Tailor-made versus standardized therapy of phobic patients

Validating the Diathesis–Stress Model Based Case Conceptualization Procedure in Cognitive Behavioral Therapies: The LIBET (Life Themes and Semi-Adaptive Plans—Implications of Biased Beliefs, Elicitation and Treatment) Procedure

Cognitive behavioral therapy (CBT) approaches use case formulation procedures based on the diathesis–stress conceptualization model, arranged in two dimensions: emotional vulnerability (present in a patient’s consciousness in terms of core beliefs) and coping strategies. Nevertheless, despite its pivotal role, there are a limited number of validation studies for this model. Life themes and semi-adaptive plans: Implications of biased beliefs, elicitation and treatment (LIBET) is a CBT case formulation method grounded on the CBT diathesis–stress model that aims to help validate the CBT case formulation model, and, in particular, its bidimensional arrangement. In LIBET, the two classic CBT dimensions are called “life themes,” which are mental states of focused attention to emotional sensitivities represented as core beliefs in consciousness, and “semi-adaptive plans,” which are the rigid management strategies of “life themes” implemented by adopting coping strategies such as anxious safety behaviors, compulsive controls and aggressive or rewarding strategies. The study uses quantitative textual analysis to validate the LIBET procedure in a clinical sample. The investigation discusses the extent to which the results can be considered a validation of the arrangement of the general CBT diathesis–stress model in the two dimensions of core beliefs and coping strategies.

Formulation in eating disorder focused family therapy: why, when and how?

In the broadest sense, formulation, or case conceptualisation, is the process of collaborative sense-making. It is something all clinicians are doing constantly, whether formally and consciously or not. Most clinicians are familiar with the general principals and need to formulate as it is a core part of clinical training across most disciplines. Treatment manuals often discuss formulation, but the practical steps involved and the process of developing, building upon and revising formulations are not always provided. In clinical practice, the active use and continued development of formulation during treatment is not always prioritised, especially beyond the initial assessment. This could be due to a number of reasons, such as a potential lack of clarity, understanding or confidence in the use of formulation across treatment, a lack of dedicated time and reflective space for formulation in the context of increasingly busy clinical settings, or a perception that it may be less necessary in the context of treatment approaches that are more structured and prescriptive. This article outlines the use of formulation in family therapy for child and adolescent eating disorders, provides guidance on how to actively include formulation more throughout treatment and discusses why this might be useful.

Psychotherapy outcome research: Implications of a new clinical taxonomy

Since the publication of DSM-III in 1980, the scientist-practitioner gap in clinical psychology has expanded, as almost all outcome research in clinical psychology has been on diagnosed mental disorders within a medical model using drug trial methodologies, whereas most practising clinicians undertake functional analyses and case formulations of clinical psychological problems (CPPs) and then apply tailored interventions within an ongoing hypothesis-testing methodology. But comparatively reliable assessment and generalizable conclusions in psychotherapy outcome research require a comprehensive theory-derived conception or operational definition of 'CPPs', standardized functional analyses, and a taxonomy of CPPs comparable to DSM's listings of mental disorders. An alternative conception and taxonomy of CPPs have recently been proposed, offering improvements in the reliability and generalizability of case formulation-based psychotherapy outcome research. It conceives of CPPs as instances of the formation and operation of self-sustaining problem-maintaining circles (PMCs) of psychological-level causal elements-that is, at the level of cognitions, behaviours, emotions, and events or situations (stimuli). The paper describes this new conception of CPPs, a subsequent nascent taxonomy of evidence-based PMCs which standardizes the underlying mechanisms that maintain CPPs, and ensuing benefits to research (as well as to practice) in clinical psychology. These benefits include being able to encompass all treatment-worthy CPPs, not just diagnosable mental disorders; to assess theory-derived intervention strategies, not just arbitrary therapy bundles; and to directly feed back into psychological theories, not just expand an atheoretical list of patented "evidence supported therapies."

Mental Health Therapy Protocols and eHealth Design: Focus Group Study

Background

Electronic health (eHealth) programs are often based on protocols developed for the original face-to-face therapies. However, in practice, therapists and patients may not always follow the original therapy protocols. This form of personalization may also interfere with the intended implementation and effects of eHealth interventions if designers do not take these practices into account.

Objective

The aim of this explorative study was to gain insights into the personalization practices of therapists and patients using cognitive behavioral therapy, one of the most commonly applied types of psychotherapy, in a youth addiction care center as a case context.

Methods

Focus group discussions were conducted asking therapists and patients to estimate the extent to which a therapy protocol was followed and about the type and reasons for personalization of a given therapy protocol. A total of 7 focus group sessions were organized involving therapists and patients. We used a commonly applied protocol for cognitive behavioral therapy as a therapy protocol example in youth mental health care. The first focus group discussions aimed at assessing the extent to which patients (N=5) or therapists (N=6) adapted the protocol. The second focus group discussions aimed at estimating the extent to which the therapy protocol is applied and personalized based on findings from the first focus groups to gain further qualitative insight into the reasons for personalization with groups of therapists and patients together (N=7). Qualitative data were analyzed using thematic analysis.

