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Patients’ Perceptions of Risky Developments During Psychotherapy

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Research on risks and unwanted effects is largely missing in psychotherapy. Using exploratory factor analysis six dimensions of personal therapy situation were identified in a preliminary study, three of them were associated with risky developments during the psychotherapeutic process: (1) (poor) quality of therapeutic relationship, (2) burden caused by psychotherapy, and (3) dependency/isolation. Based on the finding of this study an online survey was performed to examine these three dimensions. Aside from these three factors another variable was associated with risky therapy developments: the online questionnaire also asked for premature terminations of psychotherapy as a consequence of risky conditions for the therapeutic development. Risky conditions were found to be associated with the following variables: (1) the combination of female patient–male therapist, (2) the therapeutic orientation (particularly with the psychodynamic approaches) and (3) the duration of therapy. Fewer humanistic and systemic psychotherapies were found among the high risk-prone group of patients who were at risk in at least three of the four variables which were associated with risky developments. Differences in the findings of the study regarding the four therapeutic orientations stress the importance of an extensive differential indication and a cooperative partnership between patient and therapist, in order to facilitate a positive patient participation towards the choice of therapy method and subsequent successful participation throughout the course of treatment. Further studies should also focus on female patient and male therapist psychotherapies.
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... The personal attributes of the therapist, such as rigidity, uncertainty, criticism, alienation, tension, and distraction could negatively affect the outcomes of psychotherapy (16). In addition, many surveys have shown that the type of psychotherapy was also an important factor that affects side effects (8,13,17). Significantly more patients were treated with psychodynamic therapy and reported having "lasting negative effects" than those without psychodynamic therapy (8). Among the high-risk patients with side effects of psychotherapy, 11.6% were treated with CBT, 4.2% were treated with systemic therapy, 16.8% were treated with humanistic psychotherapy, and 67.2% were treated with psychodynamic therapy (17). ...
... Significantly more patients were treated with psychodynamic therapy and reported having "lasting negative effects" than those without psychodynamic therapy (8). Among the high-risk patients with side effects of psychotherapy, 11.6% were treated with CBT, 4.2% were treated with systemic therapy, 16.8% were treated with humanistic psychotherapy, and 67.2% were treated with psychodynamic therapy (17). In short, many factors are related to the side effects of psychotherapy, but we are still not sure which factors are the most relevant predictors of side effects in psychotherapy. ...
... The "theoretical orientation" is the professional theoretical background of psychotherapy that the client learns from the therapist. Our results suggested that the theoretical application of psychotherapy had a significant predictive effect on the side effects experienced, which was consistent with previous studies (8,13,17). In our study, participants who received psychodynamic therapy had significantly higher rates of side effects than other treatments ( Table 1). ...
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Background: Side effects in psychotherapy are a common phenomenon, but due to insufficient understanding of the relevant predictors of side effects in psychotherapy, many psychotherapists or clinicians fail to identify and manage these side effects. The purpose of this study was to predict whether clients or patients would experience side effects in psychotherapy by machine learning and to analyze the related influencing factors. Methods: A self-compiled “Psychotherapy Side Effects Questionnaire (PSEQ)” was delivered online by a WeChat official account. Three hundred and seventy participants were included in the cross-sectional analysis. Psychotherapy outcomes were classified as participants with side effects and without side effects. A number of features were selected to distinguish participants with different psychotherapy outcomes. Six machine learning-based algorithms were then chosen and trained by our dataset to build outcome prediction classifiers. Results: Our study showed that: (1) the most common side effects were negative emotions in psychotherapy, such as anxiety, tension, sadness, and anger, etc. (24.6%, 91/370); (2) the mental state of the psychotherapist, as perceived by the participant during psychotherapy, was the most relevant feature to predict whether clients would experience side effects in psychotherapy; (3) a Random Forest-based machine learning classifier offered the best prediction performance of the psychotherapy outcomes, with an F1-score of 0.797 and an AUC value of 0.804. These numbers indicate a high prediction performance, which allowed our approach to be used in practice. Conclusions: Our Random Forest-based machine learning classifier could accurately predict the possible outcome of a client in psychotherapy. Our study sheds light on the influencing factors of the side effects of psychotherapy and could help psychotherapists better predict the outcomes of psychotherapy.
