Lack of concordance between subjective improvement and symptom change in psychotic episodes

OBJECTIVES: Subjective, self-rated improvement in patients with schizophrenia spectrum disorders can carry significance as a first-person account of treatment outcome, and can be of importance for the individual patient's acceptance of further treatment, including psychological treatments. This study assessed the concordance between post-treatment subjective improvement and the observed symptom change after a psychotic episode. DESIGN: Longitudinal study based on daily symptom ratings. METHOD: The study sample consisted of 43 younger, primarily first- or second-episode patients. Observed symptom change was calculated as both pre-post differences and symptom trajectories. Subjective improvement was assessed at the end of treatment by using the 'Emotional and Behavioural Changes in Psychotherapy Questionnaire' (VEV), a retrospective measure of subjective change. RESULTS: The findings indicated no significant concordance between pre-post differences in symptoms and self-rated improvement, nor were final levels of symptoms related to subjective improvement. Higher initial and mean symptom levels for positive symptoms were related to a lower degree of subjective improvement. A shorter duration of an initial trend-like improvement in psychosis was shown to be associated with greater subjective improvement. CONCLUSIONS: Subjective assessment of improvement may differ markedly from symptom change. In psychotic episodes, more severe initial positive symptoms as well as a delayed improvement of positive symptoms may be related to a reduced subjective experience of improvement for the duration of the entire episode. The treatment of psychosis should take a possible discordance between subjective and objective change into account.

Competencies in arts therapies: A rating of importance, training and performance by practitioners and referring professionals in Switzerland

This survey was conducted in developing a final specialized examination for all arts therapists in Switzerland by the Council of Swiss Arts Therapy Associations (CSATA). Forty-eight generic key competencies (GKC) were sent to all 1235 arts therapists in five different disciplines in Switzerland (response 47.5%) and to 384 referring professionals and employers (RPE) listed by therapists (response 42%). The mean importance of GKC was rated high (4 points of 5) by practitioners and RPE. Different opinions on importance of GKC in disciplines included artistic ability and psychotherapeutic relative to medical orientation. The training of competencies was rated lower by practitioners (3.48 points) and different in the eight competence categories and five disciplines. Areas of weak training were identified. The performance of GKC was rated by referring professionals equally to its importance (mean +0.3 points) and showed a good understanding of competencies by RPE. Judging of performance was difficult for RPE in more than 20% of items. The results provide criteria for detailed outcome assessments and the advancement of a final examination for arts therapists in Switzerland.

Advancing psychotherapy and evidence-based psychological interventions

Psychological models of mental disorders guide research into psychological and environmental factors that elicit and maintain mental disorders as well as interventions to reduce them. This paper addresses four areas. (1) Psychological models of mental disorders have become increasingly transdiagnostic, focusing on core cognitive endophenotypes of psychopathology from an integrative cognitive psychology perspective rather than offering explanations for unitary mental disorders. It is argued that psychological interventions for mental disorders will increasingly target specific cognitive dysfunctions rather than symptom-based mental disorders as a result. (2) Psychotherapy research still lacks a comprehensive conceptual framework that brings together the wide variety of findings, models and perspectives. Analysing the state-of-the-art in psychotherapy treatment research, “component analyses” aiming at an optimal identification of core ingredients and the mechanisms of change is highlighted as the core need towards improved efficacy and effectiveness of psychotherapy, and improved translation to routine care. (3) In order to provide more effective psychological interventions to children and adolescents, there is a need to develop new and/or improved psychotherapeutic interventions on the basis of developmental psychopathology research taking into account knowledge of mediators and moderators. Developmental neuroscience research might be instrumental to uncover associated aberrant brain processes in children and adolescents with mental health problems and to better examine mechanisms of their correction by means of psychotherapy and psychological interventions. (4) Psychotherapy research needs to broaden in terms of adoption of large-scale public health strategies and treatments that can be applied to more patients in a simpler and cost-effective way. Increased research on efficacy and moderators of Internet-based treatments and e-mental health tools (e.g. to support “real time” clinical decision-making to prevent treatment failure or relapse) might be one promising way forward.