Results

Therapists used the protocol as a “toolbox” comprising different therapy tools, and personalized the protocol to enhance the therapeutic alliance and based on their therapy-provision experiences. Therapists estimated that they strictly follow 48% of the protocol, adapt 30%, and replace 22% by other nonprotocol therapeutic components. Patients personalized their own therapy to conform the assignments to their daily lives and routines, and to reduce their levels of stress and worry. Patients estimated that 29% of the provided therapy had been strictly followed by the therapist, 48% had been adjusted, and 23% had been replaced by other nonprotocol therapeutic components.

Conclusions

A standard cognitive behavioral therapy protocol is not strictly and fully applied but is mainly personalized. Based on these results, the following recommendations for eHealth designers are proposed to enhance alignment of eHealth to therapeutic practice and implementation: (1) study and copy at least the applied parts of a protocol, (2) co-design eHealth with therapists and patients so they can allocate the components that should be open for user customization, and (3) investigate if components of the therapy protocol that are not applied should remain part of the eHealth applied. To best generate this information, we suggest that eHealth designers should collaborate with therapists, patients, protocol developers, and mental health care managers during the development process.

Progress monitoring and feedback delivered in routine psychiatric care: Beneficial but not reaching those thought to need it most

Objective: The study evaluated the use and effectiveness of a progress monitoring system routinely operational in a private mental health care setting. Method: In a nonrandomized trial in which 778 consecutively admitted patients underwent a 2-week cognitive behavioral therapy intervention, the effectiveness of therapists choosing to use progress monitoring feedback to frame therapist-patient discussions about individuals' progress was evaluated. Results: Patients engaged in discussions involving progress monitoring feedback during the intervention achieved a more consistent recovery rate. Furthermore, individuals that were not-on-track to achieve a positive outcome experienced a boost to recovery immediately after receiving feedback. However, evidence suggested that therapists were not using progress monitoring to primarily focus additional resources on not-on-track patients. Conclusion: Progress monitoring feedback benefited patient recovery. However, guidelines could improve the system by directing therapists to use feedback primarily with patients not on course for a positive therapeutic outcome.

Case conceptualization from a process-based and modular perspective: Rationale and application to mood and anxiety disorders

This article presents the theoretical, clinical, and practical arguments supporting a process-based transdiagnostic approach to psychotherapy. A working definition of "psychological process" is provided, as well as a tri-dimensional categorization of psychological processes potentially involved in psychopathology. Guidelines are proposed to select psychological interventions based on the active psychopathological processes evidenced in a given case. We also provide a rationale to organize treatment as a set of modules, each addressing a specific psychopathological process. Next, we review the main processes that may be active in mood and anxiety disorders, and that are accessible to clinicians in regular practice. For each process, we propose a validated assessment questionnaire. Finally, we offer a free-access web-based instrument that allows clients to fill in these questionnaires via an internet survey, and that provides therapists with a tool to easily decode and interpret the questionnaire results and to present them to the clients.

The German Adaptation of the Therapist Beliefs about Exposure Scale: a Validation Study among Licensed Cognitive Behavioural Therapists in Germany

Background: Exposure is an effective intervention in the treatment of pathological anxiety, but it is insufficiently disseminated. Therapists’ negative attitudes towards exposure might be of relevance when considering factors contributing to the non-application of this intervention. Aims: In order to be able to measure concerns in German-speaking therapist populations, the study aimed at validating a German version of the Therapist Beliefs about Exposure Scale.Method: The scale was translated into the German language and validated in a sample of 330 German licensed cognitive behavioural therapists. Results: In the present sample, the mean total score was significantly lower than in the original study including US-American therapists. Confirmatory factor analysis did not confirm the proposed one-factor model, while the exploratory factor analysis indicated that more than one factor is necessary to explain the structure of negative attitudes towards exposure. The internal consistency was high. Higher scores (more negative beliefs) were significantly correlated with older age, holding a master's degree (vs PhD), not being specialized in the treatment of anxiety disorders and with less experience with performance of exposure gained during clinical training. Negative beliefs about exposure were further associated with the self-reported average number of sessions spent on exposure in current treatment of post-traumatic stress disorder and panic disorder, and with negative attitudes towards application of exposure sessions presented in case vignettes. Conclusions: The German adaptation provides the opportunity of measuring concerns regarding application of exposure in German-speaking therapist populations. However, the presented data reveal suggestions for further scale development.

