Research has indicated that patients in-session experience of previously avoided affects may be important for effective psychotherapy. The aim of this study was to investigate patients in-session levels of affect experiencing in relation to their corresponding levels of insight, motivation, and inhibitory affects in initial Experiential Dynamic Therapy (EDT) sessions. Four hundred sixty-six 10-min video segments from 31 initial sessions were rated using the Achievement of Therapeutic Objectives Scale. A series of multilevel growth models, controlling for between-therapist variability, were estimated to predict patients adaptive affect experiencing (Activating Affects) across session segments. In line with our expectations, higher within-person levels of Insight and Motivation related to higher levels of Activating Affects per segment. Contrary to expectations, however, lower levels of Inhibition were not associated with higher levels of Activating Affects. Further, using a time-lagged model, we did not find that the levels of Insight, Motivation, or Inhibition during one session segment predicted Activating Affects in the next, possibly indicating that 10-min segments may be suboptimal for testing temporal relationships in affective processes. Our results suggest that, to intensify patients immediate affect experiencing in initial EDT sessions, therapists should focus on increasing insight into defensive patterns and, in particular, motivation to give them up. Future research should examine the impact of specific inhibitory affects more closely, as well as between-therapist variability in patients in-session adaptive affect experiencing.

Research has indicated that patients in-session experience of previously avoided affects may be important for effective psychotherapy. The aim of this study was to investigate patients in-session levels of affect experiencing in relation to their corresponding levels of insight, motivation, and inhibitory affects in initial Experiential Dynamic Therapy (EDT) sessions. Four hundred sixty-six 10-min video segments from 31 initial sessions were rated using the Achievement of Therapeutic Objectives Scale. A series of multilevel growth models, controlling for between-therapist variability, were estimated to predict patients adaptive affect experiencing (Activating Affects) across session segments. In line with our expectations, higher within-person levels of Insight and Motivation related to higher levels of Activating Affects per segment. Contrary to expectations, however, lower levels of Inhibition were not associated with higher levels of Activating Affects. Further, using a time-lagged model, we did not find that the levels of Insight, Motivation, or Inhibition during one session segment predicted Activating Affects in the next, possibly indicating that 10-min segments may be suboptimal for testing temporal relationships in affective processes. Our results suggest that, to intensify patients immediate affect experiencing in initial EDT sessions, therapists should focus on increasing insight into defensive patterns and, in particular, motivation to give them up. Future research should examine the impact of specific inhibitory affects more closely, as well as between-therapist variability in patients in-session adaptive affect experiencing.

Research has indicated that patients’ in-session experience of previously avoided affects may be important for effective psychotherapy. The aim of this study was to investigate patients’ in-session levels of affect experiencing in relation to their corresponding levels of insight, motivation, and inhibitory affects in initial Experiential Dynamic Therapy (EDT) sessions. Four hundred sixty-six 10-min video segments from 31 initial sessions were rated using the Achievement of Therapeutic Objectives Scale. A series of multilevel growth models, controlling for between-therapist variability, were estimated to predict patients’ adaptive affect experiencing (Activating Affects) across session segments. In line with our expectations, higher within-person levels of Insight and Motivation related to higher levels of Activating Affects per segment. Contrary to expectations, however, lower levels of Inhibition were not associated with higher levels of Activating Affects. Further, using a time-lagged model, we did not find that the levels of Insight, Motivation, or Inhibition during one session segment predicted Activating Affects in the next, possibly indicating that 10-min segments may be suboptimal for testing temporal relationships in affective processes. Our results suggest that, to intensify patients’ immediate affect experiencing in initial EDT sessions, therapists should focus on increasing insight into defensive patterns and, in particular, motivation to give them up. Future research should examine the impact of specific inhibitory affects more closely, as well as between-therapist variability in patients’ in-session adaptive affect experiencing.

