Where Is the Evidence for "Evidence-Based" Therapy?

Psychoanalysis and the Experience of Homelessness

Psychoanalysis is often viewed as a practice relevant only to educated people of means. This article describes a project that matches psychoanalytically trained clinicians with unhoused and formerly unhoused adults in a large urban community. D. W. Winnicott's ideas about impingement, the holding environment, fear of breakdown, and careful monitoring of the analyst's interiority have proven to be most valuable theoretical and clinical tools. A decade-long case example demonstrates the challenges and healing potentials of the work.

Facilitators and barriers to "Positive Outcomes" from cognitive-behavioral therapy, according to young people: A thematic synthesis

OBJECTIVE

This qualitative review sought to explore how young people (YP) conceptualize positive outcomes from cognitive-behavioral therapy (CBT) and what YP perceive to be the facilitators and barriers to positive outcomes.

METHODS

A systematic literature search was conducted in June 2021 using six online databases. Studies were included if qualitative data were collected from participants who were aged up to 25, had internalizing mental health difficulties, and had received in-person CBT from trained practitioners.

RESULTS

Nineteen studies were included. The Gough Weight of Evidence framework was used to assess methodological and topical quality and relevance. A thematic synthesis identified 34 conceptualizations of positive outcomes, 57 facilitators, and 49 barriers. Descriptive and analytical themes were identified. In line with the review's pragmatic perspective, the latter were worded as practice recommendations: acknowledge YP's perspectives on outcomes, teach tangible CBT techniques, balance autonomy and support, frame CBT as "upskilling," explore nuanced barriers to engagement, and consider the power of group dynamics.

CONCLUSIONS

This review established the range of YP's views about positive outcomes from CBT, as well as facilitators and barriers to achieving these. Findings should prompt CBT practitioners to reflect and consider how their practice might be shaped through reports from YP as experts by experience.

Psychodynamic Formulation and Psychodynamic Psychotherapy for Pediatric Anxiety Disorders

Psychodynamic psychotherapy can be an effective treatment of pediatric anxiety disorders. Psychodynamic formulation can be easily integrated with other conceptualizations of anxiety (eg, biological/genetic, developmental, and social learning theory). Psychodynamic formulation helps determine whether anxiety symptoms represent innate biological responses, learned responses from early experiences, or defensive reactions to intrapsychic conflict. Child and Adolescent Anxiety Psychodynamic Psychotherapy and Psychoanalytic Child Therapy are two evidence-based manualized psychodynamic approaches to treating pediatric anxiety disorders.

The Efficacy of Two Group Interventions on Mental Representations, Attachment Security, and Trauma Symptoms in Ethnically and Socioeconomically Minoritized Young Adolescents in an Urban Middle School

Symptoms resulting from childhood trauma can negatively impact socioemotional well-being and school performance during early adolescence unless positive changes in attachment security and mental representations of significant relationships occur. A sample of 109 eighth grade urban students were randomly assigned to one of two weekly, one-hour, school-based group interventions-Storytelling/Story-Acting for Adolescents (STSA-A) or Mentalization-Based Treatment Group Intervention (MBT-G). The Object Relations Inventory (ORI), Adolescent Attachment Questionnaire (AAQ) and Child PSTD Stress Scale (CPSS) were administered to students and their primary group leaders at the beginning (October) and end (May) of the intervention protocol as outcome variables. Participants in both the STSA-A and MBT-G intervention conditions experienced significant increases in attachment security and decreases in trauma symptoms. Over the course of eight months of group intervention, affective valence of paternal mental representations significantly decreased for boys and for participants in the STSA-A condition, while affective valence of primary group leader mental representations significantly decreased for participants in the MBT-G condition. STSA-A and MBT-G were found to be efficacious at improving attachment security and reducing trauma symptoms in young adolescents. The strengths of each group intervention for addressing interpersonal issues unique to specific types of adolescents are discussed.

