Journal of Consulting and Clinical Psychology

Fischer, Melanie S.; Loiselle, Raelyn; Weber, Danielle M.; Highlander, April; McCall, Madison P.; Cain, Grace H.; Forehand, Rex; Jones, Deborah J.

doi: 10.1037/ccp0000878pmid: 38512173

Objective: Behavioral parent training (BPT) is the standard of care for early onset behavior disorders (BDs), however, not all families benefit. Emotion regulation (ER) is one potential mechanism underlying BPT outcomes, yet there are challenges in capturing intra- and interpersonal aspects of emotion regulation within parent–child interactions that are central to BPT. This study examined how vocally encoded emotional arousal unfolds during parent–child interactions and how parents and children influence each other’s arousal (Aim 1), the links between these emotion dynamics, child behavior, and parenting at baseline (Aim 2), and BPT outcome (Aim 3). Method: Families of children with BDs (N = 45) completed two interaction tasks and measures of parenting and child behavior. Parent–child dynamics of vocal fundamental frequency (f0) were modeled using actor–partner interdependence models (APIMs) and coupled linear oscillators (CLOs). Results: When considering relative levels of f0 from one talk turn to the next (APIMs), parents and children showed intrapersonal regulation and synchronizing reactivity to each other’s f0. When considering the shape of oscillations (CLOs), parents and children showed intrapersonal regulation but no reactivity. Intrapersonal regulation of f0 during the interaction was slowed for parents with more maladaptive parenting and children with more behavior problems at baseline. Conclusions: This preliminary characterization of f0 in families presenting for BPT provides insights into the emotion dynamics potentially underlying parenting behavior and child behavior.

Brose, Annette; Koval, Peter; Heinrich, Manuel; Zagorscak, Pavle; Bohn, Johannes; Knaevelsrud, Christine

doi: 10.1037/ccp0000892pmid: 38780572

Objective: Depressive symptom dynamics, including change trajectories and symptom variability, have been related to therapy outcomes. However, such dynamics have often been examined separately and related to outcomes of interest using two-step analyses, which are characterized by several limitations. Here, we show how to overcome these limitations using location-scale models in a dynamic structural equation modeling framework. Method: We introduce location-scale modeling in an accessible manner to pave the way for its use in research integrating within-person dynamics and intervention-related change in psychopathology, and we illustrate this modeling approach in a large-scale internet-based intervention for depression (N = 1,656). Using eight data points sampled across about 8 weeks, we predicted improvement across the intervention (50% symptom reduction) as a function of early change and symptom variability. Results: Early symptom change was associated with a more likely improvement across therapy. Variability of symptoms beyond change trajectories during the intervention was associated with less likely improvement. Conclusions: Location-scale models, and dynamic structural equation modeling more generally, are well suited to modeling how patterns of symptom change during psychotherapy are related to important (e.g., therapy) outcomes. Our illustrative application of location-scale modeling showed that symptom variability was associated with less overall improvement in depressive symptoms. However, this finding requires replication with more intensive sampling of symptoms before final conclusions can be drawn on when and how to distinguish maladaptive from adaptive variability during psychotherapy.

Paz, Adar; Rafaeli, Eshkol; Bar-Kalifa, Eran; Gilboa-Schechtman, Eva; Gannot, Sharon; Narayanan, Shrikanth S.; Atzil-Slonim, Dana

doi: 10.1037/ccp0000901pmid: 39052383

Objective: Affective flexibility, the capacity to respond to life’s varying environmental changes in a dynamic and adaptive manner, is considered a central aspect of psychological health in many psychotherapeutic approaches. The present study examined whether affective two-dimensional (i.e., arousal and valence) temporal variability extracted from voice and facial expressions would be associated with positive changes over the course of psychotherapy, at the session, client, and treatment levels. Method: A total of 22,741 mean vocal arousal and facial expression valence observations were extracted from 137 therapy sessions in a sample of 30 clients treated for major depressive disorder by nine therapists. Before and after each session, the clients self-reported their level of well-being on the outcome rating scale. Session-level affective temporal variability was assessed as the mean square of successive differences between consecutive two-dimensional affective measures. Results: Session outcome was positively associated with temporal variability at the session level (i.e., within clients, between sessions) and at the client level (i.e., between clients). Importantly, these associations held when controlling for average session- and client-level valence scores. In addition, the expansion of temporal variability throughout treatment was associated with steeper positive session outcome trajectories over the course of treatment. Conclusions: The continuous assessment of both vocal and facial affective expressions and the ability to extract measures of affective temporal variability from within-session data may enable therapists to better respond and modulate clients’ affective flexibility; however, further research is necessary to determine whether there is a causal link between affective temporal variability and psychotherapy outcomes.