A substantial number of patients do not improve from psychotherapy, some even deteriorate, and some terminate treatment prematurely. Identifying therapist variables that may lead to treatment failures from patients' perspectives can inform how psychotherapists can increase effectiveness. Using a semistructured protocol, we interviewed 24 patients who had experienced unsatisfying individual face-to-face psychotherapy within the last 2 years. The study procedures were guided by the consolidated criteria for reporting qualitative research. The manifest content analysis provided 13 subcategories grouped into four categories: (a) psychotherapists' negative traits (inflexible, unengaged, unemphatic, insecure), (b) unprofessionalism (superficial, violating personal boundaries, breaking confidentiality, nontransparent), (c) incompetence (unstructured, poor assessment or understanding, poor knowledge, too passive), and (d) mismatch (therapist-patient mismatch). To reduce the risk of treatment failure, psychotherapists may need a multifaceted set of relational skills, theoretical and technical competence, ethical sensitivity, and engagement. Some of the identified subcategories were complex constructs (e.g., unengaged) that may need time and effort to develop for psychotherapists. Other identified subcategories were obvious inappropriate behaviors in professional psychotherapy (e.g., breaking confidentiality). However, the categories found in this study need further quantitative investigation to assess the validity, frequency, and relative impact on treatment outcomes. Clinical Impact Statement Question: What psychotherapist shortcomings do patients perceive are associated with treatment failure? Findings: Patients' perception could be grouped into four main categories: negative traits, unprofessionalism, incompetence, and mismatch. Meaning: Psychotherapists and clinical supervisors may need to be aware of the therapist shortcomings identified in this study to increase the quality of their clinical work and reduce the risk of patient dropout. For example, psychotherapists may need to ensure that they convey warmth and empathy while supervisors may need to monitor potential violations of therapist-patient confidentiality. Next Steps: These qualitative results need to be replicated and validated by large-scale quantitative data collection to assess the prevalence of the different therapist shortcomings. Means to counter therapist shortcomings need to be developed and implemented in quality assurance systems.

Depression treatment with antidepressants is generally described as evidence-based. However, generalizations to practice recommendations seem to us to rest on the tacit assumption that treatment outcome in research trials is the sum of three factors: specific effects of the drug, expectancy effects (placebo), and spontaneous recovery. Because randomization isolates the specific effects of the drug, trials showing significant drug effects are used as evidence for prescribing the drug regardless of context. Drawing on Wampold's (2001) description of two metamodels of psychotherapy, the authors argue that available empirical evidence indicates that depression treatment with antidepressants is primarily a psychological treatment. This conclusion has far-reaching consequences for the scientific status of contemporary treatments for depression. It also affects what the doctor should focus on in a treatment with antidepressants and how to act when the patient is treatment resistant. In order to achieve the results obtained in clinical trials, the quantity and quality of support from the doctor is more important than pharmacological concerns, such as adequate doses of medicine. When faced with a treatment resistant patient, relationship factors rather than pharmacological factors should be in focus

This study investigated changes in trainees’ self-rated experience as a therapist over the course of one practicum treatment case in basic psychotherapy education in Sweden. Undergraduate students (n = 76) provided longitudinal information on their healing involvement and stressful work involvement. The results of the Development of Psychotherapists Common Core Questionnaire (DPCCQ) demonstrated that trainees’ basic relational skills, technical skills, perceived difficulties, and constructive coping strategies changed linearly, with an increasing slope. Technical expertise changed the most, and relational skills developed moderately. In-session feelings of anxiety and boredom did not change. The individualized reliable change scores show that the process during training is different for different students. Most students did not change at all, and some students even changed negatively. Investigation of how pedagogic variables affect therapists’ development is necessary to support the professional growth of trainees in their involvement with different types of psychotherapy.

Research has indicated that patients' in-session experience of previously avoided affects may be important for effective psychotherapy. The aim of this study was to investigate patients' in-session levels of affect experiencing in relation to their corresponding levels of insight, motivation, and inhibitory affects in initial Experiential Dynamic Therapy (EDT) sessions. Four hundred sixty-six 10-min video segments from 31 initial sessions were rated using the Achievement of Therapeutic Objectives Scale. A series of multilevel growth models, controlling for between-therapist variability, were estimated to predict patients' adaptive affect experiencing (Activating Affects) across session segments. In line with our expectations, higher within-person levels of Insight and Motivation related to higher levels of Activating Affects per segment. Contrary to expectations, however, lower levels of Inhibition were not associated with higher levels of Activating Affects. Further, using a time-lagged model, we did not find that the levels of Insight, Motivation, or Inhibition during one session segment predicted Activating Affects in the next, possibly indicating that 10-min segments may be suboptimal for testing temporal relationships in affective processes. Our results suggest that, to intensify patients' immediate affect experiencing in initial EDT sessions, therapists should focus on increasing insight into defensive patterns and, in particular, motivation to give them up. Future research should examine the impact of specific inhibitory affects more closely, as well as between-therapist variability in patients' in-session adaptive affect experiencing.

