Behavior therapy of obsessive-compulsive disorder (OCD) aims to reduce avoidance, rituals, and discomfort in OCD-relevant situations. The Behavioral Avoidance Test (BAT) measures these behavior-related outcomes in individually challenging OCD-related situations. The association of the BAT with OCD severity measures and its relevance for treatment outcome is, however, still unclear. The current study investigates with a retrospective analysis of a subsample of a pilot study, (1) if reactions on the BAT are related to OCD severity measures in an OCD sample (n = 28), (2) if treatment with two variants of cognitive-behavior therapy (exposure and response prevention vs. metacognitive therapy) changes the BAT scores and (3) if these changes as well as pretreatment BAT avoidance are relevant for OCD treatment outcome as measured by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). Participants rated avoidance, ritual, and discomfort in three individually challenging OCD-related situations before and after therapy. For one of these situations, BAT dimensions were rated by the therapist and an independent rater in addition to the patients’ ratings. Correlational analyses found significant correlations between BAT discomfort and OCD severity measures like the Y-BOCS. A repeated measures ANOVA with pre- and posttest scores showed that all three BAT dimensions significantly decreased during both treatments. Hierarchical regression analyses (controlling for Y-BOCS pretest scores) revealed that changes in BAT discomfort as well as pretreatment BAT avoidance scores predicted the Y-BOCS posttest score. These findings suggest that the BAT is a distinct measure of behavior-related outcomes partly being relevant for OCD treatment outcome.

Ziel: Nach einem Jahr dialektisch-behavioral orientierter Behandlung von Borderline Patienten im ambulanten Setting werden verschiedene Wirksamkeitskriterien und Therapieprozessvariablen, wie die Qualität der Therapieallianz aus Patientenperspektive untersucht. Methode: In einer naturalistischen Studie absolvierten 47 Borderline-Patienten eine DBT-orientierte Behandlung. Das Therapieergebnis wurde mittels indirekten und direkten Veränderungsmaßen, wie Patientenziele erfasst. Prozessvariablen wurden qualitativ mittels halbstrukturierter Interviews nach einem Jahr Therapie untersucht, wobei 28 Interviews in die Analyse einflossen. Speziell die Therapiebeziehung wurde zusätzlich quantitativ mit Hilfe des Working-Alliance-Inventory erfasst, welcher nach jeder Therapiesitzung erhoben wurde. Quantitative wie qualitative Analysen wurden integriert. Ergebnisse: Die meisten Patienten zeigten im Behandlungsverlauf Fortschritte innerhalb direkt, wie auch indirekt erhobener Therapieerfolgsmaße. Die Therapieallianz steht dabei in positivem Zusammenhang mit der Therapiezielerreichung und einigen BPS-relevanten Symptomen, nicht jedoch mit Reduktion von Selbstverletzung/Suizidalität. Die qualitativen Analysen der retrospektiv erlebten Wirkfaktoren zeigen hilfreiche und weniger hilfreiche Aspekte im Therapieverlauf, wobei Beziehungsfaktoren und Therapeutenvariablen durch die Patienten als besonders wichtig bewertet werden. Schlussfolgerung: Aus Patientenperspektive wird die Bedeutung der Therapieallianz hervorgehoben, die mit der Erreichung individuell definierter Therapieziele und der Reduktion einiger borderline-typischer Symptome in Verbindung steht. Die Therapieallianz wird aus Patientenperspektive vor allem durch therapeutische “Soft Skills”, wie Empathie, Selbstoffenbarung und Verständnis geformt. Darüber hinaus wird die Fähigkeit des Therapeuten, sich auf die Bedürfnisse des Patienten einzulassen und verschiedene DBT-spezifische Fertigkeiten vermitteln zu können betont. / Objective: To investigate the patient`s perspective about the key mechanisms of change, especially the quality of the therapeutic alliance and to analyse different criteria of outcomes in the first year of out-patient dialectical behavioral therapy. Method: Participants were 47 outpatients diagnosed with BPD, who enrolled in a naturalistic trial of DBT. Severity of symptoms were assessed at intake and one year after beginning of treatment. Direct and indirect methods of measurement were used, for example individual goals from patients perspective. Alliance was assessed with the Working-Alliance-Inventory for patient´s perspective for every session and in addition with a qualitative interview after one year for 28 persons of the sample. Furthermore the interview includes all more or less helpful aspects of the process of psychotherapy. The research integrates quantitative and qualitative methods. Results: Patients showed positive changes over the course of treatment measured with direct and indirect methods. Results indicate an association between alliance and some BPD symptoms and achievement of individual goals but not self-injurious acts or suicide attempt. The qualitative analysis supports differentiation between helpful and unhelpful aspects of the key mechanisms of change from patients perspective. In the client’s view, the strongest categories comprised relationship factors and therapist variables. Conclusions: Results emphasize the importance of a strong therapeutic alliance in the treatment of patients with BPD from patients perspective, but not consistently for the assessed outcomes. The alliance was experienced and formed mainly by the therapist’s “soft skills” such as empathy, self-disclosure and understanding. The therapist’s ability to attune to the client’s needs implied the use of a wide range of DBT-specific skills.