The subjective present and its modulation in clinical contexts

Time is a basic dimension in psychology, underlying behavior and experience. Timing and time perception constitute implicit processes that are often inaccessible to the individual person. Research in this field has shown that timing is involved in many areas of clinical significance. In the projects presented here, we combine timing with seemingly different fields of research, such as psychopathology, perceptual grouping, and embodied cognition. Focusing on the time scale of the subjective present, we report findings from three different clinical studies: (1) We studied perceived causality in schizophrenia patients, finding that perceptual grouping (‘binding’, ‘Gestalt formation’), which leads to visual causality perceptions, did not distinguish between patients and healthy controls. Patients however did integrate context (provided by the temporal distribution of auditory context stimuli) less into perceptions, in significant contrast to controls. This is consistent with reports of higher inaccuracy in schizophrenia patients’ temporal processing. (2) In a project on auditory Gestalt perception we investigated auditory perceptual grouping in schizophrenia patients. The mean dwell time was positively related to how much patients were prone to auditory hallucinations. Dwell times of auditory Gestalts may be regarded as operationalizations of the subjective present; findings thus suggested that patients with hallucinations had a shorter present. (3) The movement correlations of interacting individuals were used to study the non-verbal synchrony between therapist and patient in psychotherapy sessions. We operationalized the duration of an embodied ‘social present’ by the statistical significance of such associations, finding a window of roughly 5.7 seconds in conversing dyads.We discuss that temporal scales of nowness may be modifiable, e.g., by mindfulness. This yields promising goals for future research on timing in the clinical context: psychotherapeutic techniques may alter binding processes, hence the subjective present of individuals, and may affect the social present in therapeutic interactions.

Psychotherapy Research and Neurobiology: Challenge, Chance, or Enrichment? Are We Wiser 10 Years Later? (Commentary on "Psychotherapy Research and Neurobiology: Challenge, Chance or Enrichment?"(2003))

Presidential Address of the 2003 SPR annual meeting with commentary from the author, Former President of the SPR, Franz Caspar.

Bedeutung der Arbeitsallianz in der Psychotherapie

Das pantheoretische Konzept der Arbeitsallianz stellt die kollaborative Qualität der an der Therapie beteiligten Personen (i. e. zumeist der Patient und der Therapeut) in den Mittelpunkt. Die Arbeitsallianz ist die weltweit am besten untersuchte Prozessvariable in der Psychotherapie. Die vorliegende Arbeit bietet einen Überblick über den aktuellen metaanalytischen Wissensstand. Basierend auf 200 Primärstudien mit 14.000 teilnehmenden Patienten wurde der Zusammenhang zwischen Arbeitsallianz und Therapieerfolg metaanalytisch untersucht. Die Arbeitsallianz erweist sich als äußerst robuster Prädiktor, der moderate 8 % der Varianz des Therapieerfolgs erklärt. Der Zusammenhang über die verschiedenen Psychotherapietraditionen hinweg zeigte sich sowohl unter randomisierten kontrollierten, manualisierten Studienbedingungen als auch unter naturalistischen Voraussetzungen. Der Effekt fand sich zudem in den störungsspezifischen Erfolgseinschätzungen und den generelleren Erfolgsmaßen. Die moderaten Therapeuteneffekte in den Primärstudien konnten metaanalytisch bestätigt werden. Soziokulturelle Aspekte wie Substanzmissbrauch und ethnische Minoritäten moderieren den Einfluss zwischen Arbeitsallianz und Therapieerfolg. Die Nähe der Forscher zum Allianzkonzept („allegiance“) beeinflusst die Vorhersagekraft der frühen Allianz zwar statistisch bedeutsam, jedoch nicht substanziell.