... Bornstein and Bowen (14) noted earlier that there are a number of studies that assumed a correlation between dependency and depression (15), as well as other conditions such as eating disorders, anxiety disorders, alcoholism, and psychosomatic disorders (16)(17)(18). More recently, dependency was identified as a possible risk factor in psychotherapy (19,20). Furthermore, dependency has been associated with characteristics of the patients such as passive and helpless stance (21). ...
... These findings are in line with results from the first study operating the CDQ by Geurtzen et al. (21) who found a higher degree of care dependency to be associated with a higher degree of symptom severity in a large crosssectional sample of 742 outpatients with different psychiatric disorders. The negative potential of experienced dependency was also discussed and taken into consideration before (19,20,39,40). However, another study from Geurtzen et al. (23) could not find the negative association with symptom development in a sample of students receiving clinical training. ...
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Background: This study explores the association of experienced dependency in psychotherapy as measured with the CDQ (Care Dependency Questionnaire) and treatment outcome in depression. Furthermore, the course of care dependency and differences in the CDQ scores depending on the received type of treatment, MCT (metacognitive therapy), or CBASP (cognitive behavioral analysis system of psychotherapy), were investigated. Methods: The study follows a prospective, parallel group observational design. Patients suffering from depression received an 8-week intensive day clinic program, which was either CBASP or MCT. The treatment decision was made by clinicians based on the presented symptomatology and with regard to the patients' preferences. The patients reported depressive symptoms with the QIDS-SR16 (Quick Inventory of Depressive Symptomatology) and levels of experienced care dependency with the German version of the CDQ on a weekly basis. Mixed-model analyses were run to account for the repeated-measures design. Results: One hundred patients were included in the analyses. Results indicate that higher levels of care dependency might predict a less favorable outcome of depressive symptomatology. Levels of care dependency as well as depressive symptoms decreased significantly over the course of treatment. There was no significant between-group difference in care dependency between the two treatment groups. Conclusion: The results suggest that care dependency might be associated with a worse treatment outcome in depressed patients. In general, care dependency seems to be a dynamic construct, as it is changing over time, while the levels of care dependency seem to be independent from the received type of treatment. Future research should continue investigating the mechanisms of care dependency in a randomized controlled design. Clinical Trial Registration: https://www.drks.de/drks_web/ , identifier: DRKS00023779.
... It has, however, also been suggested that faceto-face treatment can be too long [50]. If the treatment pathway and thereby the interaction with the therapist lasts too long, the patient may not experience an optimal transfer of new competences into daily life and the therapy may turn into a less structured and more private kind of conversation [74][75][76]. Blending face-to-face sessions with internet-based modules may not only be a way of preventing early treatment drop-out due to ease of access but also of preventing the patient from becoming dependent on the therapist due to patient empowerment [75,76]. Additionally, blended treatment may help to prevent 'therapist drift' since the internet modules and exercises not only provide a clear working structure for the patient but also for the therapist [77]; the therapist is nudged to incorporate the full therapy protocol in the sessions, thus improving compliance with the therapy protocol on the therapist's side [78]. ...
... If the treatment pathway and thereby the interaction with the therapist lasts too long, the patient may not experience an optimal transfer of new competences into daily life and the therapy may turn into a less structured and more private kind of conversation [74][75][76]. Blending face-to-face sessions with internet-based modules may not only be a way of preventing early treatment drop-out due to ease of access but also of preventing the patient from becoming dependent on the therapist due to patient empowerment [75,76]. Additionally, blended treatment may help to prevent 'therapist drift' since the internet modules and exercises not only provide a clear working structure for the patient but also for the therapist [77]; the therapist is nudged to incorporate the full therapy protocol in the sessions, thus improving compliance with the therapy protocol on the therapist's side [78]. ...