Coyne, Alice E.; Mattson, Elsa; Bagley, Jenna M.; Klein, Alexandra B.; Shekhtman, Kathy; Payat, Sinan; Levine, Daniella S.; Feeny, Norah C.; Zoellner, Lori A.

doi: 10.1037/ccp0000837pmid: 37971811

Finsrud, Ingvild; Nissen-Lie, Helene A.; Ulvenes, Pål G.; Vrabel, KariAnne; Melsom, Linne; Wampold, Bruce

doi: 10.1037/ccp0000853pmid: 37768630

Objective: In this naturalistic study we aimed to investigate the relationships between two central change processes (affective and cognitive) and two common relationship factors (“Confidence in the therapist” and “Confidence in the treatment”), which have been shown to impact outcomes in a clinical context. We also investigated whether these interrelationships varied across treatment orientations (i.e., cognitive or psychodynamic focused). Method: The sample consisted of 631 patients with a primary anxiety or depressive disorder who were admitted to an inpatient program and treated with psychotherapy. The data consisted of weekly measures of cognitive (i.e., “rumination”) and affective (i.e., “problems with emotional clarity”) change processes as well as scores on Confidence in the therapist and Confidence in the treatment and symptom distress. A multivariate version of the latent curve model with structured residuals was used to investigate the within-patient effects of week-to-week changes in all variables. Results: Initial analyses established that both problems with emotional clarity and rumination predicted symptom distress. Further, we found that higher Confidence in the therapist predicted higher emotional clarity (but not lower rumination) whereas higher Confidence in the treatment predicted lower rumination (but did not affect emotional clarity). Post hoc analyses found that these interrelationships varied across treatment orientation (i.e., cognitive vs. psychodynamic). Discussion: The results indicate that patients’ experience of the therapist is associated with emotional change processes, and that patients’ experience of the coherence and meaningfulness of treatment, on the other hand, is associated with cognitive change processes. Implications for clinical practice are discussed.

Nardone, Stephanie; Pascual-Leone, Antonio; Kramer, Ueli; Cristoffanini, Florencia; Grandjean, Loris; Culina, Ines; McMain, Shelley

doi: 10.1037/ccp0000903pmid: 39418458

Objective: We examined whether the emotions that clients experience within session are associated with treatment outcome in dialectical behavior therapy (DBT) for borderline personality disorder (BPD). Method: Participants were 52 adults who met criteria for BPD and were enrolled in a 12-month DBT treatment. The Classification of Affective-Meaning States, an observer-rated measure of discrete emotions, was used to code videos of individual DBT sessions. Raters coded three psychotherapy sessions for each participant: one session from each of the early, working, and late phases of psychotherapy. Self-report measures of BPD symptoms were used to assess treatment outcome. Results: More emotional experience overall during the early phase predicted fewer BPD symptoms at 12-month treatment outcome, explaining 19% of the variance in symptoms. However, increases across treatment in global distress predicted higher levels of BPD (24% of the variance explained) and depression symptoms (15% explained) at termination. Increases in emotional flexibility (i.e., variation between states) from the early to working phase predicted fewer depressive symptoms at termination (14% explained). Self-compassion coded during the working phase also predicted a better treatment outcome (explaining 19%–34%). Conclusions: Clients’ in-session emotional experiences predict treatment outcome 8–10 months later. Clients with BPD may benefit from more overall exploration of their emotional experiences early in DBT, as well as expression of self-compassion. Increases in nonspecific, intense negative affect anticipates poor prognosis, whereas increases in emotional flexibility during early treatment anticipates better prognosis.

Dunn, Barnaby D.; Warbrick, Laura; Hayes, Rachel; Montero-Marin, Jesus; Reed, Nigel; Dalgleish, Tim; Kuyken, Willem