Predicting psychotherapy outcome based on therapist interpersonal skills: A five-year longitudinal study of a therapist assessment protocol

Objective: In the past decade, variation in outcomes between therapists (i.e., therapist effects) have become increasingly recognized as an important factor in psychotherapy. Less is known, however, about what accounts for differences between therapists. The present study investigates the possibility that therapists' basic therapy-related interpersonal skills may impact outcomes. Method: To examine this, psychotherapy postgraduate trainees completed both an observer- and an expert-rated behavioral assessment: the Therapy-Related Interpersonal Behaviors (TRIB). TRIB scores were used to predict trainees' outcomes over the course of the subsequent five years. Results: Results indicate that trainees' with more positively rated interpersonal behaviors assessed in the observer-rated group format but not in a single expert-rated format showed superior outcomes over the five-year period. This effect remained controlling for therapist characteristics (therapist gender, theoretical orientation [cognitive behavioral or psychodynamic], amount of supervision, patient's order within therapist's caseload), and patient characteristics (patient age, gender, number of comorbid diagnoses, global severity, and personality disorder diagnosis). Conclusions: These findings underscore the importance of therapists' interpersonal skills as a predictor of outcome and source of therapist effects. The potential utility of assessing therapists' and therapists-in-training interpersonal skills are discussed.

Working along sudden gains: Responsiveness on small and subtle early changes and exceptions

When mental health is monitored over the course of treatment, many clients report strong and stable changes, particularly early in psychotherapy. Such changes can occur both in singular events, such as sudden gains in particular symptoms, and more comprehensive ways across the World Health Organization definition of health (WHO, 1948), which includes well-being and psychosocial functioning. The present practical guideline illustrates a systematized sequence of tasks that explore rapid changes and sudden gains at a very early stage of therapy, as well as how such changes can be used in future therapeutic work. These tasks include (1) exploration of the change situation, (2) reinforcement of generalized self-efficacy and hope bonding, and (3) benefit for therapy.

Crossing borders: Ethnic minorities matter? A meta analytic examionation of the alliance-outcome relationship

Objectives: The purpose of this meta analysis was to examine the moderating impact of substance use disorder as inclusion/exclusion criterion as well as the percentage of racial/ethnic minorities on the strength of the alliance-outcome relationship in psychotherapy. It was hypothesized that the presence of a dsm axis i substance use disorders as a criterion and the presence of racial/ethnic minority as a psychosocial indicator are confounded client factors reducing the relationship between alliance and outcome. Methods: A random effects restricted maximum-likelihood estimator was used for omnibus and moderator models (k = 94). results: the presence of (a) substance use disorder and, (b) racial/ethnic minorities (overall and specific to african americans) partially moderated the alliance-outcome correlation. The percentage of substance use disorders and racial/ethnic minority status was highly correlated. Conclusions: Socio-cultural contextual variables should be considered along with dsm axis i diagnosis of substance use disorders in analyzing and interpreting mechanisms of change.

Modulation of anticipatory emotion and perception processing by cognitive control.

Strategies of cognitive control are helpful in reducing anxiety experienced during anticipation of unpleasant or potentially unpleasant events. We investigated the associated cerebral information processing underlying the use of a specific cognitive control strategy during the anticipation of affect-laden events. Using functional magnetic resonance imaging, we examined differential brain activity during anticipation of events of unknown and negative emotional valence in a group of eighteen healthy subjects that used a cognitive control strategy, similar to "reality checking" as used in psychotherapy, compared with a group of sixteen subjects that did not exert cognitive control. While expecting unpleasant stimuli, the "cognitive control" group showed higher activity in left medial and dorsolateral prefrontal cortex areas but reduced activity in the left extended amygdala, pulvinar/lateral geniculate nucleus and fusiform gyrus. Cognitive control during the "unknown" expectation was associated with reduced amygdalar activity as well and further with reduced insular and thalamic activity. The amygdala activations associated with cognitive control correlated negatively with the reappraisal scores of an emotion regulation questionnaire. The results indicate that cognitive control of particularly unpleasant emotions is associated with elevated prefrontal cortex activity that may serve to attenuate emotion processing in for instance amygdala, and, notably, in perception related brain areas.