Children’s in-session involvement in child and family therapies correlates with both positive and negative treatment outcomes. Thus, it is important to gain a better understanding of the clinical practices that facilitate children’s involvement in therapy sessions so that practitioners can employ them with greater precision. To address this need, we conducted a study to answer the following question: What clinical practices facilitate children’s in-session involvement in child and family therapies? The data consisted of 16 extant audiovisual recordings of child and family therapy sessions and 24 stimulated-recall interviews with the participants in the recordings. Following constructivist grounded theory and incorporating storyline as an additional analytical technique, we have constructed a framework consisting of four involvement-enhancing practices: managing time, staying relevant, adjusting intensity, and facilitating inclusion. Furthermore, by detailing some of the complex processes that practitioners navigate when they facilitate children’s involvement, our study adds a multilayered and dynamic dimension to the list of already established involvement facilitators. It may be used to moderate an overstandardized work culture that continues to characterize services that address children’s needs. The results may be applied to other institutional encounters, providing resonance beyond the analyzed therapy sessions.

The Dose-Effect model holds that longer therapy leads to better outcome, although increasing treatment length will yield diminishing returns, as additional sessions lead to progressively less change in a negatively accelerating fashion. In contrast, the Good-Enough-Level (GEL) model proposes that patients, therapists, or patients-with-therapists decide on ending treatment when treatment outcome is satisfactory, meaning that patients who change faster will have shorter treatments. If true, this means that aggregating among patients with different treatment lengths would yield biased results. Most previous research has shown that symptom change rate depends on treatment length, but all of these studies used data from University counseling centers in the United States. There is a need to test if previous results hold in different settings. Two datasets from Swedish community-based primary care (n = 640) and psychiatric care (n = 284) were used. Patients made session-wise ratings on the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM). Multilevel models indicated better fit for a model in which treatment length moderated symptom change rate. In the primary care sample, patients in longer treatments achieved more symptom change from pre- to posttreatment, despite having slower rate of improvement. The most important aspect of the GEL model was supported, and no evidence was found for a negatively accelerating Dose-Effect curve. Results cannot be generalized beyond about 12 sessions, due to scarcity of data for longer treatments.

The Dose-Effect model holds that longer therapy leads to better outcome, although increasing treatment length will yield diminishing returns, as additional sessions lead to progressively less change in a negatively accelerating fashion. In contrast, the Good-Enough-Level (GEL) model proposes that patients, therapists, or patients-with-therapists decide on ending treatment when treatment outcome is satisfactory, meaning that patients who change faster will have shorter treatments. If true, this means that aggregating among patients with different treatment lengths would yield biased results. Most previous research has shown that symptom change rate depends on treatment length, but all of these studies used data from University counseling centers in the United States. There is a need to test if previous results hold in different settings. Two datasets from Swedish community-based primary care (n = 640) and psychiatric care (n = 284) were used. Patients made session-wise ratings on the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM). Multilevel models indicated better fit for a model in which treatment length moderated symptom change rate. In the primary care sample, patients in longer treatments achieved more symptom change from pre- to posttreatment, despite having slower rate of improvement. The most important aspect of the GEL model was supported, and no evidence was found for a negatively accelerating Dose-Effect curve. Results cannot be generalized beyond about 12 sessions, due to scarcity of data for longer treatments.

Social anxiety disorder (SAD) is associated with considerable individual suffering and societal costs. Although there is ample evidence for the efficacy of cognitive behavior therapy, recent studies suggest psychodynamic therapy may also be effective in treating SAD. Furthermore, Internet-based psychodynamic therapy (IPDT) has shown promising results for addressing mixed depression and anxiety disorders. However, no study has yet investigated the effects of IPDT specifically for SAD. This paper describes a randomized controlled trial testing the efficacy of a 10-week, affect-focused IPDT protocol for SAD, compared with a wait-list control group. Long-term effects were also estimated by collecting follow-up data, 6, 12, and 24 months after the end of therapy. A total of 72 individuals meeting diagnostic criteria for DSM-IV social anxiety disorder were included. The primary outcome was the self-report version of Liebowitz Social Anxiety Scale. Mixed model analyses using the full intention-to-treat sample revealed a significant interaction effect of group and time, suggesting a larger effect in the treatment group than in the wait-list control. A between-group effect size Cohen's d = 1.05 (95% [CI]: [0.62, 1.53]) was observed at termination. Treatment gains were maintained at the 2-year follow-up, as symptom levels in the treated group continued to decrease significantly. The findings suggest that Internet-based affect-focused psychodynamic therapy is a promising treatment for social anxiety disorder.