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Background: A major challenge to psychological treatment for alcohol use disorder (AUD) is patient non-compliance. A promising new treatment approach that is hypothesized to increase patient compliance is blended treatment, consisting of face-to-face contact with a therapist combined with modules delivered over the internet within the same protocol. While this treatment concept has been developed and proven effective for a variety of mental disorders, it has not yet been examined for AUD. Aims: The study described in this protocol aims to examine and evaluate patient compliance with blended AUD treatment as well as the clinical and cost effectiveness of such treatment compared to face-to-face treatment only. Methods: The study design is a pragmatic, stepped-wedge cluster randomized controlled trial. The included outpatient institutions (planned number of patients: n =1800) will be randomized in clusters to implement either blended AUD treatment or face-to-face treatment only, i.e. treatment as usual (TAU). Both treatment approaches consist of motivational interviewing and cognitive behavioral therapy. Data on sociodemographics, treatment (e.g. intensity, duration), type of treatment conclusion (compliance vs. dropout), alcohol consumption, addiction severity, consequences of drinking, and quality of life, will be collected at treatment entry, at treatment conclusion, and six months after treatment conclusion. The primary outcome is compliance at treatment conclusion, and the secondary outcomes include alcohol consumption and quality of life at six-months follow-up. Data will be analyzed with an Intention-to-treat approach by means of generalized linear mixed models with a random effect for cluster and fixed effect for each step. Also, analyses evaluating cost-effectiveness will be conducted. Discussion: Blended treatment may increase treatment compliance and thus improve treatment outcomes due to increased flexibility of the treatment course. Since this study is conducted within an implementation framework it can easily be scaled up, and when successful, blended treatment has the potential to become an alternative offer in many outpatient clinics nationwide and internationally. Clinicaltrials.gov.: NCT04535258, retrospectively registered 01.09.20 Key words: alcohol use disorder, blended treatment, cognitive behavior therapy, guided internet-based treatment, motivational interviewing
... Some studies have shown that the theoretical orientation of psychotherapy signi cantly affects the occurrence of side effects [4,6]. For example, patients who experienced a poor therapeutic relationship, a high degree of dependency or isolation and a high burden through psychotherapy were more frequently treated in psychodynamic therapies [47]. Although such a therapeutic process is effective, it places great pressure on patients. ...
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Background: Side effects in psychotherapy are sometimes unavoidable. Therapists play a significant role in the side effects of psychotherapy, but there have been few quantitative studies on the mechanisms by which therapists contribute to them. Methods: We designed the Psychotherapy Side Effects Questionnaire-Therapist Version (PSEQ-T) and released it online through an official WeChat account, where 530 therapists participated in the cross-sectional analysis. The therapists were classified into groups with and without perceptions of clients’ side effects. A number of features were selected to distinguish the therapists by category. Six machine learning–based algorithms were selected and trained by our dataset to build classification models. To make the prediction model interpretable, we leveraged the Shapley Additive exPlanations (SHAP) method to quantify the importance of each feature to the therapist categories. Results: Our study demonstrated the following: 1) Of the therapists, 316 perceived the side effects of the clients in the ongoing psychotherapy sessions, with a 59.6% incidence of side effects. Among all 7 perception types of the side effects, the most common type was “make the clients or patients feel bad” (49.8%). 2) A random forest–based machine-learning classifier offered the best predictive performance to distinguish the therapists with and without perceptions of clients’ side effects, with an F1 score of 0.722 and an AUC value of 0.717. 3) When “therapists’ psychological activity” was considered a possible cause of the side effects in psychotherapy by the therapists, it was the most relevant feature for distinguishing the therapist category. Conclusions: Our study revealed that the therapist's mastery of the limitations of psychotherapy technology and theory, especially the awareness and construction of their own psychological states, was the most important factor in predicting the therapist's perception of the side effects of psychotherapy.
