Jag disputerade 2005 med avhandlingen "Ideas of cure related to psychotherapy outcome: Young adults in psychoanalytic psychotherapy" vid Karolinska Institutet, Institutionen för klinisk neurovetenskap, Sektionen för psykoterapi.

Efter detta ledde jag två forskningsprojekt som utgick från Stockholms läns landsting, Beroendecentrum Stockholm, och Karolinska Institutet, Centrum för psykiatriforskning: "Matching and Outcome of Psychotherapy at Addiction Clinics in Sweden (MOPACS)" och "Mentalization-Based Treatment for Dual Diagnosis (MBTDD) – A Randomized Controlled Trial".

Under fem års anställning vid Linköpings universitet 2011-2016 som universitetslektor och senare som biträdande professor ingick jag i forskningssamarbeten kring praktikbaserad forskning om psykoterapi, vilket innebär naturalistiska, kliniknära studier. Som docent och biträdande professor vid Linköpings universitet var jag huvudhandledare för My Frankl (disputerad 2017) och Ylva Söderberg Gidhagen (disputerad 2018) och bihandledare för Carl-Johan Uckelstam (disputerad 2021).

Sedan 2018 leder jag forskningsprojektet EaRly internet-based interventions for Children and Adolescents (ERiCA) och handledde tillsammans med professor Per Carlbring doktoranderna Karin Lindqvist (disputerad 2023) och Jakob Mechler (disputerad 2023), som är verksamma inom projektet. ERiCA-projektet studerar internetförmedlad psykologisk behandling för ungdomar med depression och projektet erhåller forskningsmedel från Kavlifonder på 5,7 miljoner kronor under åren 2019–2023. Projektet bedrivs i samarbete med Linköpings universitet. I projektet prövas en nyutvecklad affektfokuserad internetbaserad psykodynamisk behandling (IPDT) i en serie randomiserade kontrollerade studier.

Studiens hemsida är www.erica.nu.

Under 2023-2034 leder jag projektet ”Gruppbehandling inom psykiatrin för komplexa och långvariga problem”, som görs i samverkan med Norra Stockholms Psykiatri, Region Stockholm. I projektet genomför vi en pilotstudie som provar en kort gruppbehandling för patienter med komplexa och långvariga problem: ISTDP-G (Intensive Short-Term Dynamic Psychotherapy – Group).

Jag leder Forskargruppen för psykodynamisk behandlingsforskning.

I urval från Stockholms universitets publikationsdatabas

• Internet-Delivered Affect-Focused Psychodynamic Therapy for Adolescent Depression: Treatment Principles and Clinical Application in the ERiCA Project

  2024. Jakob Mechler (et al.). Journal of Infant, Child, and Adolescent Psychotherapy 23 (2), 123-141

  Artikel

  Internet-delivered, therapist-guided, self-help programs are novel ways to deliver psychotherapeutic interventions adapted from established therapy models. Such programs can be easily accessed online and may offer an important treatment option for patients who struggle with barriers to seeking out and engaging in face-to-face psychotherapy, including depressed adolescents. While there are evidence-based Internet-delivered self-help programs based on cognitive-behavioral therapies (i.e. ICBT) for adolescent depression, a program based on psychodynamic principles (i.e. IPDT) has so far been lacking. In this article we describe the IPDT program developed within the ERiCA project, which has so far been evaluated in two randomized controlled trials (RCTs). We further provide a case example from one of the trials to illustrate the treatment process and therapeutic interaction in detail. Given the novelty of the approach, we will particularly highlight and discuss how a psychodynamic understanding of adolescent development and depressive dynamics as well as affect-focused treatment principles inform the treatment, including the therapist’s role, tasks, and choice of interventions. The potential implications and utility of IPDT for regular clinical practice are elaborated as well as potential research directions for the future.

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• “I didn’t have to look her in the eyes”—participants’ experiences of the therapeutic relationship in internet-based psychodynamic therapy for adolescent depression

  2024. Karin Lindqvist (et al.). Psychotherapy Research 34 (5), 648-662

  Artikel

  Objective: To explore young people’s perceptions of the relationship with the therapist in internet-based psychodynamic treatment for adolescent depression.

  Method: As a part of a randomized controlled trial, 18 adolescents aged 15–19 were interviewed after participating in treatment. Interviews followed a semi-structured interview schedule and were analyzed using thematic analysis.

  Results: The findings are reported around four main themes: “a meaningful and significant relationship with someone who cared”, “a helping relationship with someone who guided and motivated me through therapy”; “a relationship made safer and more open by the fact that we didn’t have to meet” and “a nonsignificant relationship with someone I didn’t really know and who didn’t know me”.

  Conclusion: Even when contact is entirely text-based, it is possible to form a close and significant relationship with a therapist in internet-based psychodynamic treatment. Clinicians need to monitor the relationship and seek to repair ruptures when they emerge.

  Läs mer om “I didn’t have to look her in the eyes”—participants’ experiences of the therapeutic relationship in internet-based psychodynamic therapy for adolescent depression

• Comparing Transdiagnostic Treatments: Unified Protocol vs. Affect Phobia Therapy and the Role of Negative Effects

  2023. Per Carlbring (et al.). Abstracts and Program Parallel Sessions, 32-32

  Konferens

  Aim: The aim of the TRAbee study was to compare the effectiveness of two transdiagnostic treatment modalities, Unified Protocol (Cognitive Behavior Therapy) and Affect Phobia Therapy (Psychodynamic Psychotherapy), in alleviating psychological distress and to examine the relative differences in the incidence of negative effects as assessed by the Negative Effects Questionnaire.