Social anxiety disorder (SAD) is associated with considerable individual suffering and societal costs. Although there is ample evidence for the efficacy of cognitive behavior therapy, recent studies suggest psychodynamic therapy may also be effective in treating SAD. Furthermore, Internet-based psychodynamic therapy (IPDT) has shown promising results for addressing mixed depression and anxiety disorders. However, no study has yet investigated the effects of IPDT specifically for SAD. This paper describes a randomized controlled trial testing the efficacy of a 10-week, affect-focused IPDT protocol for SAD, compared with a wait-list control group. Long-term effects were also estimated by collecting follow-up data, 6, 12, and 24 months after the end of therapy. A total of 72 individuals meeting diagnostic criteria for DSM-IV social anxiety disorder were included. The primary outcome was the self-report version of Liebowitz Social Anxiety Scale. Mixed model analyses using the full intention-to-treat sample revealed a significant interaction effect of group and time, suggesting a larger effect in the treatment group than in the wait-list control. A between-group effect size Cohens d = 1.05 (95% [CI]: [0.62, 1.53]) was observed at termination. Treatment gains were maintained at the 2-year follow-up, as symptom levels in the treated group continued to decrease significantly. The findings suggest that Internet-based affect-focused psychodynamic therapy is a promising treatment for social anxiety disorder.

Social anxiety disorder (SAD) is associated with considerable individual suffering and societal costs. Although there is ample evidence for the efficacy of cognitive behavior therapy, recent studies suggest psychodynamic therapy may also be effective in treating SAD. Furthermore, Internet-based psychodynamic therapy (IPDT) has shown promising results for addressing mixed depression and anxiety disorders. However, no study has yet investigated the effects of IPDT specifically for SAD. This paper describes a randomized controlled trial testing the efficacy of a 10-week, affect-focused IPDT protocol for SAD, compared with a wait-list control group. Long-term effects were also estimated by collecting follow-up data, 6, 12, and 24 months after the end of therapy. A total of 72 individuals meeting diagnostic criteria for DSM–IV social anxiety disorder were included. The primary outcome was the self-report version of Liebowitz Social Anxiety Scale. Mixed model analyses using the full intention-to-treat sample revealed a significant interaction effect of group and time, suggesting a larger effect in the treatment group than in the wait-list control. A between-group effect size Cohen’s d = 1.05 (95% [CI]: [0.62, 1.53]) was observed at termination. Treatment gains were maintained at the 2-year follow-up, as symptom levels in the treated group continued to decrease significantly. The findings suggest that Internet-based affect-focused psychodynamic therapy is a promising treatment for social anxiety disorder.

Social anxiety disorder (SAD) is associated with considerable individual suffering and societal costs. Although there is ample evidence for the efficacy of cognitive behavior therapy, recent studies suggest psychodynamic therapy may also be effective in treating SAD. Furthermore, Internet-based psychodynamic therapy (IPDT) has shown promising results for addressing mixed depression and anxiety disorders. However, no study has yet investigated the effects of IPDT specifically for SAD. This paper describes a randomized controlled trial testing the efficacy of a 10-week, affect-focused IPDT protocol for SAD, compared with a wait-list control group. Long-term effects were also estimated by collecting follow-up data, 6, 12, and 24 months after the end of therapy. A total of 72 individuals meeting diagnostic criteria for DSM-IV social anxiety disorder were included. The primary outcome was the self-report version of Liebowitz Social Anxiety Scale. Mixed model analyses using the full intention-to-treat sample revealed a significant interaction effect of group and time, suggesting a larger effect in the treatment group than in the wait-list control. A between-group effect size Cohen's d = 1.05 (95% [CI]: [0.62, 1.53]) was observed at termination. Treatment gains were maintained at the 2-year follow-up, as symptom levels in the treated group continued to decrease significantly. The findings suggest that Internet-based affect-focused psychodynamic therapy is a promising treatment for social anxiety disorder. (PsycINFO Database Record

