Objective Diagnosis rates of depression and demand for psychotherapy are increasing, posing significant challenges to the mental health care system. Availability of different treatments enables patients to express their preferences. Understanding these preferences can inform policy makers and clinicians and holds the potential to increase treatment adherence and improve clinical outcomes. Method A web survey was carried out among German adults (18–74) with psychotherapy experience, using quota sampling to reflect the gender distribution of psychotherapy-seeking adults. We conducted a discrete choice experiment to measure factors influencing the choice of psychotherapy. Included attributes were setting, delivery mode, waiting time, gender and professional experience of psychotherapist. Latent class analysis (LCA) was applied to identify preference patterns. Results Respondents (n = 1575, 70.5% female, Mage = 47) preferred individual, face-to-face, shorter waiting times, female and more experienced therapists. Setting was most influential, followed by professional experience, waiting time, delivery mode and gender. LCA revealed five distinct classes that showed varying valuations of the attributes and their relative importance. Conclusion Results showed that respondents mainly homogeneously preferred specific treatment characteristics. These preferences should be considered when planning mental health services. Identification of distinct preference types suggests tailored provision of mental health care.

Objective Therapeutic alliance (TA) is positively associated with treatment outcomes in psychological therapies for psychosis. Limited research has examined TA in virtual cognitive behavioral therapy for psychosis (vCBTp). This study investigated correlates of TA in vCBTp and associations with clinical, functional, and personal recovery outcomes. Method Participants (N = 30) with schizophrenia-spectrum disorders received up to 26 sessions of individual vCBTp in a randomized controlled trial. Client- and therapist-rated TA was assessed at weeks 4 (Early Treatment) and 26 (Post-Treatment). Assessments were conducted at baseline, post-treatment, and six-month follow-up. Results Therapeutic alliance did not significantly differ across raters nor sessions, except for an increase in the therapist-rated Bond subscale. At Early Treatment, no baseline variables were correlated with client-rated alliance, and only therapist years of training and years of experience were correlated with therapist-rated alliance, although in opposite directions. Neither client- nor therapist-rated TA at either Early or Post-Treatment significantly predicted clinical, functional, or personal recovery outcomes at post- or follow-up assessments. Conclusion Therapeutic alliance can be developed and maintained in vCBTp. However, these findings highlight the complexity of this relationship between clients and clinicians and the difficulty in identifying correlates of TA and mechanisms by which it influences treatment outcomes. Trial registration: ClinicalTrials.gov identifier: NCT04752449.

Objective This pilot study aimed to assess the feasibility and informativeness of a mixed-method approach to investigate how the Self changes during psychotherapy within a Dynamic Systems Theory (DST) framework, addressing theoretical heterogeneity and the limits of conventional pre–post designs. Method Five participants undergoing psychotherapy were scheduled to complete weekly smartphone-based diary assessments over several months (≥30 scheduled prompts). Each assessment included 11 (nomothetic) ad hoc items and 2 person-specific (idiographic) items. Responses to the Narrative Assessment Interview (NAI) were analyzed using conventional qualitative content analysis to derive person-specific items and interpret quantitative trajectories (but were not analyzed as a separate qualitative outcome). Quantitative data were analyzed using time-series methods (i.e., trend analysis and ARIMA modeling). Results The Self exhibited various change patterns (e.g., linear, nonlinear, stationary, and non-stationary), characterized by the influence of past values (i.e., the autoregressive component) and innovations (the moving-average component). Moreover, participants exhibited different change dynamics. Therefore, the conditions required for ergodic generalization were often not met in these data. Conclusion The mixed-methods approach was informative, capturing the complexity of Self-change. The method was feasible in a real clinical setting, but compliance and the time required to perform the analyses were critical.