  Methods: This study is a randomized controlled trial with 2,400 participants divided into 12 subgroups based on treatment modality (CBT vs. PDT vs. waitlist), duration (8 or 16 weeks of treatment), and discussion forum access (yes/no). Participants were randomly assigned and measured weekly during treatment, and then at 6, 12, and 24 months. Inclusion criteria were: age 18 years or older, ability to read/write Swedish, access to a smartphone/computer, GAD-7 score ≥5, and/or PHQ-9 score ≥10. Exclusion criteria included: current psychological treatment, recent medication change, severe depression/suicidality. Outcome measures included the Generalized Anxiety Disorder 7-item scale (GAD-7), the Patient Health Questionnaire 9-item scale (PHQ-9), the Personality Inventory for DSM-5 (PID-5), the Reflective Functioning Questionnaire 8-item scale (RFQ- 8), the Negative Effects Questionnaire (NEQ), and the Brunnsviken Brief Quality of Life scale (BBQ).

  Results: Follow-up data is still being collected, but preliminary results, including 12-month follow-up, will be available at the ISRII conference. The results will report on the relative differences in the incidence of negative effects between the treatments as assessed by the NEQ scale.

  Conclusions: The study will provide insights into the comparative effectiveness of Unified Protocol and Affect Phobia Therapy in addressing psychological disorders in a transdiagnostic manner, as well as shedding light on the differences in negative effects experienced by patients undergoing these treatments. This information may inform future treatment approaches and help to optimize patient outcomes.

  Läs mer om Comparing Transdiagnostic Treatments: Unified Protocol vs. Affect Phobia Therapy and the Role of Negative Effects

• It turned into something else: patients’ long-term experiences of transitions to or from telepsychotherapy during the COVID-19 pandemic

  2023. Camilla von Below (et al.). Frontiers in Psychology 14

  Artikel

  Introduction: The shift from in-person therapy to telepsychotherapy during the COVID-19 pandemic was unprepared for, sudden, and inevitable. This study explored patients’ long-term experiences of transitions to telepsychotherapy and back to the office.

  Methods: Data were collected approximately two years after the declaration of COVID-19 as a pandemic. Eleven patients were interviewed (nine women and two men, aged 28 to 56, six in psychodynamic psychotherapy, five in CBT). Treatments switched between in-person and video/telephone sessions. Interview transcripts were analyzed applying the qualitative methodology of inductive thematic analysis.

  Results: (1) The patients experienced the process in telepsychotherapy as impeded. Interventions were difficult to understand and lost impact. Routines surrounding the therapy sessions were lost. Conversations were less serious and lost direction. (2) Understanding was made more difficult when the nuances of non-verbal communication were lost. (3) The emotional relationship was altered. Remote therapy was perceived as something different from regular therapy, and once back in the therapy room, the patients felt that therapy started anew. The emotional presence was experienced as weakened, but some of the patients found expressing their feelings easier in the absence of bodily co-presence. According to the patients, in-person presence contributed to their security and trust, whereas they felt that the therapists were different when working remotely, behaving in a more easygoing and familiar way, as well as more solution-focused, supportive and unprofessional, less understanding and less therapeutic. Despite this, (4) telepsychotherapy also gave the patients an opportunity to take therapy with them into their everyday lives.

  Discussion: The results suggest that in the long run, remote psychotherapy was seen as a good enough alternative when needed. The present study indicates that format alternations have an impact on which interventions can be implemented, which can have important implications for psychotherapy training and supervision in an era when telepsychotherapy is becoming increasingly common.

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• Psykodynamisk psykoterapi bör starkt rekommenderas

  2023. Björn Philips, Peter Lilliengren. Läkartidningen 120, 48-49

  Artikel

  En ny paraplyöversikt visar att psykodynamisk psykoterapi (PDT) är effektiv behandling vid depression, ångestsyndrom, personlighetssyndrom och funktionella somatiska tillstånd.

  Vid sidan av ökad forskning har en betydande metodutveckling skett inom PDT under senaste decennierna.

  PDT bör få en utökad plats inom både första linjens psykiatri och specialistpsykiatrin.

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• Therapeutic alliance is calming and curing - The interplay between alliance and emotion regulation as predictors of outcome in Internet-based treatments for adolescent depression

  2023. Karin Lindqvist (et al.). Journal of Consulting and Clinical Psychology 91 (7), 426-437

  Artikel

  Objective: Therapeutic alliance is one of the most stable predictors of outcome in psychotherapy, regardless of theoretical orientation. The alliance–outcome relationship in internet-based treatments has been investigated with mixed results. There is preliminary evidence that emotion regulation can work as a mediator for the alliance–outcome relationship. The present study aimed to investigate whether alliance predicted outcome session by session in two internet-based treatments for adolescent depression, and whether this relationship was mediated by emotion regulation.