Empirical Examinations of Modifications and Adaptations to Evidence-Based Psychotherapies: Methodologies, Impact, and Future Directions

This review describes methods used to examine the modifications and adaptations to evidence-based psychological treatments (EBPTs), assesses what is known about the impact of modifications and adaptations to EBPTs, and makes recommendations for future research and clinical care. One hundred eight primary studies and three meta-analyses were identified. All studies examined planned adaptations, and many simultaneously investigated multiple types of adaptations. With the exception of studies on adding or removing specific EBPT elements, few studies compared adapted EBPTs to the original protocols. There was little evidence that adaptations in the studies were detrimental, but there was also limited consistent evidence that adapted protocols outperformed the original protocols, with the exception of adding components to EBPTs. Implications for EBPT delivery and future research are discussed.

Improving and sustaining delivery of CPT for PTSD in mental health systems: a cluster randomized trial

BACKGROUND

Large-scale implementation of evidence-based psychotherapies (EBPs) such as cognitive processing therapy (CPT) for posttraumatic stress disorder can have a tremendous impact on mental and physical health, healthcare utilization, and quality of life. While many mental health systems (MHS) have invested heavily in programs to implement EBPs, few eligible patients receive EBPs in routine care settings, and clinicians do not appear to deliver the full treatment protocol to many of their patients. Emerging evidence suggests that when CPT and other EBPs are delivered at low levels of fidelity, clinical outcomes are negatively impacted. Thus, identifying strategies to improve and sustain the delivery of CPT and other EBPs is critical. Existing literature has suggested two competing strategies to promote sustainability. One emphasizes fidelity to the treatment protocol through ongoing consultation and fidelity monitoring. The other focuses on improving the fit and effectiveness of these treatments through appropriate adaptations to the treatment or the clinical setting through a process of data-driven, continuous quality improvement. Neither has been evaluated in terms of impact on sustained implementation.

METHODS

To compare these approaches on the key sustainability outcomes and provide initial guidance on sustainability strategies, we propose a cluster randomized trial with mental health clinics (n = 32) in three diverse MHSs that have implemented CPT. Cohorts of clinicians and clinical managers will participate in 1 year of a fidelity oriented learning collaborative or 1 year of a continuous quality improvement-oriented learning collaborative. Patient-level PTSD symptom change, CPT fidelity and adaptation, penetration, and clinics' capacity to deliver EBP will be examined. Survey and interview data will also be collected to investigate multilevel influences on the success of the two learning collaborative strategies. This research will be conducted by a team of investigators with expertise in CPT implementation, mixed method research strategies, quality improvement, and implementation science, with input from stakeholders in each participating MHS.

DISCUSSION

It will have broad implications for supporting ongoing delivery of EBPs in mental health and healthcare systems and settings. The resulting products have the potential to significantly improve efforts to ensure ongoing high quality implementation and consumer access to EBPs.

TRIAL REGISTRATION

NCT02449421 . Registered 02/09/2015.

Written case formulations in the treatment of anorexia nervosa: Evidence for therapeutic benefits

OBJECTIVE

Case formulation is a core component of many psychotherapies and formulation letters may provide an opportunity to enhance the therapeutic alliance and improve treatment outcomes. This study aimed to determine if formulation letters predict treatment satisfaction, session attendance, and symptom reductions in anorexia nervosa (AN). It was hypothesized that higher quality formulation letters would predict greater treatment satisfaction, a greater number of attended sessions, and greater improvement in eating disorder symptoms.

METHOD

Patients were adult outpatients with AN (n = 46) who received Maudsley Anorexia Nervosa Treatment for Adults (MANTRA) in the context of a clinical trial. A Case Formulation Rating Scheme was used to rate letters for adherence to the MANTRA model and use of a collaborative, reflective, affirming stance. Analyses included linear regression and mixed models.

RESULTS

Formulation letters that paid attention to the development of the AN predicted greater treatment acceptability ratings (p = 0.002). More reflective and respectful letters predicted greater reductions in Eating Disorder Examination scores (p = 0.003).

DISCUSSION

Results highlight the potential significance of a particular style of written formulation as part of treatment for AN. Future research should examine applicability to other psychiatric disorders. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:874-882).

How valid is your case formulation? Empirically testing your cognitive behavioural case formulation for tailored treatment

Although clinicians have used cognitive behavioural case formulations (CBCFs) to guide treatment for many years, the validity of the case formulation (CF) is rarely evaluated. Given the central role of the formulation in treatment planning, particularly for complex or comorbid cases, a straightforward method to empirically evaluate the validity of the CBCF could increase the effectiveness of a treatment plan tailored for a particular client. This article describes a step-by-step, person-specific approach to evaluating a CBCF that can be used for appropriate cases in a clinical practice or especially a clinical training setting. The evaluation focuses on discriminant validity of person-specific scales and constructs and patterns of predicted functional relationships between idiosyncratic cognitions and distress. The approach is illustrated with an adult seen in a training clinic who was diagnosed with generalized anxiety and recurrent major depressive disorders and who completed 28 brief end-of-day, individualized questionnaires. The clinician's CBCF hypotheses were empirically evaluated using mostly simple statistical analyses available in readily accessible worksheets. Intervention implications of the CF evaluation are discussed.