Sudden personal transformation (SPT) was defined as a subjectively reported, positive, profound, and lasting personal change that follows a relatively brief and memorable inner experience. Although such change has been described in numerous biographies, works of fiction, and religious and scholarly texts, a consistent definition and systematic program of research is lacking in the psychological literature. Moreover, almost nothing is known about what causes such change from the subjective point of view of individuals who have experienced it first hand. This study used semi-structured interviews and thematic analysis to explore the common beliefs of three participants about the factors that facilitated and the mechanisms that caused their SPT. Findings reveal that all participants reported a life transition, feeling miserable, feeling exhausted, feeling unable to resolve adverse circumstances, reaching a breaking point, and support from others facilitated their individual SPT’s. All participants also indicated that a formalized activity or ceremony as well as a process outside of their conscious control (either a higher power or a deep inner wisdom) produced or caused their SPT’s. Implications for future research and counselling practice are discussed. / Graduate

La méthodologie de l’évaluation en psychothérapie s’est longtemps limitée aux résultats issus d’essais cliniques comparatifs de groupes. L’objectif, engagé dans les années 2000, de comprendre ce qui cause son efficacité a engagé un renouvellement méthodologique. Son application concrète est peu documentée. La première partie présente, à partir d’une revue de la littérature centrée sur l’introduction de la recherche sur le processus associée aux résultats, comment le paradigme interactionnel multifactoriel de la psychothérapie a stimulé le développement de méthodes adaptées à la complexité et à l’observation en conditions naturelles. La seconde partie introduit autour de cinq axes principaux les questions méthodologiques générales et spécifiques de cette nouvelle orientation : 1. une épistémologie interactionnelle et transactionnelle ; 2. Un recentrage sur les études mixtes intensives de cas ; 3. Une investigation clinique et théorique multifocale des processus et mécanismes de changement ; 4. une forte relation clinicien-chercheur ; 5. une approche statistique innovante. La troisième partie expose l’expérience et les questions soulevées par la mise en œuvre de ce programme dans le cadre d’un réseau de recherche clinique centré sur les pratiques, du recueil des données jusqu’à l’analyse des processus et mécanismes de changement, et les résultats qui en sont issus. La quatrième partie présente une revue détaillée de la littérature. Ce travail devrait favoriser les collaborations avec les disciplines connexes et l’efficience des traitements par une meilleure connaissance des conditions et des mécanismes de changement associée au développement d’une base de données issue d’études de cas. / The methodology of assessment in psychotherapy has long been limited to results from comparative group clinical trials. The objective, expressed in the 2000s, to understand what is causing its effectiveness has involved a methodological renewal. Its concrete application is poorly documented. The first part presents, from a review of the literature focusing on the introduction of research on the process associated with outcomes, how the multifactorial interactional paradigm of psychotherapy has stimulated the development of methods adapted to the complexity and observation in natural conditions. The second part introduces the general and specific methodological questions of this new orientation around five main axes: 1. an interactional and transactional epistemology; 2. A refocusing on intensive mixed case studies; 3. A multifocal clinical and theoretical investigation of the processes and mechanisms of change; 4. a strong clinical-researcher relationship; 5. an innovative statistical approach. The third part presents the experience and issues raised by the implementation of this program as part of a practice-oriented clinical research network, from data collection to analysis of processes and mechanisms of change, and results. The fourth part presents a detailed review of the literature. This work should foster collaborations with related disciplines and treatment efficiency through a better understanding of the conditions and mechanisms of change associated with the development of a case study database.