  Method: Two hundred and seventy-two participants aged 15–19 years and diagnosed with depression were randomized to 10 weeks of internet-based psychodynamic or cognitive behavioral treatment. Both therapists and patients rated the alliance weekly. Patients also rated depressive symptoms and emotion regulation weekly. Analyses were made using cross-lagged panel modeling.

  Results: Alliance, as rated by both therapist and patient, predicted depression scores the following week. Emotion regulation rated by the patient also predicted depression scores the following week. Furthermore, alliance scores predicted emotion regulation scores the following week, which in turn predicted depression scores the week after, supporting the hypothesis that alliance influences outcome partly through emotion regulation. There were no group differences in any of these relationships.

  Conclusion: Alliance seems to play an important role in internet-based treatments, partly through emotion regulation. Clinicians working with text-based treatments should pay attention to the working alliance.

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• Therapeutic alliance is calming and curing – the interplay between alliance and emotion regulation as predictors of outcome in internet-based treatments for adolescent depression

  2023. Karin Lindqvist (et al.). SPR 54th International Annual Meeting, 73-73

  Konferens

  Läs mer om Therapeutic alliance is calming and curing – the interplay between alliance and emotion regulation as predictors of outcome in internet-based treatments for adolescent depression

• Transdiagnostic Internet interventions: A breakthrough in psychological disorders?

  2023. Per Carlbring (et al.). Abstracts from the 12th Swedish Congress on internet interventions (SWEsrii), Uppsala University, Sweden, 4-4

  Konferens

  Traditional evidence-based treatments for psychological disorders are often specific to one diagnosis. Some criticize this approach for not accounting for individual variation in symptoms. Transdiagnostic treatments aim to address this issue by being applicable to a wider range of patients. This study, called TRAbee, compares two transdiagnostic modalities: Unified Protocol (=Cognitive Behavior Therapy) and Affect Phobia Therapy (= Psychodynamic Psychotherapy). The study design is a randomized controlled trial with n=2400 participants who are divided into 12 subgroups based on treatment modality (CBT vs. PDT vs. waitlist), duration (8 or 16 weeks of treatment), and discussion forum access (yes/no). Participants were randomly assigned and measured weekly during treatment and then at 6, 12 and 24 months. Inclusion criteria: 18 years or older, ability to read/write Swedish, access to smartphone/computer, GAD-7 score ≥5, and/or PHQ-9 score ≥10. Exclusion criteria: current psychological treatment, recent medication change, severe depression/suicidality. Outcome measures include GAD7, PHQ9, PID- 5, RFQ-8, NEQ, and quality of life. Follow-up data is still being collected, but preliminary results including 12 month follow-up will be available at the SWErii conference.

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• Adverse effects in internet-based cognitive-behavior versus psychodynamic therapy

  2022. Per Carlbring (et al.). EABCT 2022: Re-Thinking CBT: providing startegies for a new way of living, 66-66

  Konferens

  Background: Internet-based psychological treatments provide many benefits for patients with psychiatric disorders, but research also suggests that negative effects might occur from the interventions involved.

  Methods: A total of 2400 participants presenting with anxiety and/or depression were randomized into 12 subgroups (n=200 each) based on treatment modality (Cognitive Behavior Therapy vs. Psychodynamic Therapy vs. Waitlist), duration (8 vs. 16 weeks), and moderated discussion forum (Yes vs. No). In addition to weekly measurements of the primary outcome measure (PHQ-9 & GAD-7), the Negative Effects Questionnaire was administered post-treatment. The Negative Effects Questionnaire has been proposed as a valuable instrument for investigating the negative effects of psychological treatments. An exploratory factor analysis suggested a six-factor solution: symptoms (“I felt more worried”), quality (“I did not always understand my treatment”), dependency (“I think that I have developed a dependency on my treatment”), stigma (“I became afraid that other people would find out about my treatment”), hopelessness (“I started thinking that the issue I was seeking help for could not be made any better”), and failure (“I lost faith in myself”).

  Results: All 2400 participants have been recruited. However, all post-assessment data is not yet collected at the time of writing (but will be by the time of the conference). This talk will focus on the occurrence and characteristics of the potential negative effects of internet-based treatment in the 12 subgroups.

  Discussion: Negative effects of psychotherapy are multifaceted, warranting careful considerations for them to be monitored and reported in research settings and routine care.

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• Lessons learned from 'TRAbee' – a large full-factorial designed study (n=2400) targeting depression and/or anxiety

  2022. Per Carlbring (et al.). EABCT 2022: Re-Thinking CBT: providing startegies for a new way of living, 117-117

  Konferens

  Background: Typically, internet-based treatment programs are effective for various psychological problems. However, diagnosing, and matching treatments to an individual's need, is a challenge and potentially resource-intensive. In addition, it is unknown what the optimal treatment length is and whether access to an online forum is beneficial for treatment adherence and subsequent outcome. In this study, the Iterapi platform fully automated all decisions and communication with the participants, maximizing scalability.

  Methods: A total of 2400 participants presenting with anxiety and/or depression were randomized into 12 subgroups (n=200 each) based on treatment modality, duration, and moderated discussion forum (Yes vs. No). Weekly measurements using PHQ9 and GAD7 were the primary outcome measures.The treatments were based on Cognitive Behavior Therapy (Unified Protocol) or Psychodynamic models and treatment principles (Affect Phobia). Both Unified Protocol and the Affect Phobia treatment program are transdiagnostic methods targeting symptoms of anxiety and depression. The participants were also randomly assigned to either having (50%) or not having (50%) access to a discussion forum that a clinician moderated. Finally, all participants of the two treatment groups and the waitlist-control group were randomly assigned to either an 8- or 16-week intervention duration.

