportation, and an open spaces factor both for pre- and posttreatment data. The convergent and divergent validity of subscales derived from the four factors were supported by an expected pattern of correlations with interview-based measures. These subscales also proved to have satisfactory internal consistencies in the independent sample.

Alliance and symptom improvement in inpatient treatment for eating disorder patients: A study of within‐patient processes

OBJECTIVE This study examined the reciprocal relationship between alliance and symptoms during treatment for patients with eating disorders (ED). METHODS Ninety one patients with EDs received inpatient cognitive-behavioral therapy treatment over 14 weeks. The study used repeated measurements during treatment and collected alliance and symptom measures. The analysis separated the effects of alliance and symptoms into between- and within-patient effects in a multilevel analysis. RESULTS The results show a reciprocal relationship with between-patient alliance predicting ED symptoms and between-patient ED symptoms predicting alliance the subsequent weeks. However, for within-patient effects only alliance predicted ED symptoms the subsequent week. DISCUSSION The results nuance the effect of the alliance in this patient group, and paint a complex picture of alliance in the psychotherapy process.