Mentalization is a developmental achievement defined as the capacity to understand behavior in terms of mental states. This study investigated mentalization in psychoanalytic psychotherapy (PPT) and cognitive behavior therapy (CBT) through a secondary data analysis of findings from a randomized controlled trial for bulimia nervosa. It was hypothesized that mentalization would predict alliance and outcome in both treatments, whereas increase in mentalization was only expected after PPT. Furthermore, it was investigated whether change in mentalization predicted symptom change. A total of 70 participants with bulimia nervosa were randomized to PPT or CBT. Participants were assessed at 3 time points with the Eating Disorder Examination and the Adult Attachment Interview (rated for reflective functioning [RF]). Therapy sessions were rated with the Vanderbilt Therapeutic Alliance Scale. Higher intake RF significantly predicted better alliance, whereas no association was observed between RF and outcome. A significant interaction between time, therapy type, and RF found RF improving more in PPT than in CBT. There was a significant association between RF change and symptom change in the PPT group. The study suggests a relation between RF and psychotherapy process, whereas the relation between RF and outcome is more complex. Furthermore, PPT seems to enhance mentalization, which seems related to symptomatic improvement, suggesting that mentalization might serve as a specific mechanism of change in PPT.

Experiential dynamic therapy (EDT) is a subgroup of short-term psychodynamic psychotherapy (STPP) that emphasizes patients in-session affective processing. To evaluate the efficacy of EDT for psychiatric conditions, we conducted a meta-analysis of randomized controlled trials. Twenty-eight studies published between 1978 and 2014 were included, encompassing 1,782 adult patients with mood, anxiety, personality, or mixed disorders. Across targeted outcome domains, medium-size between-groups effects (Cohens ds ranging from 0.39 to 0.65) favored EDT over inactive controls at posttreatment and in symptom measures at follow-up. We found no differences between EDT and active treatments (e.g., medication, cognitive-behavioral therapy, manualized supportive therapy) at posttreatment, but EDT outperformed supportive therapy at follow-up (d = 0.75). In terms of within-group effect sizes, EDT was associated with large improvements in general psychiatric symptoms (d = 1.11), depression (d = 1.33), and anxiety (d = 1.09) and with small to moderate gains in the areas of interpersonal problems (d = 0.55) and global functioning (d = 0.86). Small but significant effects suggested continued improvement between posttreatment and follow-up. Heterogeneity in pre-post effects was explored in subgroup analyses, which indicated that EDT might be most effective in depressive disorders and that individual EDT had larger effects compared with group treatment. In addition, EDT performed better in higher quality studies. We conclude that EDT is a promising treatment for psychiatric conditions in adults. Further high-quality studies evaluating contemporary versions of EDT in specific psychiatric conditions are warranted.

Experiential dynamic therapy (EDT) is a subgroup of short-term psychodynamic psychotherapy (STPP) that emphasizes patients in-session affective processing. To evaluate the efficacy of EDT for psychiatric conditions, we conducted a meta-analysis of randomized controlled trials. Twenty-eight studies published between 1978 and 2014 were included, encompassing 1,782 adult patients with mood, anxiety, personality, or mixed disorders. Across targeted outcome domains, medium-size between-groups effects (Cohens ds ranging from 0.39 to 0.65) favored EDT over inactive controls at posttreatment and in symptom measures at follow-up. We found no differences between EDT and active treatments (e.g., medication, cognitive-behavioral therapy, manualized supportive therapy) at posttreatment, but EDT outperformed supportive therapy at follow-up (d = 0.75). In terms of within-group effect sizes, EDT was associated with large improvements in general psychiatric symptoms (d = 1.11), depression (d = 1.33), and anxiety (d = 1.09) and with small to moderate gains in the areas of interpersonal problems (d = 0.55) and global functioning (d = 0.86). Small but significant effects suggested continued improvement between posttreatment and follow-up. Heterogeneity in pre-post effects was explored in subgroup analyses, which indicated that EDT might be most effective in depressive disorders and that individual EDT had larger effects compared with group treatment. In addition, EDT performed better in higher quality studies. We conclude that EDT is a promising treatment for psychiatric conditions in adults. Further high-quality studies evaluating contemporary versions of EDT in specific psychiatric conditions are warranted.

