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The study investigated the contribution of therapists and patients to the therapeutic bond and their associations (at the within and between levels) to treatment outcome. On this aim, the social relations model (SRM, aimed to analyze dyadic interpersonal data) was implemented.A novel design for individual psychotherapy studies was adopted, a many-with-many asymmetrical block dyadic design, in which several patients interact with several therapists. Hierarchical linear models were computed to study through variance partitioning the different components of the SRM and their association to treatment outcome.All SRM components (with significant effects at therapist- and patient- within and between levels) resulted in significant contributions to the bond. However, only components at the within- and between-therapist, and within-patient levels resulted in significant associations with outcome.Given the dyadic nature of the bond, our results support not only studying and offering clinical training on interpersonal therapeutic skills but also on constant monitoring and feedback of the relationship at the more idiosyncratic level.

In the present study, sessions prior to sudden gains, sudden losses, and neutral control sessions were examined regarding the processes of change resource activation, problem actuation and therapeutic alliance. With respect to these change processes, we examined whether pregain, preloss, and neutral sessions are distinguishable by particular patterns. For the current project, videos of 30 pregain, 29 preloss, and 30 neutral control sessions from n = 89 patients receiving integrative cognitive–behavioral therapy were rated minute-by-minute using Resource-Oriented Microprocess Analysis. The sample was drawn from a total of N = 365 patients, who had completed treatment or who had attended at least 20 sessions of therapy between the years of 2007 and 2011. Discriminant function and survival analyses as well as a binary logistic regression analysis were performed to identify patterns and timing of change processes associated with session types (gains, losses, and neutral sessions). The three session types differed with regard to patterns of resource activation and problem actuation. No difference concerning therapeutic alliance was found. The findings may help future studies to generate new hypotheses regarding processes that are involved in the occurrence of sudden changes. (PsycInfo Database Record (c) 2020 APA, all rights reserved)

Background Routine outcome monitoring can support clinicians to detect patients who deteriorate [not-on-track (NOT)] early in psychotherapy. Implemented Clinical Support Tools can direct clinicians’ attention towards potential obstacles to a positive treatment outcome and provide suggestions for suitable interventions. However, few studies have compared NOT patients to patients showing expected progress [on-track (OT)] regarding such obstacles. This study aimed to identify domains that have predictive value for NOT trajectories and to compare OT and NOT patients regarding these domains and the items of the underlying scales. Methods During treatment, 413 outpatients filled in the Hopkins-Symptom-Checklist-11 (depressive and anxious symptom distress) before every therapy session as a routine outcome measure. Further, the Assessment for Signal Clients, Affective Style Questionnaire, and Outcome Questionnaire-30 were applied every fifth session. These questionnaires measure the following domains, which were investigated as potential obstacles to treatment success: risk/suicidality, therapeutic alliance, motivation, social support and life events, as well as emotion regulation. Two groups (OT and NOT patients) were formed by defining a cut-off (failure boundary) as the 90% confidence interval (upper bound) of the respective patients’ expected recovery curves. In order to differentiate group membership based on the respective problem areas, multilevel logistic regression analyses were performed. Further, OT and NOT patients were compared with regard to the domains’ and items’ cut-offs by performing Pearson chi-square tests and independent samples t-tests. Results The life events and motivation scale as well as the risk/suicidality scale proved to be significant predictors of being not-on-track. NOT patients also crossed the cut-off significantly more often on the domains risk/suicidality, social support, and life events. For both OT and NOT patients, the emotion regulation domain’s cut-off was most commonly exceeded. Conclusion Life events, motivation, and risk/suicidality seem to be directly linked to treatment failure and should be further investigated for the use in clinical support tools.

Objective: This study aims at developing a treatment selection algorithm using a combination of machine learning and statistical inference to recommend patients’ optimal treatment based on their pr...

