More Light? Opportunities and Pitfalls in Digitalized Psychotherapy Process Research

While the evidence on the effectiveness of different psychotherapies is often strong, it is not settled whereby and how these therapies work. Knowledge on the causal factors and change mechanisms is of high clinical and public relevance, as it contributes to the empirically informed advancement of psychotherapeutic interventions. Here, digitalized research approaches might possess the potential to generate new insights into human behavior change, contributing to augmented interventions and mental healthcare practices with better treatment outcomes. In this perspective article, we describe recent findings of research into change mechanisms that were only feasible with digital tools and outline important future directions for this rather novel branch of research. Furthermore, we indicate several challenges and pitfalls that are to be solved, in order to advance digitalized psychotherapy process research, both methodologically and technologically.

Can we learn on Psychotherapeutic Process Dimensions with Single Case Study?

Relational psychoanalysis states that an adequate management of the intersubjective processes displayed in psychotherapy are essential to promote effective change. The analysis about some variables of the therapist and patient and the complex and co-determined interaction between them, give us new perspectives on the therapeutic process. This analysis leads us to question some topics and consider from a new view the therapist's functions and the patient's roles within the therapeutic process. A group of researchers in Spain, Argentine, Mexico and Germany have worked along a decade (1997-2008) in the Salamanca-Barcelona-Madrid Project on Psychotherapy Process Research. This project, an study conducting single case research (´The Publicist´ case), along the main phases of complete treatment (up to 200 recorded sessions), have given us the opportunity to adquire a better knowledge on therapeutic process, through the content analysis of sessions and with qualitative data using a wide variety of procedures. In this paper we are presenting relevant results concerning some inferences on therapeutic process along the whole treatment and their phases. Crossing all the studied dimensions, we propose a comprehensive model of change observed in the case object of study, considering all the approaches, both from quantitative and qualitative methods and process dimensions, both the contributions of the therapist and the patient to psychotherapeutic process. Results are discussed in the light of recent perspectives on active use of counter-transference as a therapist’s tool to improve the psychoanalytic psychotherapy process, controlling negative aspects of countertransference collusions.

What Research Evidence Is Valid for Psychotherapy Research?

Evidence-Based Medicine (EBM) have contributed to improved clinical practice with increased use of effective and life-saving treatments for severe diseases. However, the EBM model is less suitable for psychotherapy research than for pharmacological research and somatic medicine. The randomized controlled trial (RCT) design is an example of experimental methodology, which inevitably has more imperfections in psychotherapy research because psychotherapy RCTs cannot use double-blinding and the treatments tested are composite treatment packages. Long-term psychotherapy for severe and complex mental disorders is especially difficult to study with an RCT design. During the last decades, advanced analytic methods have been developed in psychotherapy process research, which enables investigation of causal connections regarding change mechanisms in psychotherapy. Therefore, we propose that the top of the research evidence hierarchy for psychotherapy should encompass: (1) RCT for circumscribed disorders, (2) cohort studies for complex disorders, and (3) advanced process studies for change mechanisms.

Experimental Variation of Relationship Styles Draft Version Preprint

Objective: In psychotherapy process research, there is a lack of experimental designs that specifically explore which therapeutic style is helpful for which patient. Thus, the aim of this study was to test the feasibility of experimentally varying the therapeutic style under realistic conditions and how this affects alliance. Method: We defined two therapeutic styles (relationship-focused vs. problem-focused) based on the interpersonal circumplex. In a randomized two-group design, 64 healthy university students (70% female, Mage=23.78 years old, SDage=2.81) were assigned to one of the styles and received a single psychological counseling session on interpersonal conflicts. We checked the manipulation success using an adherence rating and counselors’ interpersonal impressions via the Interpersonal Message Inventory (IMI-R). Primary outcome was alliance (Working Alliance Inventory, WAI). Symptom severity (Symptom Checklist, SCL-K-9) was also assessed. Results: Analyses of adherence (p< .001) and IMI-R ratings (p< .001 in friendly dimension, p=.003 in hostile dimension) were hypotheses-conform to the proposed therapeutic styles. Alliance was highly rated in both conditions and by all raters. While clients did not show any group differences, counselor and observer ratings were significantly higher in the relationship-focused than in the problem-focused condition (p=.040; p=.003). In both groups, symptom severity decreased significantly after the session (p=.020).Conclusions: The experimental variation of the therapeutic style is feasible under realistic conditions with high overall alliance ratings. The novel experimental design may provide a basis for further process research. Mediator and moderator analyses could yield more detailed information on differential relationship forming and thus an individualized therapeutic style.

