Periodic Reporting for period 2 - EBAP (Evidence-Based Assessment in Psychotherapy (EBAP) Study)
Reporting period: 2023-10-01 to 2024-09-30
Mental disorders (MDs) affect about one-tenth of the world’s population and are among the leading causes of years lived with disability. Currently, pharmacotherapy represents the first-line option in most settings in Europe and North America, but growing evidence suggests that although it is effective in the treatment of acute episodes, medication alone does not help many patients to achieve a functional recovery or to prevent mental illness (e.g. for individuals at clinical high risk of psychosis or self-injury). Psychotherapies can produce behavior and lifestyle changes essential to relapse prevention, long-term maintenance, and promoting positive function. At present, MD treatment remains, to a large extent, a “subjective clinical exercise.” Therefore, implementing evidence-based assessment (EBA) for MDs is essential to reduce their burden at individual, societal, and public health levels: using it to monitor psychotherapy processes and to evaluate progress can increase patient engagement and enhance therapy outcomes. However, to be fully effective, the EBA algorithms should be “humanized” because psychotherapeutic processes take place inside the patient-clinician relationship.
This study will
(1) develop a battery for individual psychotherapy that (a) combines EBA with measures of key elements of the therapeutic relationship (TR) (i.e. therapeutic alliance, and patient/therapist’s in-session feelings toward each other) and (b) is valid and easy enough to be administered routinely in real-world psychotherapeutic settings. Integrating measures of the TR brings back humanistic and emotional dynamics to the treatment process. It also adds sophisticated ways of thinking about the TR and its association with treatment outcomes, which are produced by a complex human relationship. The combination prevents EBA from being merely an algorithm;
(2) roll out the EBA approach in real-world psychotherapeutic settings to investigate (randomized controlled clinical trial) how it affects psychotherapy process and outcome;
(3) disseminate/notify the results to both academic and clinical communities.
This study will
(1) develop a battery for individual psychotherapy that (a) combines EBA with measures of key elements of the therapeutic relationship (TR) (i.e. therapeutic alliance, and patient/therapist’s in-session feelings toward each other) and (b) is valid and easy enough to be administered routinely in real-world psychotherapeutic settings. Integrating measures of the TR brings back humanistic and emotional dynamics to the treatment process. It also adds sophisticated ways of thinking about the TR and its association with treatment outcomes, which are produced by a complex human relationship. The combination prevents EBA from being merely an algorithm;
(2) roll out the EBA approach in real-world psychotherapeutic settings to investigate (randomized controlled clinical trial) how it affects psychotherapy process and outcome;
(3) disseminate/notify the results to both academic and clinical communities.
Three scales were developed to measure the patient's affective response to the therapist during psychotherapy sessions (SPARQ, RISQ, and SPARQ-C) and one to measure the therapist's response to the patient (CARE Scales). Developing these scales allowed researcher Alberto Stefana to gain expertise in creating psychological measures, including statistical competencies in factor analysis and item response theory. This expertise enabled collaboration with other research groups on developing short forms of validated psychological scales and contributed to two articles investigating the psychometric properties of existing scales. Another key outcome of this work was a scientific article outlining best practices for developing and validating psychological and psychiatric measures.
The pilot study planned in the outgoing phase was replaced by a longitudinal study, which tested both the EBA battery and data collection software. This study also examined the relationship between therapeutic relationship elements (such as working alliance and patient affective reactions) and session outcomes. An additional focus of the first phase was an in-depth study of bipolar disorder, resulting in three peer-reviewed journal articles and a book chapter.
During the first year of the outgoing phase, the researcher participated in activities with Helping Give Away Psychological Science (HGAPS), a nonprofit organization that supports students, researchers, and mental health professionals by disseminating accessible, evidence-based psychological science on open-access platforms. This involvement was part of a broader effort to acquire knowledge related to open science, which included using platforms such as OSF, Wikiversity, Wikipedia, ResearchGate, and Twitter. The EBAP project has dedicated pages on Wikiversity and OSF.
Additionally, the researcher secured a small grant (USD 5,000) from the China American Psychoanalytic Alliance, funding an evidence-based assessment of the clinical supervision relationship between trainee psychotherapists and supervisors. This work, under EBAP project supervision, helped refine the researcher's grant-writing skills.
During the return phase, a randomized controlled trial (RCT) was conducted. Initially, the project envisioned a four-arm RCT involving both therapists and patients with the EBA battery. However, the final design involved only the patient directly, with the therapist's involvement mediated through the patient, due to theoretical and practical considerations. This approach, if effective, would enable cost-efficient adoption across therapeutic contexts by reducing therapist workload. As a result, a two-arm RCT was conducted, enrolling 465 patients—65 more than the initial plan of 400. The main findings of this RCT have been accepted for publication in JMIR Mental Health.
In total, 13 peer-reviewed articles have been published, with 2 more accepted for publication and 4 currently under review.
