Simone Jennissen

Clinical or methodological significance of this article: Premature treatment termination in inpatient psychotherapy can have severe negative consequences for the individual patient and the mental h...

BACKGROUND Psychotherapy for depressed patients with comorbid impairments in personality functioning has proven less effective than for those without personality dysfunction, leaving patients with higher symptom load at discharge and more frequent readmissions. The introduction of the dimensional model of personality functioning in the ICD-11 and DSM-5 offers opportunities to develop new approaches for improving personality functioning. Digital interventions for depression as well as for personality disorders have been effective in reducing symptom load, but digital interventions using the new conceptualization of personality disorders are still lacking. This study addresses this gap by evaluating the newly developed digital blended-care intervention PERFUNC, for patients with depression and comorbid personality functioning in an inpatient setting as well as after discharge. OBJECTIVE The aim of this pilot study is to evaluate the feasibility, acceptance and preliminary indicators of efficacy of the digital blended-care intervention PERFUNC in a randomized controlled pilot trial. METHODS In this multicenter randomized controlled feasibility trial N=40 patients diagnosed with a depressive disorder and a comorbid personality dysfunction are randomly assigned to either the intervention group (hospital treatment as usual + PERFUNC, n=20) or the control group (hospital treatment as usual n=20). PERFUNC includes a web-based program with five modules, with exercises to improve key personality domains as well as a daily monitoring to foster self-reflection. Feasibility metrics (e.g. recruitment, utilization) will be assessed throughout the usage of PERFUNC and clinical outcomes will be assessed at baseline, discharge, and 12 weeks after discharge. RESULTS The development of PERFUNC was finalized in January 2025. Recruitment and data collection started in April 2025 and are ongoing. Data collection is expected to be completed in December 2026 and results for this pilot study are expected in 2027. CONCLUSIONS PERFUNC was developed to enhance therapeutic outcomes of depressed patients with a comorbid personality dysfunction, support continuity of care and reduce the relapse risk in a population with high clinical need. The findings of this pilot study will provide insights into the feasibility and accessibility of PERFUNC and will inform the planning of a subsequent confirmatory randomized controlled trial. CLINICALTRIAL German Clinical Trials Register ID: DRKS00034953; https://www.drks.de/DRKS00034953.

Research on nonverbal synchrony (NVS) as a core element in the therapeutic relationship has substantially increased and suggests that NVS influences therapeutic alliance and outcomes. Studies on NVS regarding body movements, vocal pitch, peripheral physiological measures, and hormonal states were included. A random-effects multilevel meta-analysis was performed on 23 publications from 13 trials. There was no significant overall association between NVS and alliance/outcome (r = .03, p = .644). Across modalities, there was a marginally significant association between higher NVS and smaller interpersonal problems (r = .10, p = .084) and a nonsignificant effect for the association between NVS and alliance (r = .06, p = .316), symptomatic outcome (r = -.06, p = .320), and other outcomes (r = .07, p = .255). There was significant heterogeneity between studies (I² = 56.47). Moderator analyses revealed that vocal pitch synchrony was negatively associated with alliance/outcome (r = -.20, p = .011), while NVS of peripheral physiological parameters was positively correlated with alliance/outcome (r = .32, p = .006). Findings suggest that specific modalities of NVS show specific associations with outcomes. More research is needed to investigate whether NVS across modalities reflects a unified underlying construct.

Objective: Depression negatively affects interpersonal functioning and influences nonverbal behavior. Interpersonal theories of depression suggest that depressed individuals engage in behaviors that initially provoke others’ support and reassurance, but eventually lead to rejection that may also be expressed nonverbally.Methods: This study investigated movement synchrony as a nonverbal indicator of support and rejection and its association with depression severity in a sample of depressed and healthy individuals. Semi-standardized diagnostic interview segments with N = 114 dyads were video recorded. Body movement was analyzed using Motion Energy Analysis, synchrony intervals were identified by computing windowed cross-lagged correlation and a peak-picking-algorithm. Depression severity was assessed via both self-rating (BDI-II) and clinician rating (HAMD).Results: Both self-rated and clinician-rated depression severity were negatively correlated with patient-led, but not clinician-led movement synchrony measures. The more depressed patients were, the less they initiated movement synchrony with their clinicians. These correlations remained significant after controlling for gender, age, gross body movement, and psychopharmacological medication.Conclusion: Findings suggest that depression may negatively affect patients’ active initiative in interaction situations. Automatized methods as used in this study can add valuable information in the diagnosis of depression and the assessment of associated social impairments.

Attachment has mostly been investigated as a stable characteristic of individuals, although theoretical considerations and recent empirical findings suggest that attachment styles are also subject to change. When attachment is investigated as a treatment factor in psychotherapy, state and trait characteristics need to be differentiated, as they warrant different conclusions. This study examined the trait- and statelike characteristics of attachment styles over the course of inpatient psychotherapy as predictors of treatment outcome. A total of N = 419 patients provided weekly measurements of attachment styles and symptoms for up to 8 weeks of inpatient psychotherapy. Data were analyzed in multilevel longitudinal models controlling for rolling admissions and weekly changes in group membership. Over the course of treatment, patients' attachment styles became more secure and less fearful-avoidant. Trait attachment security as well as gains in attachment security predicted better outcomes, while trait preoccupied and fearful-avoidant attachment as well as increases in attachment preoccupation and anxiety predicted worse outcomes. Findings imply that attachment security may grow during a relatively short inpatient treatment period and both trait attachment styles as well as changes in attachment styles predict outcome.

