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Background Therapeutic alliance has been well established as a robust predictor of face-to-face psychotherapy outcomes. Although initial evidence positioned alliance as a relevant predictor of internet intervention success, some conceptual and methodological concerns were raised regarding the methods and instruments used to measure the alliance in internet interventions and its association with outcomes. Objective The aim of this study was to explore the alliance-outcome association in a guided internet intervention using a measure of alliance especially developed for and adapted to guided internet interventions, showing evidence of good psychometric properties. Methods A sample of 223 adult participants with moderate depression received an internet intervention (ie, Deprexis) and email support. They completed the Working Alliance Inventory for Guided Internet Intervention (WAI-I) and a measure of treatment satisfaction at treatment termination and measures of depression severity and well-being at termination and 3- and 9-month follow-ups. For data analysis, we used two-level hierarchical linear modeling that included two subscales of the WAI-I (ie, tasks and goals agreement with the program and bond with the supporting therapist) as predictors of the estimated values of the outcome variables at the end of follow-up and their rate of change during the follow-up period. The same models were also used controlling for the effect of patient satisfaction with treatment. Results We found significant effects of the tasks and goals subscale of the WAI-I on the estimated values of residual depressive symptoms (γ02=−1.74, standard error [SE]=0.40, 95% CI −2.52 to −0.96, t206=−4.37, P<.001) and patient well-being (γ02=3.10, SE=1.14, 95% CI 0.87-5.33, t198=2.72, P=.007) at the end of follow-up. A greater score in this subscale was related to lower levels of residual depressive symptoms and a higher level of well-being. However, there were no significant effects of the tasks and goals subscale on the rate of change in these variables during follow-up (depressive symptoms, P=.48; patient well-being, P=.26). The effects of the bond subscale were also nonsignificant when predicting the estimated values of depressive symptoms and well-being at the end of follow-up and the rate of change during that period (depressive symptoms, P=.08; patient well-being, P=.68). Conclusions The results of this study point out the importance of attuning internet interventions to patients’ expectations and preferences in order to enhance their agreement with the tasks and goals of the treatment. Thus, the results support the notion that responsiveness to a patient’s individual needs is crucial also in internet interventions. Nevertheless, these findings need to be replicated to establish if they can be generalized to different diagnostic groups, internet interventions, and supporting formats.

Aim. Several studies have reported significant within-patient effects of the therapeutic alliance on outcome. However, it remains uncertain whether there are specific patient groups for whom an improved alliance might be particularly beneficial. The relational nature of the alliance makes patients' interpersonal problems a promising candidate for examining such differential effects. This study aims to analyze (i) between-and within-patient effects of the alliance on depression severity, (ii) the effects of patients' baseline interpersonal problems on the within-patient alliance-outcome association, and (iii) whether within-patient effects of the alliance remain significant when adjusting for patients' initial interpersonal problems. Methods. A sample of 141 patients with depression and undergoing outpatient psychotherapy completed the Inventory of Interpersonal Problems at baseline as well as a brief version of the Working Alliance Inventory and the Well-Being Index (as a proxy of depression severity) session-by-session. Results. Multilevel models revealed both significant between-and withinpatient effects of the alliance on improvements in depression severity. Patients' problems relating to agency had a significant effect on the within-patient effect of alliance, with more submissive patients benefiting more from an improved therapeutic alliance. Finally, the between-and within-patient effects of the alliance remained significant when adjusting for the patients' agentic interpersonal problems and treatment condition. Conclusions. The results provide evidence on which types of patients would particularly benefit from an improved therapeutic alliance. For patients suffering from low interpersonal agency and reporting problems with submissiveness, an enhanced alliance during the therapy process might improve treatment outcome.

