Mind, Self and Society from the Standpoint of a Social Behaviorist

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Applied Longitudinal Data Analysis Modeling Change And Event Occurrence

https://onlinelibrary.wiley.com/doi/pdf/10.1002/wps.20311

Understanding the burnout experience: recent research and its implications for psychiatry.

The AUDIT Alcohol Consumption Questions (AUDIT-C) An Effective Brief Screening Test for Problem Drinking

Representing Reality: Discourse, Rhetoric and Social Construction

The therapeutic alliance has been found to predict psychotherapy outcome in numerous studies. However, critics maintain that the therapeutic alliance is a by-product of prior symptomatic improvements. Moreover, almost all alliance research to date has used differences between patients in alliance as predictor of outcome, and results of such analyses do not necessarily mean that improving the alliance with a given patient will improve outcome (i.e., a within-patient effect). In a sample of 646 patients (76% women, 24% men) in primary care psychotherapy, the effect of working alliance on next session symptom level was analyzed using multilevel models. The Clinical Outcomes in Routine Evaluation–Outcome Measure was used to measure symptom level, and the patient version of the Working Alliance Inventory–Short form revised (Hatcher & Gillaspy, 2006) was used to measure alliance. There was evidence for a reciprocal causal model, in which the alliance predicted subsequent change in symptoms while prior symptom change also affected the alliance. The alliance effect varied considerably between patients. This variation was partially explained by patients with personality problems showing stronger alliance effect. These results indicate that the alliance is not just a by-product of prior symptomatic improvements, even though improvement in symptoms is likely to enhance the alliance. Results also point to the importance of therapists paying attention to ruptures and repair of the therapy alliance. Generalization of results may be limited to relatively brief primary care psychotherapy.

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Therapeutic Alliance Predicts Symptomatic Improvement Session by Session

Objective There is a need for rigorous methods to study the mechanisms that lead to individual-level change (i.e., process-outcome research). We argue that panel data (i.e., longitudinal study of a number of individuals) methods have 3 major advantages for psychotherapy researchers: (1) enabling microanalytic study of psychotherapeutic processes in a clinically intuitive way, (2) modeling lagged associations over time to ensure direction of causality, and (3) isolating within-patient changes over time from between-patient differences, thereby protecting against confounding influences because of the effects of unobserved stable attributes of individuals. However, dynamic panel data methods present a complex set of analytical challenges. We focus on 2 particular issues: (1) how long-term trajectories in the variables of interest over the study period should be handled, and (2) how the use of a lagged dependent variable as a predictor in regression-based dynamic panel models induces endogeneity (i.e., violation of independence between predictor and model error term) that must be taken into account in order to appropriately isolate within- and between-person effects. Method An example from a study of working alliance in psychotherapy in primary care in Sweden is used to illustrate some of these analytic decisions and their impact on parameter estimates. Results Estimates were strongly influenced by the way linear trajectories were handled; that is, whether variables were "detrended" or not. Conclusions The issue of when detrending should be done is discussed, and recommendations for research are provided. (PsycINFO Database Record

Dynamic models of individual change in psychotherapy process research.

The concept of burnout describes a number of destructive aspects in work relationships. In this study, the relations between psychiatric staff members' feelings towards their patients and burnout were analyzed. Staff feelings were measured with a feeling checklist, and burnout with BM (Burnout Measure) and MBI (Maslach's Burnout Inventory). The staff at 28 treatment units rated their feelings towards the patients as a group. The results indicated that high burnout was associated with negative feelings and low levels of burnout with positive feelings towards patients. The correlation patterns for the different measures of burnout were somewhat different. BM had the strongest correlations with unhelpful and rejecting feelings towards patients, whereas Personal accomplishment, one dimension of MBI, was most strongly correlated with accepting and close feelings. The results were interpreted as opening for the question whether negative staff feelings towards patients most profitably can be seen as an aspect of burnout or whether these two phenomena should be distinguished clinically and theoretically.

Burnout and psychiatric staff's feelings towards patients.

Objective: Although the working alliance as been found to be a robust predictor of psychotherapy outcome, critics have questioned the causal status of this effect. Specifically, the effect of the alliance may be confounded with the effect of prior symptom improvement. The objective of the present study was to test this possibility. Method: A large dataset from primary care psychotherapy was used to study relationships between alliance and outcome using piecewise multilevel path analysis. Results: Initial symptom level and symptom change up to session three predicted the alliance at session three. Working alliance significantly predicted symptom change rate from session three to termination, even while controlling for several possible confounds. Conclusions: The alliance predicts outcome over and above the effect of prior symptom improvement, supporting a reciprocal influence model of the relationship between alliance and symptom change.

Working alliance predicts psychotherapy outcome even while controlling for prior symptom improvement

Objective Developments in working alliance theory posit that the therapist's attention to fluctuations in the alliance throughout treatment is crucial. Accordingly, researchers have begun studying the alliance as a time-varying mechanism of change rather than as a static moderator. However, most studies to date suffer from bias owing to the nonindependence of error term and predictors (endogeneity). Method Patients with major depressive disorder (N = 84) from a randomized trial comparing cognitive-behavioral therapy with interpersonal psychotherapy filled out the Beck Depression Inventory-II before each session. After each session, patients and therapists filled out the Working Alliance Inventory short forms. Data were analyzed using the generalized method of moments for dynamic panel data, a method commonly applied in econometrics to eliminate endogeneity bias. Results Improvement of the alliance predicted significant reduction of depressive symptoms by the next session (patient rating: b = -4.35, SE = 1.96, p = .026, 95% confidence interval [CI] [-8.19, -0.51]; therapist rating: b = -4.92, SE = 1.84, p = .008, 95% CI [-8.53, -1.31]). In addition, there was a significant delayed effect on the session after the next (patient rating: b = -3.25, SE = 1.20, p = .007, 95% CI [-5.61, -0.89]; therapist rating: b = -5.44, SE = 1.92, p = .005, 95% CI [-9.20, -1.68]). Conclusion If the quality of patient-therapist alliance is improved in a given treatment session, depressive symptoms will likely decrease by the next session. The most important limitation of this study is its relatively small sample size. (PsycINFO Database Record

Rolf Holmqvist

Papers

Therapeutic Alliance Predicts Symptomatic Improvement Session by Session

Dynamic models of individual change in psychotherapy process research.

Burnout and psychiatric staff's feelings towards patients.

Working alliance predicts psychotherapy outcome even while controlling for prior symptom improvement

Improvement of the working alliance in one treatment session predicts improvement of depressive symptoms by the next session.