Annual Research Review: Building a science of personalized intervention for youth mental health

BACKGROUND

Within the past decade, health care service and research priorities have shifted from evidence-based medicine to personalized medicine. In mental health care, a similar shift to personalized intervention may boost the effectiveness and clinical utility of empirically supported therapies (ESTs). The emerging science of personalized intervention will need to encompass evidence-based methods for determining which problems to target and in which order, selecting treatments and deciding whether and how to combine them, and informing ongoing clinical decision-making through monitoring of treatment response throughout episodes of care. We review efforts to develop these methods, drawing primarily from psychotherapy research with youths. Then we propose strategies for building a science of personalized intervention in youth mental health.

FINDINGS

The growing evidence base for personalizing interventions includes research on therapies adapted for specific subgroups; treatments targeting youths' environments; modular therapies; sequential, multiple assignment, randomized trials; measurement feedback systems; meta-analyses comparing treatments for specific patient characteristics; data-mining decision trees; and individualized metrics.

CONCLUSION

The science of personalized intervention presents questions that can be addressed in several ways. First, to evaluate and organize personalized interventions, we propose modifying the system used to evaluate and organize ESTs. Second, to help personalizing research keep pace with practice needs, we propose exploiting existing randomized trial data to inform personalizing approaches, prioritizing the personalizing approaches likely to have the greatest impact, conducting more idiographic research, and studying tailoring strategies in usual care. Third, to encourage clinicians' use of personalized intervention research to inform their practice, we propose expanding outlets for research summaries and case studies, developing heuristic frameworks that incorporate personalizing approaches into practice, and integrating personalizing approaches into service delivery systems. Finally, to build a richer understanding of how and why treatments work for particular individuals, we propose accelerating research to identify mediators within and across RCTs, to isolate mechanisms of change, and to inform the shift from diagnoses to psychopathological processes. This ambitious agenda for personalized intervention science, although challenging, could markedly alter the nature of mental health care and the benefit provided to youths and families.

The utility of case formulation in treatment decision making; the effect of experience and expertise

OBJECTIVES

We examined whether case formulation guides the endorsement of appropriate treatment strategies. We also considered whether experience and training led to more effective treatment decisions. To examine these questions two related studies were conducted both of which used a novel paradigm using clinically relevant decision-making tasks with multiple sources of information.

METHODS

Study one examined how clinicians utilised a pre-constructed CBT case formulation to plan treatment. Study two utilised a clinician-generated formulation to further examine the process of formulation development and the impact on treatment planning. Both studies considered the effect of therapist experience.

RESULTS

Both studies indicated that clinicians used the case formulation to select treatment choices that were highly matched to the case as described in the vignette. However, differences between experts and novice clinicians were only demonstrated when clinicians developed their own formulations of case material. When they developed their own formulations the experts' formulations were more parsimonious, internally consistent, and contained fewer errors and the experts were less swayed by irrelevant treatment options.

LIMITATIONS

The nature of the experimental task, involving ratings of suitability of possible treatment options suggested for the case, limits the interpretation that formulation directs the development or generation of the clinician's treatment plan. In study two the task may still have limited the capacity to demonstrate further differences between expert and novice therapists.

CONCLUSIONS

Formulation helps guide certain aspects of effective treatment decision making. When asked to generate a formulation clinicians with greater experience and expertise do this more effectively.

Relationships between clinician-level attributes and fidelity-consistent and fidelity-inconsistent modifications to an evidence-based psychotherapy

BACKGROUND

Clinicians often modify evidence-based psychotherapies (EBPs) when delivering them in routine care settings. There has been little study of factors associated with or implications of modifications to EBP protocols. This paper differentiates between fidelity-consistent and fidelity-inconsistent modifications and it examines the potential influence of two clinician characteristics, training outcomes, and attitudes toward EBPs on fidelity-consistent and fidelity-inconsistent modifications of cognitive behavioral therapy in a sample of clinicians who had been trained to deliver these treatments for children or adults.

METHODS

Survey and coded interview data collected 2 years after completion of training programs in cognitive behavioral therapy were used to examine associations between successful or unsuccessful completion of training, clinician attitudes, and modifications. Modifications endorsed by clinicians were categorized as fidelity-consistent or fidelity-inconsistent and entered as outcomes into separate regression models, with training success and attitudes entered as independent variables.

RESULTS

Successful completion of a training program was associated with subsequent fidelity-inconsistent modifications but not fidelity-consistent modifications. Therapists who reported greater openness to using EBPs prior to training reported more fidelity-consistent modifications at follow-up, and those who reported greater willingness to adopt EBPs if they found them appealing were more likely to make fidelity-inconsistent modifications.

CONCLUSIONS

Implications of these findings for training, implementation, EBP sustainment, and future studies are discussed. Research on contextual and protocol-related factors that may impact decisions to modify EBPs will be an important future direction of study to complement to this research.