Experiential dynamic therapy (EDT) is a subgroup of short-term psychodynamic psychotherapy (STPP) that emphasizes patients’ in-session affective processing. To evaluate the efficacy of EDT for psychiatric conditions, we conducted a meta-analysis of randomized controlled trials. Twenty-eight studies published between 1978 and 2014 were included, encompassing 1,782 adult patients with mood, anxiety, personality, or mixed disorders. Across targeted outcome domains, medium-size between-groups effects (Cohen’s ds ranging from 0.39 to 0.65) favored EDT over inactive controls at posttreatment and in symptom measures at follow-up. We found no differences between EDT and active treatments (e.g., medication, cognitive–behavioral therapy, manualized supportive therapy) at posttreatment, but EDT outperformed supportive therapy at follow-up (d = 0.75). In terms of within-group effect sizes, EDT was associated with large improvements in general psychiatric symptoms (d = 1.11), depression (d = 1.33), and anxiety (d = 1.09) and with small to moderate gains in the areas of interpersonal problems (d = 0.55) and global functioning (d = 0.86). Small but significant effects suggested continued improvement between posttreatment and follow-up. Heterogeneity in pre–post effects was explored in subgroup analyses, which indicated that EDT might be most effective in depressive disorders and that individual EDT had larger effects compared with group treatment. In addition, EDT performed better in higher quality studies. We conclude that EDT is a promising treatment for psychiatric conditions in adults. Further high-quality studies evaluating contemporary versions of EDT in specific psychiatric conditions are warranted.

Different forms of psychotherapy are effective for cluster C personality disorders, but we know less about what in-session processes promote change. Contrasting successful and unsuccessful cases may elucidate processes that facilitate or impede outcome and offer suggestions for clinical practice and future research. In this exploratory outcome-process study, 10 successful and 10 unsuccessful cases were selected from a randomized trial comparing cognitive therapy and short-term psychodynamic psychotherapy for cluster C personality disorders. Videotaped sessions were rated with the Psychotherapy Process Q-Set (PQS). The treatments were compared in terms of which PQS items differentiated successful and unsuccessful cases, as well as their resemblance with PQS prototypes of "ideal treatments." Therapists behavior in early sessions was also explored. Results indicate that successful cases in our sample were characterized by a more active and engaged patient. In contrast, unsuccessful cases were characterized by a more directive or "controlling" therapist stance. Correlations with PQS prototypes were moderate to strong in both successful and unsuccessful cases, suggesting that optimal and suboptimal interpersonal processes may be independent of adherence to particular treatments. Exploration of therapist behaviors in early sessions indicated that therapists were more likely to adjust their way of working in the successful cases. Our result suggests that patient engagement and therapists early efforts to improve the therapy relationship may be pivotal for successful outcome, whereas therapist controlling behavior may obstruct the treatment process, regardless of therapy model used. The impact of these in-session processes should be examined more closely in larger samples in future studies.

Different forms of psychotherapy are effective for cluster C personality disorders, but we know less about what in-session processes promote change. Contrasting successful and unsuccessful cases may elucidate processes that facilitate or impede outcome and offer suggestions for clinical practice and future research. In this exploratory outcome-process study, 10 successful and 10 unsuccessful cases were selected from a randomized trial comparing cognitive therapy and short-term psychodynamic psychotherapy for cluster C personality disorders. Videotaped sessions were rated with the Psychotherapy Process Q-Set (PQS). The treatments were compared in terms of which PQS items differentiated successful and unsuccessful cases, as well as their resemblance with PQS prototypes of ideal treatments. Therapists' behavior in early sessions was also explored. Results indicate that successful cases in our sample were characterized by a more active and engaged patient. In contrast, unsuccessful cases were characterized by a more directive or controlling therapist stance. Correlations with PQS prototypes were moderate to strong in both successful and unsuccessful cases, suggesting that optimal and suboptimal interpersonal processes may be independent of adherence to particular treatments. Exploration of therapist behaviors in early sessions indicated that therapists were more likely to adjust their way of working in the successful cases. Our result suggests that patient engagement and therapists' early efforts to improve the therapy relationship may be pivotal for successful outcome, whereas therapist controlling behavior may obstruct the treatment process, regardless of therapy model used. The impact of these in-session processes should be examined more closely in larger samples in future studies.