  Results: All 2400 participants have been recruited. However, all post-assessment data is not yet collected at the time of writing (but will be by the time of the conference). This talk will focus on design considerations and lessons learned from the 'TRAbee' study.

  Discussion: Since the weekly assessment of outcome has been collected, the statistical power is strong, especially since the total number of participants is 2400. The outcome will answer several dissemination questions, including treatment length, discussion boards' added value, and treatment type (CBT vs. PDT).

  Läs mer om Lessons learned from 'TRAbee' – a large full-factorial designed study (n=2400) targeting depression and/or anxiety

• TRAbee: Internet-delivered transdiagnostic self-help treatments for anxiety and/or depression: Preliminary results from a full-factorial designed randomized control trial

  2022. Per Carlbring (et al.). Abstracts from the 11th Swedish Congress on internet interventions (SWEsrii), Gothenburg, Sweden, 23-24 May 2022, 14-15

  Konferens

  Traditional evidence-based psychological treatments are often diagnosis-specific, with treatment manuals being developed for specific diagnoses. This methodology has been criticized by some for not corresponding with the clinical reality of individual variability of symptoms, comorbitity with other psychiatric diagnoses and subclinical symptoms of other conditions. A possible way of adapting treatments to clinical reality is through transdiagnostic modes of treatment.

  Transdiagnostic treatments have the great advantage of potentially being suitable to a larger, and likely more representative population. Within psychological treatment there are two main transdiagnostic modalities; Unified Protocol and Affect Phobia Therapy. Unified Protocol is based on Cognitive Behaviour Therapy and is directed at emotional regulation as an important maintaining, transdiagnostic factor. Affect phobia therapy has its theoretical roots in modern Psychodynamic Theory and is focused on breaking unconscious maladaptive patterns. Unified Protocol and Affect Phobia Therapy have to our knowledge never been compared with each other, which this study aims to accomplish.

  The current study is a randomized controlled trial with a full factorial design. A total of 2400 participants will be divided into 12 different subgroups (2 * treatment duration [8 vs 16 weeks], 2 * discussion forum access [yes vs. no], and 3 * treatment [Unified Protocol vs. Affect Phobia Therapy vs. Waitlist).

  Inclusion criteria for the study are the following: Ability to read and write Swedish, access to smartphone or computer, minimum age of 18 years, and total GAD-7 ≥ 5 points and/or PHQ-9 ≥ 10 points.

  Exclusion criteria for the study are the following: Concurrent psychological treatment, initiation of or change in medication for anxiety or depression within the previous month, or self-reported severe depression (PHQ-9 total score ≥ 20) or suicidality (PHQ-9, item 9 > 2). Participants who report severe depression or suicidality will be excluded and recommended to seek other treatment.

  GAD7 and PHQ9 are the main outcome measures. Secondary measures are: Personality Inventory for DSM Short Form, Reflective Functioning Questionnaire 8, Negative Effects Questionnaire, and Brunnsviken Brief Quality of Life Scale.

  The study is still recruiting, but preliminary results will be available at the time of the SWErii conference.

  Läs mer om TRAbee: Internet-delivered transdiagnostic self-help treatments for anxiety and/or depression

• Therapist-guided internet-based psychodynamic therapy versus cognitive behavioural therapy for adolescent depression in Sweden: a randomised, clinical, non-inferiority trial

  2022. Jakob Mechler (et al.). The Lancet Digital Health 4 (8), e594-e603

  Artikel

  Background: Adolescent major depressive disorder (MDD) is highly prevalent and associated with lifelong adversity. Evidence-based treatments exist, but accessible treatment alternatives are needed. We aimed to compare internet-based psychodynamictherapy (IPDT) with an established evidence-based treatment (internet-based cognitive behavioural therapy [ICBT]) for the treatment of adolescents with depression.

  Methods: In this randomised, clinical trial, we tested whether IPDT was non-inferior to ICBT in the treatment of adolescent MDD. Eligible participants were 15–19 years old, presenting with a primary diagnosis of MDD according to DSM-5. Participants were recruited nationwide in Sweden through advertisements on social media, as well as contacts with junior and senior high schools, youth associations, social workers, and health-care providers. Adolescents who scored 9 or higher on the Quick Inventory of Depressive Symptomatology for Adolescents (QIDS-A17-SR) in an initial online screening were contacted by telephone for a diagnostic assessment using the Mini International Neuropsychiatric Interview. Participants were randomly assigned to ICBT or IPDT. Both interventions comprised eight self-help modules delivered over 10 weeks on a secure online platform. The primary outcome was change in depression severity measured weekly by the QIDS-A17-SR. Primary analyses were based on an intention-to-treat sample including all participants randomly assigned. A non-inferiority margin of Cohen's d=0·30 was predefined. The study is registered at ISRCTN, ISRCTN12552584.