Antibiotic-resistant Enterobacteriaceae are regularly detected in livestock. As pathogens, they cause difficult-to-treat infections and, as commensals, they may serve as a source of resistance genes for other bacteria. Slaughterhouses produce significant amounts of wastewater containing antimicrobial-resistant bacteria (AMRB), which are released into the environment. We analyzed the wastewater from seven slaughterhouses (pig and poultry) for extended-spectrum β-lactamase (ESBL)-carrying and colistin-resistant Enterobacteriaceae. AMRB were regularly detected in pig and poultry slaughterhouse wastewaters monitored here. All 25 ESBL-producing bacterial strains (19 E. coli and six K. pneumoniae) isolated from poultry slaughterhouses were multidrug-resistant. In pig slaughterhouses 64% (12 of 21 E. coli [57%] and all four detected K. pneumoniae [100%]) were multidrug-resistant. Regarding colistin, resistant Enterobacteriaceae were detected in 54% of poultry and 21% of pig water samples. Carbapenem resistance was not detected. Resistant bacteria were found directly during discharge of wastewaters from abattoirs into water bodies highlighting the role of slaughterhouses for environmental surface water contamination.

Objective: Both good therapeutic bond as well as extra-therapeutic social support seem to enhance treatment outcomes. Some features of the therapeutic bond are similar to experiences in extra-therapeutic relationships (e.g., feelings of trust or belongingness). Patients with a lack of social support might benefit particularly from a good therapeutic bond, because a well-formed bond can partly substitute relationship needs. This study replicates former research (main effects of bond and social support) and investigates the hypothesized interaction between both constructs. Method: Data from 1206 adult patients receiving cognitive-behavioral outpatient therapy were analyzed. Patients rated early therapeutic bond, their impairment, as well as their social support. Multilevel regression analyses were applied to test for main effects and interactions between bond and social support predicting therapy outcome post treatment. Results: Consistent with prior research, both therapeutic bond and social support predicted therapy outcome. Among patients with high social support, the impact of the therapeutic bond was minimal, while patients with low social support benefited most from a good therapeutic bond. Conclusions: Results suggest that both the therapeutic bond and social support play a role in therapy outcomes and that good therapeutic bond quality might be especially important if a patient lacks social support.

Technische Fortschritte in den letzten 20 Jahren eröffnen neue Chancen in Bezug auf umfangreiche Datenerhebungen und neue Interventionsformen im Gesundheitsbereich, im Speziellen in der Psychotherapie. Computergestützte Ansätze werden unter dem Begriff E-Mental-Health zusammengefasst und können auf dem Weg für eine evidenzbasierte Personalisierung in der ambulanten Face-to-Face Psychotherapie unterstützen (Precision Mental Health). Diese auch unter dem Begriff “blended mental health” bekannt gewordene Variante einer empirisch gestützten Personalisierung kann sowohl die Planung der Behandlung zu Therapiebeginn, als auch die Anpassung im Behandlungsverlauf [eProzessdiagnostik] beinhalten. Exemplarisch wird eine mögliche Umsetzung der Personalisierung in der klinischen Praxis anhand des Trierer Therapie Navigators (TTN) aufgezeigt sowie die zugrundeliegenden Forschungskonzepte dargestellt. Im TTN werden datengestützte Anpassungen im Behandlungsverlauf durch eProzessdiagnostik, Feedback und Unterstützungshilfen in fünf klinischen Therapiefeldern (1. Krisenmanagement/Suizidalität; 2. Motivation/Therapieziele; 3. Therapiebeziehung/Interpersonale Fähigkeiten; 4. Soziale Unterstützung/Kritische Lebensereignisse; 5. Emotions- und Selbstregulation) ermöglicht. Insbesondere bei Patientinnen und Patienten mit einem erhöhten Risiko für einen ungünstigen Verlauf oder Therapieabbruch (Dropout) ist eine solche Feedback-gestützte Therapie hilfreich. Abschließend werden Perspektiven zur Weiterentwicklung, z.B. Nutzung zusätzlicher Datenquellen, und zur Umsetzung in der klinischen Aus- und Weiterbildung diskutiert.