... Dazu gibt es unseres Wissens nur wenige Daten, sodass sich die Frage stellt, welche Wahrnehmungs-und Erfahrungsschemata zu diesen Einschätzungen führen. In einer Fragebogenuntersuchung an Patienten von Leitner et al. [2013] scheinen die humanistischen und systemischen Psychotherapien tatsächlich seltener zu unerwünschten Ereignissen in der Therapie zu führen. Dies scheint ein interessantes Thema für zukünftige verfahrensvergleichende Untersuchungen zu sein. ...
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Hintergrund: Die Aufklärung, Erkennung, Vorbeugung und Bearbeitung von Psychotherapienebenwirkungen stellt hohe Anforderungen an Therapeuten. Grundsätzlich gilt zudem, dass es psychologische Barrieren gibt, negative therapeutische Entwicklungen wahrzunehmen und dem eigenen therapeutischen Handeln zuzuordnen. Dazu trägt bei, dass dieses Thema bislang in der Ausbildung eher wenig Beachtung findet und kaum systematisch abgehandelt wird. Um den eventuellen Handlungsbedarf abschätzen zu können, sind Daten von Interesse zu den einschlägigen Einstellungen und Kenntnissen von Therapeuten in Ausbildung. Methode: In einem halbstrukturierten Interview wurden 100 Psychotherapeuten in Ausbildung mit dem Schwerpunkt Verhaltenstherapie zu Nebenwirkungen ihrer Arbeit befragt. Die Therapeuten machten Angaben zur Qualität, Häufigkeit und den möglichen Ursachen von Psychotherapienebenwirkungen. Ergebnisse: Therapeuten in Ausbildung rechnen in etwa jedem 2. Fall mit dem Auftreten von Nebenwirkungen. Sie erwarten vor allem Symptomverschlechte­rung und negative Entwicklungen im sozialen Netz. Es zeigt sich eine Tendenz, das eigene Verfahren und die eigenen Behandlungen für weniger riskant zu halten als die der Kollegen. Ursachen von Nebenwirkungen sehen die Therapeuten vor allem in der therapeutischen Beziehung sowie The­rapeutenvariablen und weniger in Patientencharakteristika. Schlussfolgerung: Psychotherapeuten in Ausbildung sind sich dem Problem der Nebenwirkungen durchaus bewusst, was ein guter Ansatzpunkt für die Vermittlung entspre­chender Ausbildungsinhalte ist. An den Aus- und Weiterbildungsinstituten sollten Seminare zum Problem der Psychotherapienebenwirkungen zum Standard gehören.
Article
Measurement of adverse effects of psychological therapy is inconsistent due to ambiguity about the concept. The perspective of people undertaking psychological therapy (that is, experts by experience) has largely been overlooked. This study will investigate whether there is consensus between the opinions of professionals and experts by experience. The Delphi method was used. In Round 1 thematic analysis was used to analyse qualitative responses. Wilcoxon rank‐sum tests were used to examine group differences in Rounds 2 and 3. The study protocol was prospectively registered, reference osf.io/f9wp7. Fifty‐one professionals and 51 experts by experience generated 147 potential adverse effects in Round 1, across 9 themes; including “therapy amplifies problem”, “emotional lability” and “sense of self”. Each item was rated for overall consensus in Rounds 2 (n=62) and 3 (n=63). Thirty‐eight items were rated as essential, very important or important to include on a list of potential adverse effects. A further 12 items were rated as important by the expert by experience group only. Professionals were more conservative in their ratings. There appeared to be consensus between professionals and experts by experience on what to include in a list of adverse effects of psychological therapy (the EDAPT), including novel adverse effects which have not been previously considered. Further research is required to understand which adverse effects are necessary, unnecessary, or indeed harmful to psychotherapy outcomes.