  Findings: Between Aug 19, 2019, and Oct 7, 2020, 996 young people completed screening; 516 (52%) were contacted for a diagnostic interview. 272 participants were eligible and randomly assigned to ICBT (n=136) or IPDT (n=136). In the ICBT group, 51 (38%) of 136 participants were classified as remitted, and 54 (40%) of 136 participants were classified as remitted in the IPDT group. Within-group effects were large (ICBT: within-group d=1·75, 95% CI 1·49 to 2·01; IPDT: within-group d=1·93, 1·67 to 2·20; both p<0·0001). No statistically significant treatment difference was found in the intention-to-treat analysis. Non-inferiority for IPDT was shown for the estimated change in depression during treatment (d=–0·18, 90% CI –0·49 to 0·13; p=0·34). All secondary outcomes showed non-significant between-group differences.

  Interpretation: IPDT was non-inferior to ICBT in terms of change in depression for the treatment of adolescents with MDD. This finding increases the range of accessible and effective treatment alternatives for adolescents with depression.

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• Transdiagnostic self-help treatments for anxiety and/or depression: A full-factorial RCT investigating psychotherapeutic modalities, discussion boards and treatment length

  2022. Per Carlbring (et al.). International Society for Research onInternet Interventions 11th Scientific Meeting, 19-19

  Konferens

  Context

  Typically, internet-based treatment programs are effective for a wide range of specific psychiatric diagnoses. However, diagnosing, and matching treatments to an individuals' need, is a challenge and potentially resource intensive. In this study, a computer automatically made the decision on inclusion and exclusion.

  Methods: A total of 2400 participants presenting with anxiety and/or depression were randomized into 12 subgroups (n=200 each) based on treatment modality (Cognitive Behavior Therapy vs. Psychodynamic Therapy vs. Waitlist), duration (8 vs. 16 weeks) and moderated discussion forum (Yes vs. No). Weekly measurements using PHQ9 and GAD7 were the primary outcome measures.

  Intervention (if relevant): Unified Protocol is a transdiagnostic Cognitive Behavior Therapy method for symptoms of anxiety and depression. The Affect Phobia treatment program was based on Psychodynamic models and treatment principles. The participants were also randomly assigned to either having (50%) or not having (50%) access to a discussion forum that was moderated by a clinician. Finally, all participants of the two treatment groups and the waitlist-control group were also randomly assigned to either an 8- or 16-week intervention duration.

  Results: All 2400 participants have been recruited. However, all post-assessment data is not yet collected at the time of writing (but will be by the time of the conference). The results will show if transdiagnostic treatment is better than a waitlist, if there is a relative difference between Cognitive Behavior Therapy and Psychodynamic treatment, if there is a relative difference between a 8 or 16 week long treatment, and if a discussion group has any added value.

  Conclusions: Since weekly assessment of outcome has been collected the statistical power is strong, especially since the total number of participants is 2400.

  Implications: The outcome will give a clear answer to several dissemination questions including treatment length, the added value of discussion boards and type of treatment (CBT vs. PDT).

  Läs mer om Transdiagnostic self-help treatments for anxiety and/or depression

• “Good job!”: Therapists' encouragement, affirmation, and personal address in internet-based cognitive behavior therapy for adolescents with depression

  2022. Ida Berg (et al.). Internet Interventions 30

  Artikel

  Internet-delivered interventions are generally effective for psychological problems. While the presence of a clinician guiding the client via text messages typically leads to better outcomes, the characteristics of what constitutes high-quality communication are less well investigated. This study aimed to identify how an internet therapist most effectively communicates with clients in internet-delivered cognitive behavioral therapy (ICBT). Using data from a treatment study of depressed adolescents with a focus on participants who had a positive outcome, messages from therapists were analyzed using thematic analysis. The study focused on the therapist's 1) encouragement and 2) affirmation, and how the therapists used 3) personal address. The analysis resulted in a total of twelve themes (Persistence Wins, You Are a Superhero, You Make Your Luck, You Understand, Hard Times, You Are Like Others, My View on the Matter, Time for a Change, Welcome In, Let Me Help You, You Affect Me, and I Am Human). Overall, the themes form patterns where treatment is described as hard work that requires a motivated client who is encouraged by the therapist. The findings are discussed based on the cognitive behavioral theoretical foundation of the treatment, prior research on therapist behaviors, and the fact that the treatment is provided over the internet.

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• Loss of Rituals, Boundaries, and Relationship

  2022. Andrzej Werbart (et al.). Frontiers in Psychology 13

  Artikel

  Telepsychotherapy is an increasingly common way of conducting psychotherapy. Previous research has shown that patients usually have positive experiences of online therapy, however, with large individual differences. The aim of this study was to explore patients’ experiences of transition from in-person psychotherapy sessions to telepsychotherapy during the COVID-19 pandemic, as well as variation in the experiences with regard to the patients’ personality orientation. Seven psychotherapy patients in Sweden were interviewed and the transcripts were analyzed using thematic analysis. Additionally, the participants were asked to rate their dissatisfaction/satisfaction with the transition, how hindering/helpful the transition was, and how unsafe/safe they felt after the transition in comparison to before. Personality orientation on relatedness or self-definition was assessed applying a self-assessment instrument (Prototype Matching of Anaclitic-Introjective Personality Configuration; PMAI). The participants experienced telepsychotherapy as qualitatively different from in-person psychotherapy. They reported several essential losses: the rituals surrounding therapy sessions were lost, including the transitional time and space between their every-day life and the therapy sessions, less therapeutic work was done, the therapists could lose their therapeutic stance, the sense of rapport was impaired, and the patients felt less open and emotionally available. On the other hand, some patients could feel freer online. As six of the participants had an anaclitic personality orientation, the present study could especially contribute to the understanding of how patients with strong affiliative needs and fear of abandonment experience the transition to meeting their therapists via communication technology. The participants’ self-ratings showed that they were only marginally dissatisfied with the transition and experienced the transition as slightly hindering, whereas they felt rather safe after the transition, indicating low concordance between qualitative and quantitative evaluations. New studies are needed to explore the introjective patients’ experiences of the transition. An essential topic is also to collect evidence and to test how the impaired sense of rapport when using communication technology can be remedied by adequate, patient-tailored interventions, a topic that has to be included in psychotherapy education and training.