Different forms of psychotherapy are effective for cluster C personality disorders, but we know less about what in-session processes promote change. Contrasting successful and unsuccessful cases may elucidate processes that facilitate or impede outcome and offer suggestions for clinical practice and future research. In this exploratory outcome-process study, 10 successful and 10 unsuccessful cases were selected from a randomized trial comparing cognitive therapy and short-term psychodynamic psychotherapy for cluster C personality disorders. Videotaped sessions were rated with the Psychotherapy Process Q-Set (PQS). The treatments were compared in terms of which PQS items differentiated successful and unsuccessful cases, as well as their resemblance with PQS prototypes of "ideal treatments." Therapists' behavior in early sessions was also explored. Results indicate that successful cases in our sample were characterized by a more active and engaged patient. In contrast, unsuccessful cases were characterized by a more directive or "controlling" therapist stance. Correlations with PQS prototypes were moderate to strong in both successful and unsuccessful cases, suggesting that optimal and suboptimal interpersonal processes may be independent of adherence to particular treatments. Exploration of therapist behaviors in early sessions indicated that therapists were more likely to adjust their way of working in the successful cases. Our result suggests that patient engagement and therapists' early efforts to improve the therapy relationship may be pivotal for successful outcome, whereas therapist controlling behavior may obstruct the treatment process, regardless of therapy model used. The impact of these in-session processes should be examined more closely in larger samples in future studies. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Studying experienced therapists' implicit theorizing may contribute to our understanding of what is helpful and what hinders treatment with particular patient populations. In this study, 16 therapists' views of curative factors, hindering factors, and outcome were explored in 22 interviews conducted at termination of individual psychoanalytic psychotherapy with young adults. Grounded theory methodology was used to construct a tentative model of therapeutic action based on the therapists' implicit knowledge. The results indicated that developing a close, safe and trusting relationship was viewed as the core curative factor in interaction with the patient making positive experiences outside the therapy setting and the therapist challenging and developing the patient's thinking about the self. The therapeutic process was experienced as a joint activity resulting in the patient becoming a subject and acquiring an increasing capacity to think and process problems. The patient's fear about close relationships was seen as hindering treatment and leading to core problems remaining. The model is discussed in relation to major theories of therapeutic action in the psychoanalytic discourse and previous research focusing on young adults' view of curative and hindering factors in psychotherapy. Implications for practice and further research are suggested.

Studying experienced therapists' implicit theorizing may contribute to our understanding of what is helpful and what hinders treatment with particular patient populations. In this study, 16 therapists' views of curative factors, hindering factors, and outcome were explored in 22 interviews conducted at termination of individual psychoanalytic psychotherapy with young adults. Grounded theory methodology was used to construct a tentative model of therapeutic action based on the therapists' implicit knowledge. The results indicated that developing a close, safe and trusting relationship was viewed as the core curative factor in interaction with the patient making positive experiences outside the therapy setting and the therapist challenging and developing the patient's thinking about the self. The therapeutic process was experienced as a joint activity resulting in the patient becoming a subject and acquiring an increasing capacity to think and process problems. The patient's fear about close relationships was seen as hindering treatment and leading to core problems remaining. The model is discussed in relation to major theories of therapeutic action in the psychoanalytic discourse and previous research focusing on young adults' view of curative and hindering factors in psychotherapy. Implications for practice and further research are suggested.

The patients’ view of curative and hindering factors in psychoanalytic psychotherapy was explored, starting from conducting the Private Theories Interview with 22 young adult patients at termination of their therapies. A tentative theoretical model of therapeutic action was constructed using grounded theory methodology.Talking About Oneself, Having a Special Place and Relationship, and Exploring Together With the Therapist were perceived as curative factors by the patients, leading to therapeutic impacts such as New Relational Experiences and Expanding Self-Awareness. Hindering aspects included experiencing that Talking Is Difficult and that Something Was Missing in therapy, interacting with negative impacts such as Self-Knowledge Is Not Enough and Experiencing Mismatch. Methodological issues, the question of common versus specific factors, and implications for clinical practice are discussed.