BackgroundThis currently recruiting randomized controlled trial investigates the effects of integrating components of Emotion-Focused Therapy (EFT) into Psychological Therapy (PT), an integrative form of cognitive-behavioral therapy in a manner that is directly mirroring common integrative practice in the sense of assimilative integration. Aims of the study are to understand how both, an existing therapy approach as well as the elements to be integrated, are affected by the integration and to clarify the role of emotional processing as a mediator of therapy outcome.MethodsA total of 130 adults with a diagnosed unipolar depressive, anxiety or adjustment disorder (seeking treatment at a psychotherapy outpatient clinic) are randomized to either treatment as usual (PT) with integrated emotion-focused components (TAU + EFT) or PT (TAU). Primary outcome variables are psychopathology and symptom severity at the end of therapy and at follow up; secondary outcome variables are interpersonal problems, psychological wellbeing, quality of life, attainment of individual therapy goals, and emotional competency. Furthermore, process variables such as the quality of the therapeutic relationship are studied as well as aptitude-treatment interactions. Variables are assessed at baseline, after 8 and 16 sessions, at the end of therapy, after 25 ± 3 sessions, and at 6, 12 and 36 month follow-up. Underlying mechanisms of change are investigated. Statistical analyses will be conducted using the appropriate multilevel approaches, mainly two-level regression and growth analysis.DiscussionThe results of this study will indicate whether the integration of emotion-focused elements into treatment as usual increases the effectiveness of Psychological Therapy. If advantages are found, which may be limited to particular variables or subgroups of patients, recommendations for a systematic integration, and caveats if also disadvantages are detected, can be formulated. On a more abstract level, a cognitive behavioral (represented by PT) and humanistic/experiential (represented by EFT) approach will be integrated. It must be emphasized that mimicking common practice in the development and continued education of psychotherapists, EFT is not integrated as a whole, but only elements of EFT that are considered particularly important, and can be trained in an 8-day training plus supervision of therapies.Trial registrationClinicalTrials.gov, NCT02822443, 22 June 2016, retrospectively registered

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The ability to mentalize has been discussed as potential change mechanism in psychotherapy. Reflective functioning (RF) offers an empirical framework for the assessment of mentalization in therapy sessions. In the present study, we assessed RF longitudinally and examined its association with symptomatic distress, symptom severity of depression and anxiety, and interpersonal problems over the course of treatment. Thirty-seven patients diagnosed with depression or anxiety disorders received 25 ± 3 sessions of integrative cognitive-behavioral therapy (CBT) in an outpatient setting. The observer-rated in-session Reflective Functioning Scale (RFS) was applied to transcripts of therapy Sessions 1, 8, 16, and 24. The effects of RF were investigated both within and between patients using hierarchical linear modeling. RF significantly increased over the course of treatment, and this improvement in RF was significantly associated with depressive symptoms. This means that after a session where patients positively deviated from their own average RF during treatment, they reported lower depression severity. In post hoc analyses, we found a significant interaction effect of the within-and between-patient RF effects on interpersonal problems. Patients with overall higher levels of RF and with positive deviations from their own average RF over the course of treatment tended to have less interpersonal problems during psychotherapy. The present study contributes to the preliminary evidence that changes in RF may serve as a common factor in psychotherapy in contrast to being a specific factor in psychodynamic therapies. More longitudinal studies are necessary to gain a better understanding of RF as a change mechanism in psychotherapy. Public Significance StatementThe present study suggests that the capacity to perceive and understand oneself and others (mentalization) improves over the course of cognitive-behavioral therapy in patients with depressive and anxiety disorders. Further, mentalization is associated with psychotherapy outcome: after a session where patients positively deviated from their own average ability to mentalize, they reported lower depression severity; patients with overall higher levels of mentalizing over the course of treatment and with positive deviations from their own average ability to mentalize, tended to have less interpersonal problems during psychotherapy. It may thus be beneficial for practitioners to find ways of improving their patients' ability to mentalize over the course of treatment and thereby interpersonal problems (possibly also other psychotherapy outcomes).

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Objectives: This paper presents a randomized controlled trial on assimilative integration, which is aimed at integrating elements from other orientations within one approach to enrich its conceptual and practical repertoire. Elements from Emotion-Focused Therapy (EFT) were integrated into a form of cognitive behavior therapy: Psychological Therapy (PT). In one treatment condition, EFT was added to PT (+EFT) with the intent to enhance therapists' working with emotions. In the other condition, concepts and interventions based on the socialpsychological selfregulation approach were added to PT (+SR). Our assumption was that the +EFT would lead to greater and deeper change, particularly in the follow-up assessments.