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• The Depression

  2021. Nick Midgley (et al.). International Journal of Environmental Research and Public Health 18 (24)

  Artikel

  Introduction: Face-to-face therapy is unavailable to many young people with mental health difficulties in the UK. Internet-based treatments are a low-cost, flexible, and accessible option that may be acceptable to young people. This pilot study examined the feasibility, acceptability and effectiveness of an English-language adaptation of internet-based psychodynamic treatment (iPDT) for depressed adolescents, undertaken during the COVID-19 pandemic in the UK. Methods: A single-group, uncontrolled design was used. A total of 23 adolescents, 16–18 years old and experiencing depression, were recruited to this study. Assessments were made at baseline and end of treatment, with additional weekly assessments of depression and anxiety symptoms. Results: Findings showed that it was feasible to recruit to this study during the pandemic, and to deliver the iPDT model with a good level of treatment acceptability. A statistically significant reduction in depressive symptoms and emotion dysregulation was found, with large effect size, by the end of treatment. Whilst anxiety symptoms decreased, this did not reach statistical significance. Conclusions: The findings suggest that this English-language adaptation of iPDT, with some further revisions, is feasible to deliver and acceptable for adolescents with depression. Preliminary data indicate that iPDT appears to be effective in reducing depressive symptoms in adolescents.

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• Sudden gains and large intersession improvements in internet-based psychodynamic treatment (IPDT) for depressed adolescents

  2021. Jakob Mechler (et al.). Psychotherapy Research 31 (4), 455-467

  Artikel

  Objective: Sudden gains (SGs) have often been found associated with better treatment outcome across different psychiatric disorders. However, no studies have evaluated SGs in internet-based treatment targeting adolescent depression. Method: The sample consisted of 66 adolescents diagnosed with major depressive disorder, attending psychodynamic internet-based treatment. Effects of SGs were evaluated at posttreatment and 6-month follow-up. We also evaluated effects of large intersession improvements (LIIs; sudden and relatively large gains, between sessions, without the stability criterion). Effects of SGs and LIIs early in treatment were also investigated. Results: A total of 17 patients (25.75%) experienced an SG. The effect of having an SG or early SG was non-significant after treatment (d = 0.48) and at follow-up (d= 0.66). However, having an LII was related to better outcome after treatment (d = 0.97) and at follow-up (d = 0.76). Early LIIs were associated with significantly better results at end of treatment (d = 0.72).Conclusions: The original criteria of SGs might be overly conservative and thus miss important improvements in depression. Relatively large intersession gains, regardless of stability, seem to be predictive of outcome.

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• The role of the working alliance in psychological treatment of substance use disorder outpatients

  2021. Ylva Gidhagen (et al.). Psychotherapy Research 31 (5), 557-572

  Artikel

  Objective: The main objective of this study was to explore the relationship between alliance and treatment outcome of substance use disorder (SUD) outpatients in routine care. Attachment, type of substance use, and treatment orientation were analyzed as potential moderators of this relationship.

  Method: Ninety-nine SUD outpatients rated their psychological distress before every session. Patients and therapists rated the alliance after every session. At treatment start and end, the patient completed the Alcohol Use Disorders Identification Test (AUDIT), the Drug Use Disorders Identification Test (DUDIT), and the Experiences in Close Relationships (ECR-S). Data were analyzed using multilevel growth curve modeling and Dynamic Structural Equation Modeling (DSEM).

  Results: The associations between alliance and outcome on psychological distress and substance use were, on average, weak. Within-patient associations between patient-rated alliance and outcome were moderated by self-rated attachment. Type of abuse moderated associations between therapist-rated alliance and psychological distress. No moderating effect was found for treatment orientation.

  Conclusions: Patients' attachment style and type of abuse may have influenced the association between alliance and problem reduction. A larger sample size is needed to confirm these findings.

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• What Research Evidence Is Valid for Psychotherapy Research?

  2021. Björn Philips, Fredrik Falkenström. Frontiers in Psychiatry 11

  Artikel

  Evidence-Based Medicine (EBM) have contributed to improved clinical practice with increased use of effective and life-saving treatments for severe diseases. However, the EBM model is less suitable for psychotherapy research than for pharmacological research and somatic medicine. The randomized controlled trial (RCT) design is an example of experimental methodology, which inevitably has more imperfections in psychotherapy research because psychotherapy RCTs cannot use double-blinding and the treatments tested are composite treatment packages. Long-term psychotherapy for severe and complex mental disorders is especially difficult to study with an RCT design. During the last decades, advanced analytic methods have been developed in psychotherapy process research, which enables investigation of causal connections regarding change mechanisms in psychotherapy. Therefore, we propose that the top of the research evidence hierarchy for psychotherapy should encompass: (1) RCT for circumscribed disorders, (2) cohort studies for complex disorders, and (3) advanced process studies for change mechanisms.