Background: Telephone emergency services (TES) provide an essential part of suicide prevention and emotional support services across different health care settings. TES are usually provided by paraprofessional counselors, who need specific training in listening skills to meet the demands of callers. Method: This project developed a competency-based training for listening skills which was then evaluated in a randomized controlled waitlist study across four EU countries (Germany, Hungary, Italy, and the Netherlands). Each country provided one training group and one waitlist group. Across countries, a total of 71 (trained: n = 36, waiting: n = 35) counselor trainees were assessed in a standardized, simulated emergency call with an actor client either before or after training participation. Calls were audiotaped and competencies in listening skills were evaluated by external raters using a standardized rating form. Results: Trained counselors showed significantly better listening skills than participants from the waitlist condition. Conclusion: Results provide support for the efficacy of a competency-based training for listening skills in the field of TES across Europe. Furthermore, results demonstrated that a standardized competency-based assessment with an actor client is suitable to assess listening skills.

This study investigated the interplay between agency and therapeutic bond in predicting patient symptoms in outpatient psychotherapy. A total of N = 731 patients provided measurements of agency (Therapeutic Agency Inventory; TAI), therapeutic bond (bond subscale of Working Alliance Inventory-Short Form Revised [WAI-SR]), and symptoms (Symptom Checklist Short Form [SCL-K11]) every fifth session of long-term treatment for up to 60 sessions. When investigated in separate models, both more agency and a stronger therapeutic bond predicted symptom improvement. However, within-person changes and between-person differences in agency predicted symptom improvement over and above the effects of therapeutic bond. Multilevel response surface analysis was used to further investigate the interplay between agency and therapeutic bond. When both agency and therapeutic bond levels were high, symptoms improved the most. When agency and therapeutic bond ratings differed, symptom ratings were significantly lower when agency exceeded therapeutic bond levels than when therapeutic bond ratings exceeded agency. Findings suggest that both agency and therapeutic bond are important treatment factors, but outcome could be improved when a strong therapeutic bond is combined with an equally strong sense of agency that empowers patients to pursue changes in their lives. When a strong therapeutic bond is present, but the patient feels less agentic, therapists may want to foster agency to improve outcomes. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Objective: The association between alliance and therapy outcome is one of the most investigated factors in psychotherapy research. However, even studies using advanced methods estimate effects over a specific time period (interval) between measurement occasions. Thus, it remains unknown how the magnitude and direction of effects depend on the considered time interval, resulting in limited comparability across studies. The current study examines the influence of time on the within-person relationship between alliance and symptom severity. Method: Alliance (WAI-SR) and symptom severity (SCL-K11) were assessed every fifth session in N = 650 patients receiving up to 100 weekly sessions (mode = 55; M = 41.03; SD = 27.23) of individual psychotherapy in a German outpatient clinic. Bivariate continuous-time (CT) structural equation modeling (SEM) was used to estimate within-person cross- and auto-effects. Results: Analysis revealed significant reciprocal within-person cross-effects with stronger relative effects of SCL-K11 on WAI-SR (a₂₁) than vice versa (a₁₂). CT analysis showed that both cross-lagged effects increased for longer time intervals with strongest effects for time intervals of about 40 sessions (a₂₁ = -.47; a₁₂ = -.19). Conclusions: Alliance and symptom severity showed a reciprocal relationship. Expanding current evidence, our analysis showed how the magnitude of these effects depends on the considered time interval. Applying CT-SEM on longitudinal data of the alliance outcome association complements current cross-lagged panel analysis and allows to compare results of studies which are based on different time intervals between measurement occasions. Methodological, theoretical, and clinical implications are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

This study aimed to investigate change in insight into maladaptive interpersonal patterns over the course of psychotherapy, as well as the specificity of insight as a change mechanism in dynamic treatments. A total of 100 patients received up to 16 sessions of either cognitive or dynamic therapy for major depressive disorder in a randomized clinical trial. Assessments of insight (Insight into Conflictual Relationship Patterns scale) and depression severity (Hamilton Depression Inventory) took place at the beginning of treatment, at month 2, and month 5. Patient insight significantly improved over the course of dynamic treatments. Gains in insight from the beginning to month 2 of treatment were a significant predictor of decreases of depressive symptoms from month 2 to month 5 of treatment in the dynamic, but not in the cognitive treatment group, despite a nonsignificant interaction. Results provide support for insight as a change factor in dynamic therapies. Better self-understanding of dysfunctional interaction patterns could help patients to find more adaptive ways of behaving, to form more satisfying relationships, and to improve their depression.

The alliance is dyadic in its nature with both the patient and the therapist contributing. Relatively little is known about the effects of congruence between patient and therapist perception of alliance on treatment outcome. The current study investigated how patient and therapist agreement and disagreement about the alliance predict symptom severity over the course of long-term psychotherapy. We investigated N = 361 patients nested within N = 102 therapists longitudinally every 5th session across long-term treatment. Multilevel polynomial regression with response surface analysis was used to predict symptom severity five sessions later from congruence of the alliance ratings. Throughout treatment, patient and therapist agreement about stronger alliances significantly predicted lower subsequent patient-reported symptom distress. Patient and therapist disagreement was a marginally significant predictor of subsequent symptom distress. There was no significant difference in the effects of alliance agreement and disagreement on symptoms across time in long-term treatment. Findings support the importance of alliance agreement and disagreement as predictors of subsequent patient symptom severity.