doi: 10.1037/ccp0000902pmid: 39418459

Objective: Mindfulness-based cognitive therapy (MBCT) is a viable alternative to maintenance antidepressant medication (M-ADM) to reduce risk of relapse/recurrence (RR) in recurrent depression, but its mechanism of action is not yet fully articulated. This secondary analysis of the PREVENT trial examined if MBCT with support to taper medication (MBCT-TS) reduces risk of RR in part by enhancing positive affect (PA). Method: In a single-blind, parallel, group randomized controlled trial, adults with ≥3 prior depressive episodes, but not currently in episode and who were taking M-ADM, were randomized to receive either MBCT-TS or ongoing maintenance M-ADM. The primary outcome was RR over 24-month follow-up. Levels of positive affect were assessed at intake and posttreatment. The original PREVENT trial was preregistered (ISRCTN 26666654), but this secondary analysis was not. Results: Four hundred and twenty-four individuals (predominantly female and of White British ethnicity) were recruited, with 212 randomized to each arm. MBCT-TS led to significantly greater PA relative to M-ADM at posttreatment assessment (Δ = 2.78, 95% CI [1.47, 4.08], p < .001). RR was experienced during follow-up by 194 individuals (100 M-ADM; 94 MBCT-TS). Greater intake PA predicted a reduced hazard of RR across treatments (p < .001; hazard ratio = .96, 95% CI [0.94, 0.98]). In individuals who had not relapsed by posttreatment with complete data (121 M-ADM; 145 MBCT-TS), greater increase in PA from intake to posttreatment mediated reduced risk of subsequent RR (p = .04). Conclusions: These findings suggest that greater levels of PA predict reduced risk of RR and that MBCT-TS in part acts to protect from RR when withdrawing from M-ADM by increasing PA.

Rosencrans, Peter L.; Walker, Rosemary S. W.; Coyne, Alice E.; Baier, Allison L.; Klein, Alexandra B.; Shekhtman, Kathy; Bowling, Alexandra R.; Feeny, Norah C.; Zoellner, Lori A.

doi: 10.1037/ccp0000898pmid:

Fernández-Álvarez, Javier; Babl, Anna; Botella, Cristina; grosse Holtforth, Martin; Gómez Penedo, Juan Martín

doi: 10.1037/ccp0000860pmid: 39418461

Objective: The aim of this study was to disaggregate the between-patient and within-patient effects of emotion regulation (ER) on treatment outcome and explore relevant trait-like moderators of the within-patient effects. Method: Three hundred thirty-nine patients with heterogenous clinical conditions were admitted to psychotherapy at a clinical center. During the intake evaluation, patients completed the Inventory of Interpersonal Problems, the Outcome Questionnaire 30, and the State Difficulties of Emotion Regulation Scale. Subsequently, patients responded to the Outcome Questionnaire 30 and State Difficulties of Emotion Regulation Scale every session for the initial five sessions, followed by assessments every two sessions until the 15th session and then every four sessions until the end of treatment. Results: Multilevel models revealed significant between- and within-patient effects of ER on clinical distress. That is, patients with lower average levels of ER difficulties showed greater benefit from treatment, and lower ER difficulties over the course of treatment were associated with lower clinical distress. Furthermore, interactive models demonstrated that lower average levels of ER throughout treatment and fewer interpersonal problems at the beginning of treatment were associated with better treatment outcome. Conclusion: These findings provide evidence supporting the role of ER as a mechanism of change. The interaction between trait-like components and state-like fluctuations of ER suggests a capitalization model for the role of ER in psychotherapy.

Sønderland, Nils M.; Solbakken, Ole A.; Eilertsen, Dag E.; Nordmo, Magnus; Monsen, Jon T.

doi: 10.1037/ccp0000814pmid: 37166832

Objective: This systematic review and meta-analysis summarize current knowledge on emotional change processes and mechanisms and their relationship with outcomes in psychotherapy. Method: We reviewed the main change processes and mechanisms in the literature and conducted meta-analyses of process/mechanism–outcome associations whenever methodologically feasible. Results: A total of 121 studies, based on 92 unique samples, met criteria for inclusion. Of these, 85 studies could be subjected to meta-analysis. The emotional change processes and mechanisms most robustly related to improvement were fear habituation across sessions in exposure-based treatment of anxiety disorders (r = .38), experiencing in psychotherapy for depression (r = .44), and emotion regulation in psychotherapies for patients with various anxiety disorders (r = .37). Common methodological problems were that studies often did not ascertain representative estimates of the processes under investigation, determine if changes in processes and mechanisms temporally preceded outcomes, disentangle effects at the within- and between-client levels, or assess contributions of therapists and clients to a given process. Conclusions: The present study has identified a number of emotional processes and mechanisms associated with outcome in psychotherapy, most notably fear habituation, emotion regulation, and experiencing. A common denominator between these appears to be the habitual reorganization of maladaptive emotional perception. We view this as a central pan-theoretical change mechanism, the essence of which appears to be increased differentiation between external triggers and one’s own affective responses, which facilitates tolerance for affective arousals and leads to improved capacity for adaptive meaning-making in emotion-eliciting situations.