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• A relational perspective on the association between working alliance and treatment outcome

  2020. Carl-Johan Uckelstam (et al.). Psychotherapy Research 30 (1), 13-22

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  Objective: Evidence is inconclusive on whether variability in alliance ratings within or between therapists is a better predictor of treatment outcome. The objective of the present study was to explore between and within patient and therapist variability in alliance ratings, reciprocity among them, and their significance for treatment outcome. Method: A large primary care psychotherapy sample was used. Patient and therapist ratings of the working alliance at session three and patient ratings of psychological distress pre–post were used for analyses. A one-with-many analytical design was used in order to address problems associated with nonindependence. Results: Within-therapist variation in alliance ratings accounted for larger shares of the total variance than between-therapist variation in both therapist and patient ratings. Associations between averaged patient and therapist ratings of the alliance for the individual therapists and their average treatment outcome were weak but the associations between specific alliance ratings and treatment outcome within therapies were strong. Conclusions: The results indicated a substantial dyadic reciprocity in alliance ratings. Within-therapist variation in alliance was a better predictor of treatment outcome than between-therapist variation in alliance ratings.

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• Affect-Focused Psychodynamic Internet-Based Therapy for Adolescent Depression

  2020. Karin Lindqvist (et al.). Journal of Medical Internet Research 22 (3)

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  Background: Adolescent depression is one of the largest health issues in the world and there is a pressing need for effective and accessible treatments.

  Objective: This trial examines whether affect-focused internet-based psychodynamic therapy (IPDT) with therapist support is more effective than an internet-based supportive control condition on reducing depression in adolescents.

  Methods: The trial included 76 adolescents (61/76, 80% female; mean age 16.6 years), self-referred via an open access website and fulfilling criteria for major depressive disorder. Adolescents were randomized to 8 weeks of IPDT (38/76, 50%) or supportive control (38/76, 50%). The primary outcome was self-reported depressive symptoms, measured with the Quick Inventory of Depressive Symptomatology for Adolescents (QIDS-A17-SR). Secondary outcomes were anxiety severity, emotion regulation, self-compassion, and an additional depression measure. Assessments were made at baseline, postassessment, and at 6 months follow-up, in addition to weekly assessments of the primary outcome measure as well as emotion regulation during treatment.

  Results: IPDT was significantly more effective than the control condition in reducing depression (d=0.82, P=.01), the result of which was corroborated by the second depression measure (d=0.80, P<.001). IPDT was also significantly more effective in reducing anxiety (d=0.78, P<.001) and increasing emotion regulation (d=0.97, P<.001) and self-compassion (d=0.65, P=.003). Significantly more patients in the IPDT group compared to the control group met criteria for response (56% vs 21%, respectively) and remission (35% vs 8%, respectively). Results on depression and anxiety symptoms were stable at 6 months follow-up. On average, participants completed 5.8 (SD 2.4) of the 8 modules.

  Conclusions: IPDT may be an effective intervention to reduce adolescent depression. Further research is needed, including comparisons with other treatments.

  Trial Registration: International Standard Randomised Controlled Trial Number (ISRCTN) 16206254; http://www.isrctn.com/ISRCTN16206254

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• Autistic traits in mentalization-based treatment for concurrent borderline personality disorder and substance use disorder

  2020. Helena C. Kaltenegger, Björn Philips, Peter Wennberg. Scandinavian Journal of Psychology 61 (3), 416-422

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  Autism is suggested to be a dimensional construct and often represents a comorbid state. However, research on the clinical implications of the presence of autistic traits is scarce. This study aimed to investigate the impact of subclinical autistic traits in mentalization-based treatment (MBT) for concurrent borderline personality disorder (BPD) and substance use disorder (SUD). Based on the data of a randomized controlled feasibility study by Philips, Wennberg, Konradsson, and Franck (2018), secondary analyses were conducted. It was tested, if patients' (N = 46) levels of autistic traits were associated with treatment outcome measured in the course of and after treatment using interviews and self-report measures. Participants' autistic traits were not associated with the change in the severity of BPD throughout and at the end of the treatment. However, results showed associations between autistic traits and the change in patients' consumption of alcohol in the course of MBT. Furthermore, there was an association between autistic traits and the change in mentalizing capacity at the end of MBT, indicating that elevated autistic traits were associated with an improvement in mentalizing capacity. Autistic traits on a subclinical level do not appear to be a complicating factor in MBT for concurrent BPD and SUD. On the contrary, in terms of mentalizing capacity autistic traits might be associated with a larger potential for improvement or facilitate treatment outcome. Further research is needed to explore the role of higher autistic traits in treatment of this special patient group.

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• Emotion Regulation as a Time-Invariant and Time-Varying Covariate Predicts Outcome in an Internet-Based Psychodynamic Treatment Targeting Adolescent Depression

  2020. Jakob Mechler (et al.). Frontiers in Psychiatry 11

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  Objective: Although psychodynamic psychotherapy is efficacious in the treatment of depression, research on mechanisms of change is still scarce. The aim of this study was to investigate if and how emotion regulation affects outcome both as a time-invariant and a lagged time-varying predictor.