The Comorbidity of PTSD and MDD: Implications for Clinical Practice and Future Research

The high prevalence of post-traumatic stress disorder (PTSD) and major depressive disorder (MDD) comorbidity is well established, with comorbidity rates often between 30 and 50%. However, despite the high prevalence of this comorbidity, very few researchers have explored specific treatments for individuals who present with comorbid PTSD and MDD. Further, there has not been explicit examination of the mechanisms through which MDD influences trauma-focused therapy. As individuals with comorbid PTSD and MDD often present with a more chronic course of impairment and in some instances, a more delayed response to treatment, the need for such research is imperative. It will be proposed that there is merit in targeting depression within the treatment of comorbid PTSD and MDD. Accordingly, in this article we review explanations for the high PTSD and MDD comorbid relationship and highlight variables likely to explain such comorbidity. Theoretical accounts for how depression impedes optimal recovery from PTSD and the associated empirical findings are illustrated. We consequently argue that there is a need to develop and test treatments that target both PTSD and MDD symptoms. Directions for future research are highlighted.

Empirically Validated Interventions for Adult Disorders

The movement towards evidence-based practice in psychology and medicine should offer few problems in cognitive-behaviour therapies because it is consistent with the principles by which they have been developed and disseminated. However, the criteria for assessing empirical status, including the heavy emphasis on manualised treatments, need close examination. A possible outcome of the evidence-based movement would be to focus on the application of manualised treatments in both training and clinical practice; problems with that approach are discussed. If we are committed to evidence-based treatment, comparisons between psychological and pharmacological interventions should also be included so that rational health care decisions can be made. We should not be afraid of following the evidence, even when it supports treatments that are not cognitive-behavioural in stated orientation. Such results should be taken as an opportunity for theoretical development and new empirical inquiry rather than be a cause for concern.

The Content, Quality and Impact of Cognitive Behavioural Case Formulation During Treatment of Obsessive Compulsive Disorder

Background: Case formulation (CF) is considered a core component of cognitive behavioural therapy (CBT). Despite this, few studies have explored the content and quality of CFs in routine practice and any associated impact on treatment outcome. Aims: This study investigated (1) the content, timing and quality of CF for patients (N = 29) with Obsessive Compulsive Disorder; (2) the impact of CF on symptoms, distress and therapeutic alliance; and (3) the relationship between CF quality and treatment outcome. Method: CF content and quality were assessed from audiotapes of routine CBT sessions using a validated coding manual and evaluated against treatment outcomes at different stages of therapy. Results: CFs were developed early during treatment and contained strong behavioural and cognitive components, with a focus on symptoms and maintaining factors. CF quality ratings ranged from rudimentary to excellent. A significant improvement in distress and the therapeutic alliance occurred following the introduction of CF, but no significant relationship was found between CF quality and outcome at any stage of treatment. Conclusion: CF may be valuable in reducing patient attrition, due to its impact early in treatment. Further research is needed to explore the most important components of CF. Theoretically sound and disorder specific measurement tools for evaluating CFs are required.

The Effect of Client Case Complexity on Clinical Decision Making

In mental health care, clinicians’ treatment decisions are expected to be based on the formulation (i.e., exploration of the causing and maintaining mechanisms) of the client’s problems. Previous research showed two things: clinicians’ case formulations mainly contain descriptive information instead of explanatory information and it is unclear to what extent treatment decisions are actually based on case formulations. In this study, we tested whether the complexity of client problems influences case formulation quality and we investigated to what extent case formulations explain treatment decisions for simple and complex client problems. Results show that case formulations for complex problems were of lower quality than those for simple problems. Also, we found that case formulations are only weakly associated with treatment decisions, for both types of problems. We conclude that clinicians give higher quality case formulations when these may be least needed, that is: for simple cases, for which an empirically supported treatment is available. Clinicians appear to base treatment decisions on descriptions of overt client symptoms rather than on case formulations.

The importance of theory in cognitive behavior therapy: a perspective of contextual behavioral science

For the past 30 years, generations of scholars of cognitive behavior therapy (CBT) have expressed concern that clinical practice has abandoned the close links with theory that characterized the earliest days of the field. There is also a widespread assumption that a greater working knowledge of theory will lead to better clinical outcomes, although there is currently very little hard evidence to support this claim. We suggest that the rise of so-called "third generation" models of CBT over the past decade, along with the dissemination of statistical innovations among psychotherapy researchers, have given new life to this old issue. We argue that theory likely does matter to clinical outcomes, and we outline the future research that would be needed to address this conjecture.

Therapist effects and the outcome-alliance correlation in cognitive behavioral therapy for panic disorder with agoraphobia

Although the alliance-outcome correlation is well established, no published studies to date have separated between therapists' and patients' contributions while controlling for early symptom change. In this study, we examined therapist effects in two trials of CBT for panic disorder with agoraphobia (PDA) and the impact of therapists' and patients' contribution to the alliance on outcome and attrition in one trial. Alliance ratings were obtained from patients and therapists early and late in treatment (n = 133). Data were analyzed using multi-level modeling controlling for early symptom change. No therapist effects were found. The patients' contribution to the alliance predicted outcome (in both panic severity and anxiety sensitivity) and attrition. The therapists' contribution to the alliance predicted attrition but not outcome. Results suggest that the patient's contribution to the alliance plays an important role in CBT for PDA and that including common factors into research on CBT may help elucidate treatment processes.