The present study aimed to examine whether patients' pretherapy motivation was related to other patient characteristics and whether it predicted retention in psychotherapy. Data were collected within a naturalistic outcome study of various forms of psychotherapy for patients (N = 172) with substance use disorders (SUD). Therapy motivation was measured using the Client Motivation for Therapy Scale (CMOTS), including the variables autonomous motivation, controlled motivation, and amotivation. Female patients had higher levels of autonomous motivation (d = .53), lower levels of controlled motivation (d = -.32), and lower levels of amotivation (d = -.62). Level of symptoms and impairment was significantly positively correlated with controlled motivation (r = .31). Autonomous motivation was positively correlated with four expectation subscales associated with constructive therapeutic work, whereas amotivation was negatively correlated with three of these subscales. Controlled motivation was positively correlated with the subscales external orientation, defensiveness, and support. In a logistic regression, amotivation stood out as a negative predictor of retention, in terms of starting in psychotherapy after assessment or not. Quite surprisingly, autonomous motivation was not a significant predictor of retention. The present study indicates that amotivation is a risk factor for early dropout among SUD patients. More efforts should be directed at preparing patients for psychotherapy through strengthening motivation.

The present study aimed to examine whether patients' pretherapy motivation was related to other patient characteristics and whether it predicted retention in psychotherapy. Data were collected within a naturalistic outcome study of various forms of psychotherapy for patients (N = 172) with substance use disorders (SUD). Therapy motivation was measured using the Client Motivation for Therapy Scale (CMOTS), including the variables autonomous motivation, controlled motivation, and amotivation. Female patients had higher levels of autonomous motivation (d = .53), lower levels of controlled motivation (d = -.32), and lower levels of amotivation (d = -.62). Level of symptoms and impairment was significantly positively correlated with controlled motivation (r = .31). Autonomous motivation was positively correlated with four expectation subscales associated with constructive therapeutic work, whereas amotivation was negatively correlated with three of these subscales. Controlled motivation was positively correlated with the subscales external orientation, defensiveness, and support. In a logistic regression, amotivation stood out as a negative predictor of retention, in terms of starting in psychotherapy after assessment or not. Quite surprisingly, autonomous motivation was not a significant predictor of retention. The present study indicates that amotivation is a risk factor for early dropout among SUD patients. More efforts should be directed at preparing patients for psychotherapy through strengthening motivation.

This naturalistic study presents outcomes for three therapy types practiced in psychiatric public health care in Sweden. Data were collected over a 3-year period at 13 outpatient psychiatric care services participating in the online Quality Assurance of Psychotherapy in Sweden (OAPS) system. Of the 1,498 registered patients, 14% never started psychotherapy, 17% dropped out from treatment, and 36% dropped out from data collection. Outcome measures included symptom severity, quality of life, and self-rated health. Outcomes were studied for 180 patients who received cognitive behavioral, psychodynamic, or integrative/eclectic therapy after control for dropout representativity. Among treatment completers, patients with different pretreatment characteristics seem to have received different treatments. Patients showed significant improvements, and all therapy types had generally good outcomes in terms of symptom reduction and clinical recovery. Overall, the psychotherapy delivered by the Swedish public health services included in this study is beneficial for the majority of patients who complete treatment. Multilevel regression modeling revealed no significant effect for therapy type for three different outcome measures. Neither did treatment duration have any significant effect. The analysis did not demonstrate any significant therapist effects on the three outcome measures. The results must be interpreted with caution, as there was large attrition and incomplete data, nonrandom assignment to treatment, no treatment integrity control, and lack of long-term follow-up.

This naturalistic study presents outcomes for three therapy types practiced in psychiatric public health care in Sweden. Data were collected over a 3-year period at 13 outpatient psychiatric care services participating in the online Quality Assurance of Psychotherapy in Sweden (OAPS) system. Of the 1,498 registered patients, 14% never started psychotherapy, 17% dropped out from treatment, and 36% dropped out from data collection. Outcome measures included symptom severity, quality of life, and self-rated health. Outcomes were studied for 180 patients who received cognitive behavioral, psychodynamic, or integrative/eclectic therapy after control for dropout representativity. Among treatment completers, patients with different pretreatment characteristics seem to have received different treatments. Patients showed significant improvements, and all therapy types had generally good outcomes in terms of symptom reduction and clinical recovery. Overall, the psychotherapy delivered by the Swedish public health services included in this study is beneficial for the majority of patients who complete treatment. Multilevel regression modeling revealed no significant effect for therapy type for three different outcome measures. Neither did treatment duration have any significant effect. The analysis did not demonstrate any significant therapist effects on the three outcome measures. The results must be interpreted with caution, as there was large attrition and incomplete data, nonrandom assignment to treatment, no treatment integrity control, and lack of long-term follow-up.