  Method: The sample consisted of 67 adolescents diagnosed with major depressive disorder, attending affect-focused psychodynamic internet-based treatment (IPDT). Linear mixed models were used to analyze emotion regulation as a baseline predictor and to assess the effect of within-person changes in emotion regulation on depression.

  Results: Analyses suggested that emotion regulation at baseline was a significant predictor of outcome, where participants with relatively larger emotion regulation deficits gained more from IPDT. Further, the results showed a significant effect of improved emotion regulation on subsequent depressive symptomatology. When not controlling for time, increased emotion regulation explained 41.23% of the variance in subsequent symptoms of depression. When detrending the results were still significant, but the amount of explained variance was reduced to 8.7%.

  Conclusion: The findings suggest that patients with relatively larger deficits in emotion regulation gain more from IPDT. Decreased emotion regulation deficits seem to act as a mechanism of change in IPDT as it drives subsequent changes in depression.

  International Standard Randomised Controlled Trial Number (ISRCTN) 16206254, https://doi.org/10.1186/ISRCTN16206254.

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• Health care consumption and psychiatric diagnoses among adolescent girls 1 and 2 years after a first-time registered child sexual abuse experience

  2020. Gita Rajan (et al.). European Child and Adolescent Psychiatry

  Artikel

  Child sexual abuse (CSA) is a crime against human rights with severe health consequences, and suicidal actions, stress, eating disorders, and borderline disorder are common among survivors of CSA. The objective of this study was to analyze how health care consumption patterns developed among adolescent girls in the Stockholm Region, Sweden, 1 and 2 years after the first registration of CSA experience appeared in their medical record, as compared to age-matched controls without such registration. In this cohort study, number of healthcare visits, comorbidities, and prescribed drugs were collected through the Stockholm Region administrative database (VAL), for girls age 12-17 with registration of CSA experience in their medical record (n = 519) and age-matched controls (n = 4920) between 2011 and 2018. Healthcare consumption patterns remained higher among the girls with a registered CSA experience compared to the controls, both 1 and 2 years after the first CSA experience registration. Highest odds ratios (ORs) were found for suicide attempts [OR 26.38 (12.65-55.02) and 6.93 (3.48-13.49)]; stress disorders [25.97 (17.42-38.69) and 15.63 (9.82-24.88)]; psychosis [OR 19.39 (1.75-214.13) and 9.70 (1.36-68.95)], and alcohol abuse [OR 10.32 (6.48-16.44) and 6.09 (1.98-18.67)], 1 and 2 years, respectively, after the first CSA experience registration. The drug prescriptions were also significantly higher among the girls with a CSA experience registration than for the controls. The results highlight the need to systematically evaluate and develop assessment, treatment planning, and interventions offered to adolescent girls after their first CSA experience registration.

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• Internet-based psychodynamic versus cognitive behaviour therapy for adolescents with depression

  2020. Jakob Mechler (et al.). Trials 21 (1)

  Artikel

  Background: Adolescent depression is a common mental health problem and there is an urgent need for effective and accessible treatments. Internet-based interventions solve many obstacles for seeking and receiving treatment, thus increasing access to effective treatments. Internet-based cognitive behavioural therapy (ICBT) for adolescent depression has demonstrated efficacy in previous trials. In order to broaden the range of evidence-based treatments for young people, we evaluated a newly developed affect-focused Internet-based psychodynamic treatment (IPDT) in a previous study with promising results. The purpose of the planned study is to evaluate the efficacy of IPDT for adolescent depression in a non-inferiority trial, comparing it to ICBT.

  Methods: The study will employ a parallel randomized non-inferiority design (ratio 1:1; n = 270). Eligible participants are adolescents 15–19 years suffering from depression. The primary hypothesis is that IPDT will be non-inferior to ICBT in reducing depressive symptoms from pre-treatment to end of treatment. Secondary research questions include comparing outcomes of IPDT and ICBT regarding anxiety symptoms, emotion regulation and self-compassion. Additional data will be collected to evaluate cost-effectiveness as well as investigating predictors, moderators and mediators of outcome. In addition, we will examine long-term outcome up to 1 year after end of treatment. Diagnostic interviews with MINI 7.0 will be used to establish primary diagnosis of depression as well as ruling out any exclusion criteria. Both treatments consist of eight modules over 10 weeks, complemented with therapist support through text messages and weekly chat sessions. Primary outcome measure is the Quick Inventory of Depressive Symptomatology in Adolescents Self-Rated (QIDS-A17-SR). Primary outcome will be analysed using data from all participants entering the study using a multilevel growth curve strategy based on the weekly measurements of QIDS-A17-SR. The non-inferiority margin is defined as d = 0.30.

  Discussion: This trial will demonstrate whether IPDT is non-inferior to ICBT in the treatment of adolescent depression. The study might therefore broaden the range of evidence-based treatment alternatives for young people struggling with depression. Further analyses of data from this trial may increase our knowledge about “what works for whom” and the pathways of change for two distinct types of interventions.

  Trial registration: ISRCTN12552584, Registered on 13 August 2019.

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