Background The therapeutic alliance is an important factor in psychotherapy, affecting both therapy processes and outcome. Therapy transfers may impair the quality of the therapeutic alliance and increase symptom severity. The aim of this study is to investigate the impact of patient transfers in cognitive behavioural therapy on alliance and symptoms in the sessions after the transfer. Method Patient- and therapist-rated therapeutic alliance and patient-reported symptom severity were measured session-to-session. Differences in the levels of alliance and symptom severity before (i.e., with the original therapist) and after (i.e., with the new therapist) the transfer session were analysed. The development of alliance and symptom severity was explored using multilevel growth models. Results A significant drop in the alliance was found after the transfer, whereas no differences were found with regard to symptom severity. After an average of 2.93 sessions, the therapeutic alliance as rated by patients reached pretransfer levels, whereas it took an average of 5.05 sessions for therapist-rated alliance levels to be at a similar level as before the transfer. Inter-individual differences were found with regard to the development of the therapeutic alliance over time. Conclusions Therapy transfers have no long lasting negative effects on either symptom impairment or the therapeutic alliance.

Zusammenfassung. Theoretischer Hintergrund: Chronische Depressionen gehen mit einer langwierigen Belastung einher und verursachen hohe Krankheitskosten. Ein möglicher Ansatz zur Behandlung könnte die Loving Kindness Meditation (LKM) sein. Methode: In dieser Pilot-Studie wurde ein LKM-Gruppenprogramm eingesetzt und bezüglich der Effektivität untersucht. N = 2207 Fälle aus Wartelistendaten wurden stufenweise zu der LKM-Gruppe (n = 12) zugeordnet. Zwei Kontrollgruppen (n = 134 und n = 12) wurden gebildet, indem zunächst die Ein-und Ausschlusskriterien angewandt wurden und dann die verbliebene Stichprobe basierend auf der Kovariatenverteilung mittels Propensity Score Matching (PSM) angepasst wurde. Die Gruppen wurden anhand des OQ-30 verglichen. Ergebnisse: Im Prä-Post-Vergleich zeigten sich im OQ-30 signifikante Verbesserungen. Allerdings zeigte sich das so nicht in den symptomspezifischen Instrumenten (BDI-II und HAM-D). Im Vergleich zu der gesamten Wartelistenstichprobe (n = 134) ergaben sich signifikante Verbesserungen im OQ-30. Verglichen mit der PSM-Wartelistenkontrollgruppe zeigten sich marginal signifikante Unterschiede im OQ-30, signifikante Unterschiede konnten bezüglich der Depressionsitems des OQ-30 nachgewiesen werden. In der Interventionsgruppe ergaben sich mehr reliable Verbesserungen im OQ-30 als in den Wartelistenkontrollgruppen. Schlussfolgerung: Die Pilotstudie zeigte eine geringere Abbruchquote als Vorgängerpilotstudien und eine gute Prä-Post Effektstärke im OQ-30, sowie im Vergleich zu den beiden Wartelistekontrollgruppen. Allerdings zeigten sich keine konsistenten Prä-Post Effekte in den Depressionsskalen. Eine weitere umfangreichere Studie mit aktiver Kontrollgruppe wäre nötig, um das Programm hinsichtlich seiner Effektivität, bezüglich des Abbruchs sowie der Heterogenität der Effekte in den Depressionsskalen weiter untersuchen zu können.