Psychotherapie und Wissenschaft

Klinische Praxis und Psychotherapieforschung werden häufig als Spannungsfelder mit wenigen Berührungspunkten angesehen. Trotz erheblicher empirischer Erkenntnisgewinne über die letzten Jahrzehnte hinweg spielen in der klinischen Praxis oft Forschungsergebnisse nur eine untergeordnete Rolle für das Fällen von Therapieentscheidungen oder die Auswahl von Behandlungsstrategien. Stattdessen vertrauen Therapeuten häufig auf das eigene klinische Urteil, was beispielsweise zu einer Unterschätzung der Wahrscheinlichkeit von Therapiemisserfolgen führen kann. Flexible Behandlungskonzepte werden in der Praxis häufig standardisierten Interventionen bevorzugt, beispielsweise in der Annahme, letztere würden von Patienten nicht akzeptiert. Jedoch gibt es neben überzeugenden Wirksamkeitsnachweisen auch aktuelle Daten, die eine hohe Wertschätzung standardisierter Interventionen wie strukturierte Interviews durch Patienten belegen. Neue Studien zeigen, dass eine wissenschaftlich orientierte Ausbildung sowohl die Akzeptanz evidenzbasierter Behandlungsmöglichkeiten durch Therapeuten als auch den Therapieerfolg erhöhen können. Um eine breitere Dissemination von Ergebnissen aus der Forschung zu erreichen sowie evidenzbasierte Behandlung zu fördern, sollten Psychotherapieforscher ihre Ergebnisse Praktikern leichter zugänglich machen und angehende Psychotherapeuten müssen eine wissenschaftlich fundierte Ausbildung erhalten.

The Role of Formulation-based Treatment for Sexual Offenders

The assessment of sexual offenders consists of the systematic collection of clinically relevant information in order to detect clinical problems and to provide clear treatment targets. A key but neglected issue in the area of sexual offending concerns the role of individual case formulations in the determination of offenders' treatment needs. In this paper, we investigate the relative strengths and weaknesses of manual-based treatment (MBT) and formulation-based treatment (FBT) for sex offenders. On the one hand, FBT has the advantages of greater flexibility and a more individualistic focus, and arguably is better equipped to deal with more complex clinical presentations. On the other hand, MBT has the advantages of standardisation and less reliance on clinicians' (flawed) judgement, and may be a more efficient use of scarce resources. We conclude that clinicians should initially provide manual-based treatment rather than that based on individualised case formulations. However, we also suggest that there are at least four situations where FBT represents a valuable strategy, namely when confronted with particularly complex or unusual cases, when standardised treatment has failed, or when there are significant threats to the therapeutic relationship. Finally, we briefly discuss some possibilities for research, and caution that our mixed model is only proposed as a temporary solution and that ultimately any model concerning treatment selection needs to be empirically based and conceptually defensible.

Theoretical and practical barriers to practitioners' willingness to seek training in empirically supported treatments

To identify barriers to the dissemination of empirically supported treatments (ESTs), a random sample of psychologists in independent practice (N=1291) was asked to complete measures of attitudes towards ESTs and willingness to attend a 3-hour, 1-day, or 3-day workshop in an EST of their choice. The strongest predictor of unwillingness to obtain EST training was the amount of time and cost required for the workshop, followed by objections to the need for EST training. Psychodynamic (compared to cognitive-behavioral) and more experienced practitioners agreed more strongly with the objections to ESTs overall, as did those whose graduate schools had not emphasized psychotherapy research. Results suggest that both practical and theoretical barriers are significant obstacles to EST dissemination.

Expert reasoning in psychotherapy case formulation

Therapist reasoning in case formulation construction was investigated. Sixty-five psychodynamic or cognitive-behavioral therapists classified as experts, experienced, or novices generated "think aloud" formulations based on six standardized vignettes. Formulations were reliably transcribed, segmented into idea units, and content coded. ANOVA and sequential analysis compared formulation content and reasoning processes. Expert formulations contained more descriptive, diagnostic, inferential, and treatment planning information. They focused more on given and inferred symptoms, on adult relationship history, on inferred psychological mechanisms, on the need for further evaluation, and on plans to focus on treatment expectations and symptoms. They exhibited more forward (inferential) than backward (deductive) reasoning and, compared with non-experts, they exhibited more forward and backward reasoning. Results are discussed in terms of cognitive science models for expert problem solving and on implications for psychotherapy training, practice, and research.

