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The Mentalisation Switch: Therapist Reflective Capacity and Alliance Dynamics in Digital MCT+ for Bipolar Disorder—A Longitudinal Quantitative Case Series.

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Title: The Mentalisation Switch: Therapist Reflective Capacity and Alliance Dynamics in Digital MCT+ for Bipolar Disorder—A Longitudinal Quantitative Case Series.
Authors: Maluenda‐Gatica, Roberto (AUTHOR), Araya, Christian (AUTHOR), Morán‐Kneer, Javier (AUTHOR), Ríos, Ulises (AUTHOR), Moritz, Steffen (AUTHOR), MacBeth, Angus (AUTHOR)
Source: Clinical Psychology & Psychotherapy. Mar2026, Vol. 33 Issue 2, p1-16. 16p.
Subjects: Diagnosis of mental depression, Bipolar disorder, Psychotherapists, Psychotherapy, Digital technology, Psychological distress, Cognitive testing, T-test (Statistics), Research funding, Data analysis, Questionnaires, Statistical sampling, Reflection (Philosophy), Treatment effectiveness, Quantitative research, Anxiety, Descriptive statistics, Telemedicine, Longitudinal method, Patient-professional relations, Videoconferencing, Quality of life, Case-control method, Statistics, Cognitive therapy, Therapeutic alliance, Individualized medicine, Data analysis software, Psychosocial factors, Evaluation
Geographic Terms: Chile
Abstract: Objective: This study conducted a preliminary naturalistic effectiveness evaluation of Individualised Metacognitive Therapy (MCT+) delivered via videoconferencing for individuals with bipolar I disorder (BD‐I) in a real‐world clinical setting in Chile. It also explored how therapist characteristics—specifically mentalisation capacity—influence the therapeutic alliance in digital psychotherapy. Methods: A longitudinal quantitative case series design was implemented across 14 therapist–patient dyads. Patients received 12 weekly sessions of MCT+ online. Standardised measures assessed anxiety (GAD‐7), depression (PHQ‐9), metacognitive beliefs (MCQ‐30), psychological distress (CORE‐10) and quality of life (WHOQOL‐BREF). Therapeutic alliance was tracked session‐by‐session (WAI‐S). Therapist mentalisation and attachment were evaluated at baseline (MASC‐SP, RFQ‐8, ECR‐12). Changes in outcome measures were analysed using paired t‐tests, effect sizes (Cohen's d), correlations, reliable change indices (RCI) and hierarchical linear modelling (HLM). Results: Across the intervention, there were significant decreases in anxiety (d = 0.64) and improvements in metacognitive beliefs (d = 0.37). Depression showed a modest improvement (d = 0.34), while changes in quality of life were negligible (d = −0.21). Hierarchical modelling indicated a significant interaction between automatic and controlled mentalisation (b = −0.45, p = 0.008), suggesting that flexible adjustment supported therapeutic alliance development. Attachment style showed no significant associations with the alliance (largest unadjusted effect: ρ = −0.54, p = 0.073; all adjusted ps > 0.99). Conclusions: Digital MCT+ showed preliminary effectiveness in reducing anxiety and maladaptive metacognitive beliefs among individuals with BD‐I, with more limited effects on depression and quality of life. Importantly, therapist mentalisation flexibility—the capacity to shift between automatic and controlled modes, or the mentalisation switch—emerged as a central mechanism for alliance building and engagement in digital contexts, highlighting a key target for clinical training and future research. Summary: Digital MCT+ may be a useful adjunctive intervention for individuals with BD‐I, particularly for reducing anxiety and maladaptive metacognitive beliefs.Therapeutic alliance in videoconferencing psychotherapy appears to be shaped not only by technique, but by therapists' capacity to flexibly adjust their mentalising stance.Early alliance building may benefit from intuitive, affectively attuned therapist responses, whereas later phases may require more explicit, reflective mentalisation to support task and goal alignment.Overreliance on both intuitive and highly self‐reflective mentalising simultaneously may hinder relational attunement in digital therapy.Training and supervision in digital psychotherapy should attend not only to therapists' reflective capacity but also to the timing and flexibility with which different mentalising modes are deployed. [ABSTRACT FROM AUTHOR]
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Database: Psychology and Behavioral Sciences Collection
Description
Abstract:Objective: This study conducted a preliminary naturalistic effectiveness evaluation of Individualised Metacognitive Therapy (MCT+) delivered via videoconferencing for individuals with bipolar I disorder (BD‐I) in a real‐world clinical setting in Chile. It also explored how therapist characteristics—specifically mentalisation capacity—influence the therapeutic alliance in digital psychotherapy. Methods: A longitudinal quantitative case series design was implemented across 14 therapist–patient dyads. Patients received 12 weekly sessions of MCT+ online. Standardised measures assessed anxiety (GAD‐7), depression (PHQ‐9), metacognitive beliefs (MCQ‐30), psychological distress (CORE‐10) and quality of life (WHOQOL‐BREF). Therapeutic alliance was tracked session‐by‐session (WAI‐S). Therapist mentalisation and attachment were evaluated at baseline (MASC‐SP, RFQ‐8, ECR‐12). Changes in outcome measures were analysed using paired t‐tests, effect sizes (Cohen's d), correlations, reliable change indices (RCI) and hierarchical linear modelling (HLM). Results: Across the intervention, there were significant decreases in anxiety (d = 0.64) and improvements in metacognitive beliefs (d = 0.37). Depression showed a modest improvement (d = 0.34), while changes in quality of life were negligible (d = −0.21). Hierarchical modelling indicated a significant interaction between automatic and controlled mentalisation (b = −0.45, p = 0.008), suggesting that flexible adjustment supported therapeutic alliance development. Attachment style showed no significant associations with the alliance (largest unadjusted effect: ρ = −0.54, p = 0.073; all adjusted ps > 0.99). Conclusions: Digital MCT+ showed preliminary effectiveness in reducing anxiety and maladaptive metacognitive beliefs among individuals with BD‐I, with more limited effects on depression and quality of life. Importantly, therapist mentalisation flexibility—the capacity to shift between automatic and controlled modes, or the mentalisation switch—emerged as a central mechanism for alliance building and engagement in digital contexts, highlighting a key target for clinical training and future research. Summary: Digital MCT+ may be a useful adjunctive intervention for individuals with BD‐I, particularly for reducing anxiety and maladaptive metacognitive beliefs.Therapeutic alliance in videoconferencing psychotherapy appears to be shaped not only by technique, but by therapists' capacity to flexibly adjust their mentalising stance.Early alliance building may benefit from intuitive, affectively attuned therapist responses, whereas later phases may require more explicit, reflective mentalisation to support task and goal alignment.Overreliance on both intuitive and highly self‐reflective mentalising simultaneously may hinder relational attunement in digital therapy.Training and supervision in digital psychotherapy should attend not only to therapists' reflective capacity but also to the timing and flexibility with which different mentalising modes are deployed. [ABSTRACT FROM AUTHOR]
ISSN:10633995
DOI:10.1002/cpp.70260