Background: Trauma focused cognitive behavioral therapy (Tf-CBT) and eye movement desensitization and reprocessing (EMDR) are two highly effective treatment options for post-traumatic stress disorder (PTSD). Yet, on an individual level, PTSD patients vary substantially in treatment response. The aim of the paper is to test the application of a treatment selection method based on a personalized advantage index (PAI). Method: The study used clinical data for patients accessing treatment for PTSD in a primary care mental health service in the north of England. PTSD patients received either EMDR (N = 75) or Tf-CBT (N = 242). The Patient Health Questionnaire (PHQ-9) was used as an outcome measure for depressive symptoms associated with PTSD. Variables predicting differential treatment response were identified using an automated variable selection approach (genetic algorithm) and afterwards included in regression models, allowing the calculation of each patient’s personalized advantage index (PAI). Results: Age, employment status, gender and functional impairment were identified as relevant variables for Tf-CBT. For EMDR, baseline depressive symptoms as well as prescribed antidepressant medication were selected as predictor variables. Fifty-six percent of the patients (n = 125) had a PAI equal or higher than one standard deviation. From those patients, 62 (50%) did not receive their model-predicted treatment and could have benefited from a treatment assignment based on the PAI. Conclusions: Using a PAI-based algorithm has the potential to improve clinical decision-making and to enhance individual patient outcomes, although further replication is necessary before such an approach can be implemented in prospective studies.

The present article gives an overview of quality assurance measures in outpatient psychotherapy. Therefore, we review elements considered important to assure quality in general and for psychotherapy in particular. We focus on possibilities to assure the quality of psychotherapy outcomes. Recently, an increased outcome orientation has gained considerable attention and is emphasized by national and international policy makers. Finally, recent developments in feedback research are discussed and practical applications presented.

Zusammenfassung. Theoretischer Hintergrund: Trotz der gut belegten generellen Wirksamkeit von Psychotherapie wird die Zahl der Patienten, die nicht auf eine Therapie ansprechen oder sich sogar im Verlauf verschlechtern, auf etwa ein Drittel geschätzt. Da Therapeuten im Vergleich zu empirischen Algorithmen weniger gut in der Lage sind negative Entwicklungen zu entdecken oder zu prognostizieren, brauchen sie zusätzliche Unterstützung in Form von kontinuierlichen Rückmeldungen über den Fortschritt ihrer Patienten. Solche Feedbackinterventionen können als empirisch basierte Unterstützung des Supervisions- oder Intervisionsprozesses verstanden werden. Diese Interventionen haben ihre Wirksamkeit zur Reduktion therapeutischer Misserfolge in zahlreichen Einzelstudien und Meta-Analysen wiederholt zeigen können. Fragestellung: Wie nutzen Therapeuten ein solches Feedback in ihrer praktischen Arbeit und in welchem Ausmaß spielen Therapeutenfaktoren dabei eine Rolle? Methode: In der vorliegenden Studie wurden 72 Therapeuten für 648 ihrer Patienten unmittelbar nach der Therapie dazu befragt, wie sie das psychometrische Feedback genutzt haben. Therapeutenunterschiede wurden mittels Mehrebenenmodellen ermittelt. Ergebnisse: Es konnte gezeigt werden, dass Therapeuten für einen Großteil ihrer Patienten das Feedback verwendeten. In etwa einem Drittel der Fälle gab es den Therapeuten den Anstoß zusätzliche Hilfen (z. B. Supervision/Intervision) zu beanspruchen. Ähnlich einer personengestützten Supervision wurde für über die Hälfte der Patienten das Feedback genutzt um therapeutische Interventionen anzupassen. Ob und in welcher Form es genutzt wurde hing jedoch stark von dem Therapeuten ab. Je nach Verwendungsart konnten Therapeutenunterschiede zwischen 27 % und 52 % der Feedbacknutzung erklären. Die Wahrscheinlichkeit, dass Therapeuten die Nutzungsmöglichkeiten des Feedbacks anwendeten war größer, wenn diese angaben im Durchschnitt zufriedener mit den grafischen Rückmeldungen zu sein. Schlussfolgerungen: Diese Ergebnisse machen deutlich, dass es zu einem großen Teil nicht nur vom Therapieverlauf oder den Charakteristika der jeweiligen Patienten abhängt wie Therapeuten das Feedback nutzen, sondern auch von Variablen, die den Therapeuten betreffen.

