Mitt huvudområde för forskning och undervisning är psykodynamisk psykoterapi, särskilt nutida varianter som mentaliseringsbaserad terapi, affektfokuserad terapi och relationell psykoterapi. Min kliniska erfarenhet kommer främst från vuxenpsykiatriska området och omfattar ett ganska brett spektrum av psykiska problem, som personlighetsproblematik, psykos, depression och substansbrukssyndrom. Jag undervisar både på psykolog- och psykoterapeutprogrammet, främst om psykodynamisk diagnostik och behandling, samt om forskningsmetodik.
Jag är ordförande i Svenskt Forum för Mentalisering (www.mentalisering.se).
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 handleder tillsammans med professor Per Carlbring doktoranderna Karin Lindqvist och Jakob Mechler, 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.
I urval från Stockholms universitets publikationsdatabas
Loss of Rituals, Boundaries, and Relationship
2022. Andrzej Werbart (et al.). Frontiers in Psychology 13Artikel
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.
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.
Sudden gains and large intersession improvements in internet-based psychodynamic treatment (IPDT) for depressed adolescents
2021. Jakob Mechler (et al.). Psychotherapy Research 31 (4), 455-467Artikel
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.
The role of the working alliance in psychological treatment of substance use disorder outpatients
2021. Ylva Gidhagen (et al.). Psychotherapy Research 31 (5), 557-572Artikel
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.
What Research Evidence Is Valid for Psychotherapy Research?
2021. Björn Philips, Fredrik Falkenström. Frontiers in Psychiatry 11Artikel
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.
A relational perspective on the association between working alliance and treatment outcome
2020. Carl-Johan Uckelstam (et al.). Psychotherapy Research 30 (1), 13-22Artikel
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.
Affect-Focused Psychodynamic Internet-Based Therapy for Adolescent Depression
2020. Karin Lindqvist (et al.). Journal of Medical Internet Research 22 (3)Artikel
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
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), 416-422Artikel
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.
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 11Artikel
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.
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 PsychiatryArtikel
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.
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.