The pilot study planned in the outgoing phase was replaced by a longitudinal study, which tested both the EBA battery and data collection software. This study also examined the relationship between therapeutic relationship elements (such as working alliance and patient affective reactions) and session outcomes. An additional focus of the first phase was an in-depth study of bipolar disorder, resulting in three peer-reviewed journal articles and a book chapter.
During the first year of the outgoing phase, the researcher participated in activities with Helping Give Away Psychological Science (HGAPS), a nonprofit organization that supports students, researchers, and mental health professionals by disseminating accessible, evidence-based psychological science on open-access platforms. This involvement was part of a broader effort to acquire knowledge related to open science, which included using platforms such as OSF, Wikiversity, Wikipedia, ResearchGate, and Twitter. The EBAP project has dedicated pages on Wikiversity and OSF.
Additionally, the researcher secured a small grant (USD 5,000) from the China American Psychoanalytic Alliance, funding an evidence-based assessment of the clinical supervision relationship between trainee psychotherapists and supervisors. This work, under EBAP project supervision, helped refine the researcher's grant-writing skills.
During the return phase, a randomized controlled trial (RCT) was conducted. Initially, the project envisioned a four-arm RCT involving both therapists and patients with the EBA battery. However, the final design involved only the patient directly, with the therapist's involvement mediated through the patient, due to theoretical and practical considerations. This approach, if effective, would enable cost-efficient adoption across therapeutic contexts by reducing therapist workload. As a result, a two-arm RCT was conducted, enrolling 465 patients—65 more than the initial plan of 400. The main findings of this RCT have been accepted for publication in JMIR Mental Health.
In total, 13 peer-reviewed articles have been published, with 2 more accepted for publication and 4 currently under review.
Three new questionnaires have been developed. An article describing their development and validation has been published in a top peer-reviewed journal. Two further article are currently under review. The scales will be made freely available via open science platforms (e.g. OSF, Wikiversity, and academic-focused social media) to researchers and clinicians in at least three languages (i.e. English, Spanish, and Italian).
We tested our EBA battery as part of a routine process monitoring and feedback system through an RCT. The findings do not provide conclusive evidence for the efficacy of the EBA battery, however, the intervention offers important clinical and theoretical insights by influencing patients’ perceptions of the genuineness dimension of the therapeutic relationship. Our post-hoc interpretation suggests that the items composing the genuineness dimension of the real relationship relate to being oneself with the therapist, openness and honesty, the ability to communicate one’s moment-to-moment inner experience, and the expression of feelings in therapy. Therefore, we hypothesize that the intervention, which required patients to reflect on these aspects of their personal relationship with their therapist, may have heightened their awareness of inner struggles or resistances within the relationship. In this context, the lower scores observed in the RRI-C-SF genuineness dimension may not indicate a deterioration of the real relationship with the therapist, but rather a more realistic and accurate perception of it.
Furthermore, the analyses conducted thus far have provided important information regarding the occurrence of erotic feelings during psychotherapy sessions from both patients’ and therapists’ perspectives. These findings also shed light on the interplay of different elements within the therapeutic relationship. One of the most notable findings is that the bond dimension of the alliance appears to be sufficiently distinct from the task and goal dimensions, warranting consideration as a separate construct. We are currently actively working on a series of secondary analyses to advance our understanding of in-session feelings, including how in-session emotional dynamics impact patient engagement, the therapy process, and outcomes, as well as how therapies work through interpersonal versus specific technique factors.
We tested our EBA battery as part of a routine process monitoring and feedback system through an RCT. The findings do not provide conclusive evidence for the efficacy of the EBA battery, however, the intervention offers important clinical and theoretical insights by influencing patients’ perceptions of the genuineness dimension of the therapeutic relationship. Our post-hoc interpretation suggests that the items composing the genuineness dimension of the real relationship relate to being oneself with the therapist, openness and honesty, the ability to communicate one’s moment-to-moment inner experience, and the expression of feelings in therapy. Therefore, we hypothesize that the intervention, which required patients to reflect on these aspects of their personal relationship with their therapist, may have heightened their awareness of inner struggles or resistances within the relationship. In this context, the lower scores observed in the RRI-C-SF genuineness dimension may not indicate a deterioration of the real relationship with the therapist, but rather a more realistic and accurate perception of it.
Furthermore, the analyses conducted thus far have provided important information regarding the occurrence of erotic feelings during psychotherapy sessions from both patients’ and therapists’ perspectives. These findings also shed light on the interplay of different elements within the therapeutic relationship. One of the most notable findings is that the bond dimension of the alliance appears to be sufficiently distinct from the task and goal dimensions, warranting consideration as a separate construct. We are currently actively working on a series of secondary analyses to advance our understanding of in-session feelings, including how in-session emotional dynamics impact patient engagement, the therapy process, and outcomes, as well as how therapies work through interpersonal versus specific technique factors.