Chapter
Zuerst stehen in der Reihe der historischen Quellen und Referenzwissenschaften bestimmte Strömungen der Philosophie. Nach Hippokrates werden in den Gesundheitsberufen Philosophie und Heilkunde verbunden. Die Integrative Therapie beruft sich ausdrücklich auf philosophische Ansätze. Sie sieht sich in der asklepiadischen Tradition einer ganzheitlichen Gesundheitsfürsorge und Heilkunst, die heute in vielem durch Biomedizin und Neurowissenschaften bestätigt wird. Referenzphilosophien von Maurice Merleau-Ponty, Gabriel Marcel, Paul Ricœur, Emmanuel Lévinas, Michel Foucault und Jacques Derrida werden vorgestellt.
Chapter
Um Menschen in ihrer Komplexität zu sehen, wird die Notwendigkeit einer methodenübergreifenden Mehrdimensionalität in Diagnostik und Therapie postuliert. Das Verfahren Integrative Therapie nutzt unterschiedliche Erkenntniswege und Quellen. Gezeigt wird im Entwicklungsweg des Verfahrens die untrennbare Verflechtung von Personen, deren Sozialisation und des kulturellen Hintergrundes. Das strukturgebende Modell des Tree of Science der Integrativen Therapie mit seiner Auffächerung in Metatheorie, klinische Theorie, Praxeologie und Praxis wird vorgestellt. Das Körper-Seele-Geist-Verhältnis wird mit der Annahme ausgeführt, dass sich der Körper auf das Materielle bezieht und Seele/Geist auf das Transmaterielle, auf Gedanken, Gefühle und Volitionen. Ein kurzer Blick auf die naturwissenschaftliche Medizin zeigt bereits 1965 den Brückenschlag zu einem differenziert formulierten Zugang zum Menschen. Die Umsetzung dieser Sicht fand in Österreich 2015 Einzug in die Ausbildungsordnung für Ärzte. Der lange Weg zur staatlichen Anerkennung des Integrativen Therapieverfahrens in Österreich wird skizziert.
Chapter
Für die Integrative Therapie wird mit den Studien an der Europäischen Akademie für psychosoziale Gesundheit (EAG) und den Replikationsstudien an der Donau-Universität Krems (DUK) in den Jahren 1994–2009 der Beleg für die Effektivität dieses Behandlungsverfahrens erbracht. Der Verlauf der psychotherapeutischen Interventionen wird aus vielen unterschiedlichen Perspektiven vorgestellt. Die Messzeiten des Untersuchungsdesigns umfassen eine Eingangs- und Abschlusserhebung und eine katamnestische Erhebung. Mit den Erhebungsinstrumenten werden die Veränderung der Symptomatik, die Veränderung im interpersonalen Verhalten, von depressiven Beschwerden, der Angstsymptomatik gemessen. Auch wird die Veränderung der allgemeinen Lebenszufriedenheit und von Aspekten körperlichen Befindens erfragt.
Chapter
Eine zusammenhängende Theorie und eine sich daraus ergebende Praxis ist im Strukturkonzept Tree of Science vorgelegt. Dieses Konzept bildet eine Grundlage für eine systematische Reflexion, Diskussion und Weiterentwicklung. Die Grundprinzipien, die diese Struktur tragen, werden erläutert. Im Intersubjektivitätsprinzip wird auf die menschliche Existenz als gemeinsame Existenz hingewiesen. Das Bewusstseinsprinzip befasst die therapeutische Praxis mit dem Umgang von Bewusstheitsprozessen. Das Sozialitätsprinzip unterstreicht das soziale Wesen des Menschen, und die Sozialisation in der psychotherapeutischen Ausbildung wird kritisch hinterfragt. Weitere zentrale Charakteristika der Integrativen Therapie werden im Leiblichkeitsprinzip und Entwicklungsprinzip beschrieben. Vor diesem Hintergrund wird die Behandlung in der Integrativen Therapie durch ein Interaktionsmodell mit seinem Bezugsrahmen diskutiert. Die Entwicklung und Gliederung der veränderungswirksamen Heilfaktoren werden dargestellt.
Chapter
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