Seeing the Situational Gestalt - Movement in Therapeutic Spaces

SummaryThis paper starts with a short review of recent developments in psychotherapy process research and analyzes that a medical, or better, technical approach in process research – using words such as ‘intervention’, ‘effect’ and ‘outcome’ – is gradually acknowledged as only one side of psychotherapy; the other, more human or ‘humanistic’ side, is ‘conversation’, described by prominent authors as ‘low technology’. Conversation analysis cannot study psychotherapy as a whole. Sessions are subdivided into ‘situations’. What are situations? I make a proposal to answer this question by three components: open up, select and control options. Then, 11 transcribed extracts from psychoanalytical therapy sessions are used to describe three types of situations and the special kind of requirements they demand from a therapist. Obviously, such situations appear during a session, they can be handled if therapists are sensitized for certain difficulties to arise. Shift-of-situation and double meaning are new observations in this approach to define the situational gestalt and train ‘seeing’ it.

Adapting Evidence-Based Practice for Sexual and Gender Minorities

This chapter reviews the history of scientific evidence regarding sexual and gender minority (SGM) mental health, from the unscientific, homophobic theories of the early 20th century to the pioneering research that paved the way for the accurate evidence on SGM mental health that researchers currently possess and continue to acquire. This chapter also discusses historical impediments to creating evidence-based treatments for SGM mental health, including a lack of clear treatment targets and treatment studies specific to SGM, as well as the recent progress toward overcoming these barriers as illustrated in the chapters throughout this handbook. The chapter offers several justifications for the widespread use and dissemination of evidence-based treatments with SGM, including ethical, professional, and scientific considerations in this pursuit. Finally, it provides suggestions for future research to advance evidence-based practice for SGM, spanning psychiatric epidemiology to psychotherapy process research.

Process-symptom-bridges in psychotherapy: an idiographic network approach

Aim: Real-time monitoring of psychotherapeutic processes was recently described as a promising, new way of track-ing periods of change in ongoing treatments. This approach generates complex, multivariate datasets that have to be presented in an intuitive way for clinicians to aid their clinical decision-making. Using network modeling and new approaches in centrality analyses, we examine “bridge nodes” between symptom stress and aspects of the psychotherapeutic process between therapy session (intersession processes, ISP). Method: We recorded intersession processes as well as depressive and anxiety symptoms using daily questionnaires in ten cases. Regularized, thresholded intraindividual dynamic networks were estimated. We applied bridge centrality analysis to identify individual bridges between psychotherapeutic processes and symptoms in the resulting models. Casewise interpretations of bridge centrality values are offered. Results: Bridge centrality analysis revealed individual bridge nodes between intersession processes and symptom severity. Strength and direction of bridges varied substantially across individuals. Conclusion: Given current methodological challenges, idiographic network studies are feasible and offer important insights for psychotherapy process research. In this case, we demonstrated how patients deal with periods of increased symptom stress. In this case we have described how patients deal with their therapy under increased symptom load. Bridges between psychotherapeutic processes and symptom stress are a promising target for monitoring systems based on ISP. Future studies should examine the clinical utility of network-based monitoring and feedback in ongoing therapies. In the near future, process feedback systems based on idiographic models could serve clinicians to improve treatments. Keywords: depression, anxiety, intersession processes, ecological momentary assessment, network analysis

Process-symptom-bridges in psychotherapy: an idiographic network approach

Aim: real-time monitoring of psychotherapeutic processes was recently described as a promising, new way of tracking periods of change in ongoing treatments. This approach generates complex, multivariate datasets that have to be presented in an intuitive way for clinicians to aid their clinical decision-making. Using network modeling and new approaches in centrality analyses, we examine “bridge nodes” between symptom stress and aspects of the psychotherapeutic process between therapy session (intersession processes, ISP). Method: we recorded intersession processes as well as depressive and anxiety symptoms using daily questionnaires in ten cases. Regularized, thresholded intraindividual dynamic networks were estimated. We applied bridge centrality analysis to identify individual bridges between psychotherapeutic processes and symptoms in the resulting models. Case-wise interpretations of bridge centrality values are offered.Results: bridge centrality analysis revealed individual bridge nodes between intersession processes and symptom severity. Strength and direction of bridges varied substantially across individuals. Conclusion: given current methodological challenges, idiographic network studies are feasible and offer important insights for psychotherapy process research. In this case, we demonstrated how patients deal with periods of increased symptom stress. In this case we have described how patients deal with their therapy under increased symptom load. Bridges between psychotherapeutic processes and symptom stress are a promising target for monitoring systems based on ISP. Future studies should examine the clinical utility of network-based monitoring and feedback in ongoing therapies. In the near future, process feedback systems based on idiographic models could serve clinicians to improve treatments.