Validity Issues in Cognitive-Behavioral Case Formulation

Despite considerable interest and growth in methods to develop or generate cognitive behavioral case formulations (CBCFs), relatively little conceptual and empirical work has focused on the validation or testing of these formulations. A case formulation can be regarded as an idiographic theory of the person and his or her life situation. This complex set of clinical judgments consists of a measurement model including the behavior problems or distress constructs and how they are measured; and a causal model involving variables such as thoughts or beliefs hypothesized to trigger and maintain this person’s distress or dysfunction. This article describes four types of validity issues in CBCF and how these validity issues can be evaluated using person-specific, intraindividual data collected daily or multiple times a day. Specific topics include the evaluation of content and construct (convergent and discriminant) validity for the measurement model, and the evaluation of predictive and treatment-related validity for the causal model. One goal of the person-specific evaluation of CBCF validity is to develop an intraindividual statistical prediction model that has the advantages of actuarial prediction yet is fine-grained and tailored to the specific issues and life circumstances of greatest relevance for a particular individual. Greater attention to evaluation of validity issues in CBCF is important for future research comparing formulation-based to manualized treatment. Implications and applications to clinical practice and training are discussed.

Effectiveness of systematic treatment selection for psychodynamic and cognitive-behavioural therapy: randomised controlled trial in routine mental healthcare

BACKGROUND

Although cognitive-behavioural therapy (CBT) and psychodynamic therapy (PDT) are both effective treatments for mental disorders, they show clear dissimilarities concerning their therapeutic models and treatment rationales.

AIMS

To determine the effectiveness of systematic treatment selection (STS) to CBT or PDT in a mental healthcare setting compared with a control procedure of random treatment selection (RTS).

METHOD

A randomised controlled trial in a consecutive sample of 291 in-patients with at least one ICD-10 mental disorder was performed. The primary outcome was symptom severity (General Severity Index of the Symptom Checklist-14) at 6-month follow-up. Health-related quality of life was the secondary outcome, determined using the Short Form-8.

RESULTS

Analyses revealed no general effect for systematic treatment selection. However, there was a differential effect: systematic selection resulted in a better longer-term outcome for PDT, but not for CBT; STS-PDT patients showed a significantly larger reduction in symptom severity than RTS-PDT patients. This difference was not observed in CBT.

CONCLUSIONS

Since systematic treatment selection seems to be able to optimise treatment outcome, at least for PDT, pursuing systematic treatment assignment strategies in mental healthcare settings is a worthwhile endeavour.

Interesting practitioners in training in empirically supported treatments: research reviews versus case studies

It has been repeatedly demonstrated that clinicians rely more on clinical judgment than on research findings. We hypothesized that psychologists in practice might be more open to adopting empirically supported treatments (ESTs) if outcome results were presented with a case study. Psychologists in private practice (N=742) were randomly assigned to receive a research review of data from randomized controlled trials of cognitive-behavioral treatment (CBT) and medication for bulimia, a case study of CBT for a fictional patient with bulimia, or both. Results indicated that the inclusion of case examples renders ESTs more compelling and interests clinicians in gaining training. Despite these participants' training in statistics, the inclusion of the statistical information had no influence on attitudes or training willingness beyond that of the anecdotal case information.

Balancing fidelity and adaptation in the dissemination of empirically-supported treatments: The promise of transdiagnostic interventions

Assessing treatment fidelity is a core methodological consideration in the study of treatment outcome; it influences both the degree to which changes can be attributed to the intervention and the ability to replicate and disseminate the intervention. Efforts to increase access to evidence-based psychological treatments are receiving unprecedented support; but pressures exist to adapt treatments to service settings, running the risk of compromising fidelity. However, little evidence is available to inform the necessary conditions for the transportation of interventions to service provision settings, and the degree to which fidelity is even evaluated or emphasized in dissemination and implementation programs varies dramatically. Moreover, adaptation is associated with several benefits for dissemination efforts and may address relevant barriers to adoption. A particularly promising strategy for maximizing the benefits of both fidelity and adaptation is the use of transdiagnostic interventions. Such treatments allow for greater flexibility of the pacing and content of treatment, while still providing structure to facilitate testing and replication. Preliminary evidence supports the efficacy of this strategy, which may be particularly conducive to dissemination into service provision settings. At this time, further research is needed to evaluate the relationships among fidelity, adaptation, and outcome, and to determine the potential for transdiagnostic treatments to facilitate dissemination.

Therapist responsiveness to child engagement: flexibility within manual-based CBT for anxious youth

Therapy process research helps delineate common and specific elements essential to positive outcomes as well as develop best practice training protocols. Child involvement and therapist flexibility were rated in 63 anxious youth (ages 8-14) who received cognitive-behavioral therapy. Therapist flexibility, defined as therapist attempts to adapt treatment to a child's needs, was hypothesized to act as an engagement strategy that serves to increase child involvement during therapy. Flexibility was significantly related to increases in later child engagement, which subsequently predicted improvement in posttreatment diagnosis and impairment. Therapist flexibility was not associated with earlier measures of child engagement, so a mediation model could not be supported. It was also hypothesized that the impact of flexibility would be greatest for cases who began treatment highly disengaged (i.e., early involvement would moderate the effect of flexibility). Basic descriptive data supported this model, but formal analyses failed to confirm. Further descriptive analyses suggest therapists employ a range of adaptations and a profile of flexible applications within a manual-based treatment is provided. Treatment, measurement, and dissemination issues are discussed.