Objective Suicidal ideation is a central clinical risk in psychotherapy. Patients’ engagement with therapy between sessions, captured by intersession processes (ISP), may be particularly informative for understanding risk and resilience. This study examined associations between ISP and suicidal ideation, distinguishing between-person vulnerabilities from within-person crisis dynamics. Method We analyzed routine outpatient data (N = 73, 2,586 total sessions), including an eight-item short version of the Intersession Experiences Questionnaire (IEQ-S) and the PHQ-9 suicidal ideation item. Multilevel logistic mixed-effects models treated suicidal ideation as a binary outcome, disaggregated between- and within-person effects, and included linear, quadratic, and cubic terms. Results At the between-person level, more frequent problem-focused application of therapeutic insights was associated with a lower likelihood, whereas higher levels of negative emotional ISP were linked to a higher likelihood of reporting suicidal ideation, following nonlinear trajectories. At the within-person level, increases in positive emotional engagement and problem-focused application co-occurred with a lower likelihood, whereas increases in imagining therapeutic dialogue and negative emotions were related to a higher likelihood of reporting suicidal ideation. Conclusion ISP reflect the internalized therapeutic alliance and clinically meaningful cognitive–affective processes, signaling crisis escalation, but also pointing to mechanisms of change. ISP may be valuable monitoring targets.

Objective This pilot randomized controlled trial (RCT) aimed to preliminarily assess the efficacy and acceptability of Cognitive behavioral therapy (CBT) and Emotion-focused therapy (EFT) in short-term treatment of depression within a Norwegian mental health program. The study also addresses procedural elements relevant for future research development. Method In a parallel two-arm RCT, 111 participants (mean age: 42, 70.6% female) with major depression were randomly allocated to 9–18 sessions of either CBT (n = 55) or EFT (n = 56). Five participants in CBT and four in EFT withdrew their consent, resulting in final sample sizes of CBT (n = 50) and EFT (n = 52). Self-reported depressive symptoms (BDI-II) were measured post-session and at 3-, 6-, and 12-month follow-ups. Data were analyzed using multilevel modeling. Results The results showed a significant improvement in symptoms from start to follow-up, as measured by the BDI-II (d = 0.56; 95% CI: 0.45, 0.66). No significant differences were found between conditions; however, the small sample size prevents definitive conclusions about possible differences. Drop-out was low (Total: 6.31%; CBT: 10.91%, EFT: 1.79%). Conclusion Our findings support the efficacy and acceptability of CBT and EFT in short-term treatment of depression in a Norwegian setting. Trial registration: ClinicalTrials.gov identifier: NCT04690946..

Introduction: Psychological pain is a central risk factor for suicidal behaviour. Nonverbal synchrony between patients and therapists has been shown to facilitate the development of therapeutic alliance, which in turn is linked to symptom reduction. Building on these associations, the present study investigated whether movement synchrony in suicide-specific therapy exceeds random synchrony and whether it is associated with patients’ psychological pain. Method: A sample of 95 video recordings from therapy sessions of the Attempted Suicide Short Intervention Program (ASSIP) were analysed using Motion Energy Analysis to assess synchrony in head and upper body movements. Psychological pain was assessed using the Suicide Status Form II (SSF-II). Results: Genuine synchrony was significantly greater than pseudosynchrony t(110.16) = 4.314, p < .001, d = 0.49, 95% CI [0.005, 0.014], confirming the validity of the synchrony measurement. Additionally, movement synchrony was negatively correlated with psychological pain (r(84) = −.319, p = .003). This relationship remained significant after controlling for potential mediating factors (r(84) = −.302, p = .008). Conclusion: This study highlights the role of nonverbal synchrony in suicide-specific therapy, demonstrating that it exceeds random synchrony and is associated with lower levels of psychological pain.