Background Whereas therapist effects on outcome have been a research topic for several years, the influence of therapists on premature treatment termination (dropout) has hardly been investigated. Since dropout is common during psychological treatment, and its occurrence has important implications for both the individual patient and the healthcare system, it is important to identify the factors associated with it. Method Participants included 707 patients in outpatient psychotherapy treated by 66 therapists. Multilevel logistic regression models for dichotomous data were used to estimate the impact of therapists on patient dropout. Additionally, sociodemographic variables, symptoms, personality style and treatment expectations were investigated as potential predictors. Results It was found that 5.7% of variance in dropout could be attributed to therapists. The therapist's effect remained significant after controlling for patient's initial impairment. Furthermore, initial impairment was a predictor of premature termination. Other significant predictors of dropout on a patient level were male sex, lower education status, more histrionic and less compulsive personality style and negative treatment expectations. Conclusions The findings indicate that differences between therapists influence the likelihood of dropout in outpatient psychotherapy. Further research should focus on variables, which have the potential to explain these inter-individual differences between therapists (e.g., therapist's experience or self-efficacy). Copyright © 2016 John Wiley & Sons, Ltd. Key Practitioner Messages There are substantial differences between therapists concerning their average dropout rates. At the patient level, higher initial impairment, male sex, lower education, less compulsive personality style, more histrionic personality style and low treatment expectations seem to be risk factors of non-consensual treatment termination. Psychometric feedback during the course of treatment should be used to identify patients who are at risk for dropout.

This study estimates feedback and therapist effects and tests the predictive value of therapists' and patient attitudes toward psychometric feedback for treatment outcome and length.Data of 349 outpatients and 44 therapists in private practices were used. Separate multilevel analyses were conducted to estimate predictors and feedback and therapist effects.Around 5.88% of the variability in treatment outcome and 8.89% in treatment length were attributed to therapists. There was no relationship between the average effectiveness of therapists and the average length of their treatments. Initial impairment, early alliance, number of diagnoses, feedback as well as therapists' and patients' attitudes toward feedback were significant predictors of treatment outcome. Treatments tended to be longer for patients with a higher number of approved sessions by the insurance company, with higher levels of interpersonal distress at intake, and for those who developed negatively (negative feedback) over the course of their treatment.Therapist effects on treatment outcome and treatment length in routine care seem to be relevant predictors in the context of feedback studies. Therapists' attitudes toward and use of feedback as well as patients' attitudes toward feedback should be further investigated in future research on psychometric feedback.

The present article gives an overview of quality assurance measures in outpatient psychotherapy. Therefore, we review elements considered important to assure quality in general and for psychotherapy in particular. We focus on possibilities to assure the quality of psychotherapy outcomes. Recently, an increased outcome orientation has gained considerable attention and is emphasized by national and international policy makers. Finally, recent developments in feedback research are discussed and practical applications presented.

Electrically powered hydraulic steering (EPHS) was developed in the early 1990s from the demand for power-saving steering systems which can be controlled independently from the internal combustion engine. The capabilities of these systems has been successively expanded.

Real-time monitoring of plant water status under field conditions remains difficult to quantify. Here we give evidence that the magnetic-based leaf patch clamp pressure (LPCP) probe is a non-invasive and online-measuring method that can elucidate short- and long-term temporal and spatial dynamics of leaf water status of trees with high precision in real time. Measurements were controlled remotely by telemetry and data transfer to the Internet. Concomitant measurements using the pressure chamber technique (frequently applied for leaf water status monitoring) showed that both techniques yield in principle the same results despite of the high sampling variability of the pressure chamber data. There was a very good correlation between the output pressure signals of the LPCP probe and the balancing pressure values (on average r 2 = 0.90 ± 0.05; n = 8), i.e. the external pressure at which water appears at the cut end of a leaf under pressure chamber conditions. Simultaneously performed direct measurements of leaf cell turgor pressure using the well-established cell turgor pressure probe technique evidenced that both techniques measure relative changes in leaf turgor pressure. The output pressure signals of the LPCP probe and the balancing pressure values were inversely correlated to turgor pressure. Consistent with this, the balancing pressure values and the cell turgor pressure values could be fitted quite well by the same firm theoretical backing derived recently for the LPCP probe ( Zimmermann et al., 2008 ). This finding suggests that use of the LPCP probe technique in agricultural water management can be built up on the knowledge accumulated on spot leaf or stem water potential measurements.