Efficacy of EMDR in children: a meta-analysis

The efficacy of eye movement desensitization and reprocessing (EMDR) in children with post-traumatic stress symptoms was meta-analytically examined from the perspective of incremental efficacy. Overall post-treatment effect size for EMDR was medium and significant (d=.56). Results indicate efficacy of EMDR when effect sizes are based on comparisons between the EMDR and the non-established trauma treatment or the no-treatment control groups, and the incremental efficacy when effect sizes are based on comparisons between the EMDR and the established (CBT) trauma treatment. The discussion focuses on the future replication of EMDR findings and further research on post-traumatic stress in children.

Behavioural Analysis: Does It Matter?

Behavioural or, in more general terms, problem analysis is usually regarded as the prerequisite of behaviour therapy. In behaviour therapy research, however, problem analysis does not play a key role. Patients are usually assigned to treatment methods on the basis of clinical diagnosis. It could be assumed that the lack of attention to the patient's individual characteristics should lead to poorer therapy outcome results. However, empirical data of a project reviewed in this paper in fact showed that assigning patients to standard treatment merely on the basis of clinical diagnoses provides results equal to or even better than those of optimized individual therapy strategies. Two premises of problem analysis were therefore tested. It could be shown that therapists would diagnose different problem conditions not only for patients with different types of phobia, but also, as expected, for patients with identical diagnoses. However, this did not—as would be expected according to the second premise of problem analysis—result in choosing different individual therapy strategies. One reason for these findings could be that behaviour therapy research has been able to provide treatment programs that have been differentiated and gradually optimized for specific diagnostic groups. To decide on the application of these treatment programs, clinical diagnoses are necessary. It is suggested that clinical diagnosis and problem analysis should be complementary. An integrative model is suggested.

A literature review exploring the efficacy of case formulations in clinical practice. What are the themes and pertinent issues?

There is a paucity of research exploring the validity, reliability and impact on clinical outcome of Cognitive Behavioural Psychotherapy (CBP) case formulations. This review considers a variety of literature that relates to formulations and their use, it also draws on other types of psychotherapy where there appears to be a more established and robust research base. The literature review explores the research that has taken place within CBP and considers the themes that emerge from this research. Several themes were identified and these relate to decision-making and experience, specific guidelines to aid quality of formulations and a significant lack of understanding of clients' views on the formulation process and its outcome. It is unclear whether formulations do influence the successfulness of therapy. Recommendations are made as to what further research is needed and the form this should take.

The Science and Practice of Case Conceptualization

Case conceptualization is a foundation of cognitive-behavioural therapy (CBT) because it describes and explains clients' presentations in ways that inform interventions. Yet the evidence base challenges the claimed benefits of case conceptualization. This paper reviews the rationale and evidence base for case conceptualization and outlines a new approach that uses the metaphor of a case conceptualization crucible in which a client's particular history, experience and strengths are synthesized with theory and research to produce an original and unique account of clients' presenting issues. The crucible metaphor illustrates three key defining principles of case conceptualization. First, heat drives chemical reactions in a crucible. In our model, collaborative empiricism between therapist and client provides the heat. Second, like the chemical reaction in a crucible, conceptualization develops over time. Typically, it begins at more descriptive levels, later a conceptualization incorporates explanatory elements and, if necessary, it develops further to include a longitudinal explanation of how pre-disposing and protective factors influence client issues. Finally, new substances formed in a crucible are dependent on the chemical characteristics of the materials put into it. Rather than simply look at client problems, our model incorporates client strengths at every stage of the conceptualization process to more effectively alleviate client distress and promote resilience.

Can assessors and therapists predict the outcome of long-term psychotherapy in borderline personality disorder?

Surprisingly few studies have investigated the accuracy of prognostic assessments of therapy outcome by clinicians. The objective of the present study was to investigate the relationship between clinicians' prognostic assessments and patient characteristics and treatment outcome. Seventy-one patients with a borderline personality disorder randomly allocated to schema-focused therapy (SFT) or transference-focused psychotherapy (TFP) were assessed every 3 months for 3 years. Prognostic assessments proved to be unrelated to patients' biographical (i.e., age, gender, education level, and employment level) and clinical characteristics (i.e., number of Axis I and Axis II diagnoses, and severity of psychiatric symptoms or borderline personality pathology). Clinical assessors as well as therapists rated the probability of success for SFT to be higher than for TFP. Prospective assessments of assessors and therapists accurately predicted different indices of outcome above and independent of patient characteristics. The prediction of outcome in the TFP condition in particular proved to be valid. Identifying prognostic markers of treatment outcome as used by clinicians in their prognostic assessments may improve current prediction models and patient-treatment matching.