Objective The aim of this study was to identify therapist characteristics associated with effective rupture resolution processes. We examined the association between therapists’ experience of professional self-doubt (PSD) and the resolution of alliance ruptures. Methods Data from 4,986 sessions of 535 clients treated by 53 therapists in a primary care setting were analyzed. The interaction between rupture occurrence and therapists’ levels of general (state-like) or session-related (trait-like) PSD on alliance change was analyzed using multilevel modeling. Additionally, the moderating role of therapists’ feelings of inadequacy on this interaction was investigated. Results A significant interaction between rupture occurrence and the quadratic term of trait-like PSD was found, with both higher and lower levels predicting lower client alliance ratings after ruptures. Additionally, increased state-like PSD during ruptures led to improved client alliance ratings among therapists with lower feelings of inadequacy. Conclusion The results contribute to a more refined understanding of the effect of therapist characteristics on rupture resolution, indicating that moderate levels of trait-like PSD are optimal, and state-like PSD effects depend on therapists’ feelings of adequacy.

Objective A substantial number of therapists in the eating disorder (ED) field have experienced an ED themselves, yet research on professionals using their personal ED experience as a therapeutic tool is scarce. This study explores the perspectives of recovered ED professionals (REDPs) who intentionally employ their experiential knowledge in ED treatment, examining its use, advantages, and challenges. Method Semi-structured interviews were conducted with 20 REDPs using a topic list with open-ended questions based on our research aim and a previous literature review (Bijkerk et al., 2024). Results REDPs play a key role in treatment, with self-disclosure occurring in various forms. Experiential knowledge of REDPs offers benefits like motivation, hope, and understanding, but also challenges such as potential client burden or misguidance. Successful implementation of experiential knowledge requires organizational adjustments (supervision, work guidance and adequate training) and the REDPs’ responsibility to create the right conditions for using their experiential knowledge efficiently. Conclusion Applying lived experience in practice by REDPs requires additional competence as it places these professionals into a difficult position of having to balance self-disclosure with ethical risks to clients and the risks to one’s personal and professional self. Moreover, beneficial use of experiential knowledge in practice requires organizational support.

Objective This systematic review (PROSPERO CRD42023399665) synthesized evidence from process-based microanalytic studies investigating therapist–client verbal exchanges in psychotherapy, focusing on sequential and time-series patterns. Method From an initial pool of 1890 articles, 33 studies were included. Studies were conducted in 10 countries, retrieved from seven databases in three languages, and focused exclusively on outpatient psychotherapy. All studies employed observational coding systems and microanalytic methods to examine moment-to-moment interactions. Results Despite variation in coding systems and contexts, a consistent pattern emerged: when clients engaged in improvement-related verbalizations or followed therapeutic directions, therapists typically responded with approval, forming a triadic sequence (therapist prompt → client change-oriented verbalization → therapist approval). In contrast, therapists’ responses to client verbalizations misaligned with therapeutic goals were inconsistent, showing no reproducible pattern across studies. Conclusion Although outcomes were not directly assessed, findings suggest that therapist-client verbal interaction systematicity relates to in-session change. To enhance microanalytic research, we argue for a bottom-up approach emphasizing detailed, AI-assisted descriptions of therapist–client interactions before applying theory-driven sequential analyses.

Objective To examine multiple emotion regulation strategies as mediators in ACT compared to CBT for anxiety. It was hypothesized that augmenting acceptance and reducing suppression, distraction, and perseverative thinking would mediate the effect of ACT compared to CBT. Cognitive reappraisal was included as a competitive mediator. Method Data were collected as part of a randomized controlled trial comparing ACT and CBT in a sample of 314 older adults with anxiety symptomatology. Participants filled in self-report questionnaires assessing anxiety symptom severity (Generalized Anxiety Disorder-2) and the putative mediators a total of five times over the course of treatment. Latent growth curve models, parallel process models, random intercept-cross lagged panel models, and autoregressive latent trajectory models were used to model the hypothesized prospective and mediational relationship. Results ACT differentially affected acceptance, suppression, and distraction, and changes in all mediators (except acceptance) showed significant cross-sectional associations with outcome. Only cognitive reappraisal predicted subsequent anxiety levels and vice versa, irrespective of treatment. However, none of the emotion regulation variables mediated the effect of ACT. Conclusions The discrepancy with previous positive findings on emotion regulation as a mediator may be attributed to earlier studies not using a longitudinal design and analysis on the within-person level.