Background and Aims: Effects of four irrigation treatments on leaf turgor pressure of grapevines were studied using the novel leaf patch clamp pressure (LPCP) probe. Data were correlated with yield and yield components. Methods and Results: The LPCP probe measures leaf water status by monitoring the attenuation of an external pressure applied magnetically to a leaf patch. The output pressure signals, P p, are inversely correlated with cell turgor pressure. Measurements showed that changes in transpiration and stomatal conductance induced by environmental parameters were reflected nearly immediately in Pp. Ongoing non-irrigation resulted in a continuous increase of Pp, in the occurrence of stomatal oscillations and in an increased turgor pressure recovery phase during afternoon. Interestingly, analysis of the numerous diurnal Pp data sets showed that east-directed leaves responded more sensitively to water stress than west-directed leaves. Conclusions: For the cultivar and conditions used in this study, the probe data as well as the yield data support irrigation on a 3-day basis with relatively small amounts of water. Significance of the Study: The results show that the LPCP probe is a user-friendly, high precision instrument for online-monitoring of leaf turgor pressure in dependency on changes in microclimate and irrigation, thus helping growers to increase yield while simultaneously saving water.

Turgor pressure provides a sensitive indicator for irrigation scheduling. Leaf turgor pressure of Musa acuminate was measured by using the so-called leaf patch clamp pressure probe, i.e. by application of an external, magnetically generated and constantly retained clamp pressure to a leaf patch and determination of the attenuated output pressure P(p) that is highly correlated with the turgor pressure. Real-time recording of P(p) values was made using wireless telemetric transmitters, which send the data to a receiver base station where data are logged and transferred to a GPRS modem linked to an Internet server. Probes functioned over several months under field and laboratory conditions without damage to the leaf patch. Measurements showed that the magnetic-based probe could monitor very sensitively changes in turgor pressure induced by changes in microclimate (temperature, relative humidity, irradiation and wind) and irrigation. Irrigation effects could clearly be distinguished from environmental effects. Interestingly, oscillations in stomatal aperture, which occurred frequently below turgor pressures of 100 kPa towards noon at high transpiration or at high wind speed, were reflected in the P(p) values. The period of pressure oscillations was comparable with the period of oscillations in transpiration and photosynthesis. Multiple probe readings on individual leaves and/or on several leaves over the entire height of the plants further emphasised the great impact of this non-invasive turgor pressure sensor system for elucidating the dynamics of short- and long-distance water transport in higher plants.

An advanced non-invasive, field-suitable and inexpensive leaf patch clamp pressure probe for online-monitoring of the water relations of intact leaves is described. The probe measures the attenuated output patch clamp pressure, P(p), of a clamped leaf in response to an externally applied input pressure, P(clamp). P(clamp) is generated magnetically. P(p) is sensed by a pressure sensor integrated into the magnetic clamp. The magnitude of P(p) depends on the transfer function, T(f), of the leaf cells. T(f) consists of a turgor pressure-independent (related to the compression of the cuticle, cell walls and other structural elements) and a turgor pressure-dependent term. T(f) is dimensionless and assumes values between 0 and 1. Theory shows that T(f) is a power function of cell turgor pressure P(c). Concomitant P(p) and P(c) measurements on grapevines confirmed the relationship between T(f) and P(c). P(p) peaked if P(c) approached zero and assumed low values if P(c) reached maximum values. The novel probe was successfully tested on leaves of irrigated and non-irrigated grapevines under field conditions. Data show that slight changes in the microclimate and/or water supply (by irrigation or rain) are reflected very sensitively in P(p).