Unipolare Depression – psychodynamische Vielfalt

Versorgungsengpässe in der ambulanten Psychotherapie haben in den letzten Jahren zu diversen Gesetzesinitiativen geführt. Eine davon war die Einführung von diagnosespezifischen Behandlungskontingenten. Ausgehend von diesem gesundheitspolitischen Vorhaben fragten wir uns, inwiefern empirische Daten für oder gegen eine solche Praxis sprechen, das heißt, wie „homogen“ Patient:innen mit derselben ICD-10-Diagnose aus psychodynamischer Sicht sind. Mithilfe der qualitativen Inhaltsanalyse wurden 13 Berichte von Patient:innen mit der Erstdiagnose F33.1 (Rezidivierende depressive Störung, gegenwärtig mittelgradige Episode) ausgewertet, die im Rahmen des Gutachtenverfahrens geprüft wurden. Zusätzlich schätzten wir das generelle Funktionsniveau ein und verglichen die Reife der Abwehr mit dem Vorliegen komorbider psychischer Diagnosen. Es wurden 56 Seiten Textmaterial analysiert. Wir identifizierten 4 Konflikttypen (Selbstwert, Nähe-Distanz, Unterwerfung, Schuld) sowie strukturelle Beeinträchtigungen in 4 Bereichen (Selbst- und Objektwahrnehmung, Selbstregulierung, Bindung und Identität), bei Vorliegen verschiedener Therapieziele und Interaktionsformen. Die Abwehr bewegte sich auf unreifem bis neurotischen Niveau, was nicht im Zusammenhang mit dem Vorliegen komorbider Diagnosen stand. Das Funktionsniveau ließ auf ein breites Spektrum genereller Beeinträchtigung schließen. Unsere Ergebnisse legen nahe, dass Depressionen vielfältige psychodynamische Hintergründe haben. Dies steht im Widerspruch zu der Idee einer Zuordnung von ICD-10-Diagnose und Behandlungskontingent.

Trans-diagnostic determinants of psychotherapeutic treatment response: The pressing need and new opportunities for a more systematic way of selecting psychotherapeutic treatment in the age of virtual service delivery

Numerous forms of psychotherapy have demonstrated effectiveness for individuals with specific mental disorders. It is, therefore, the task of the clinician to choose the most appropriate therapeutic approach for any given client to maximize effectiveness. This can prove to be a difficult task due to at least three considerations: (1) there is no treatment approach, method or model that works well on all patients, even within a particular diagnostic class; (2) several treatments are equally efficacious (i.e., more likely to be effective than no treatment at all) when considered only in terms of the patient's diagnosis; and (3) effectiveness in the real-world therapeutic setting is determined by a host of non-diagnostic factors. Typically, consideration of these latter, trans-diagnostic factors is unmethodical or altogether excluded from treatment planning - often resulting in suboptimal patient care, inappropriate clinic resource utilization, patient dissatisfaction with care, patient demoralization/hopelessness, and treatment failure. In this perspective article, we argue that a more systematic research on and clinical consideration of trans-diagnostic factors determining psychotherapeutic treatment outcome (i.e., treatment moderators) would be beneficial and - with the seismic shift toward online service delivery - is more feasible than it used to be. Such a transition toward more client-centered care - systematically considering variables such as sociodemographic characteristics, patient motivation for change, self-efficacy, illness acuity, character pathology, trauma history when making treatment choices - would result in not only decreased symptom burden and improved quality of life but also better resource utilization in mental health care and improved staff morale reducing staff burnout and turnover.

The therapeutic effects of the therapists' ability to pass their patients' tests in psychotherapy

INTRODUCTION

According to Control-Mastery Theory (CMT)-a cognitive-dynamic relational theory of mental functioning, psychopathology, and psychotherapy-patients come to therapy with an unconscious plan to disprove their pathogenic beliefs and achieve adaptive goals. One of the primary ways patients work to disconfirm their pathogenic beliefs is by testing them within the therapeutic relationship.

OBJECTIVES

The present study aimed to replicate and expand the results of previous studies suggesting that therapists' responses that disconfirmed patient's pathogenic beliefs were predictive of patients' within-session progress. Moreover, we wanted to investigate whether these interventions correlated with the therapeutic alliance.

METHODS

Transcriptions of 81 sessions from five brief psychodynamic psychotherapies were assessed by 11 independent raters. For each case, the patient's plan was formulated and tests identified, the accuracy of the therapist's responses to these tests was rated, and the impact of the therapist's interventions on the patient's subsequent communications and their relationship with the therapeutic alliance was measured.

RESULTS

The results supported the central hypothesis of the CMT that when the therapist's interventions passed the patient's tests, the patient showed signs of improvement. Moreover, the ability of the therapist to pass the patient's tests correlated with the therapeutic alliance.

CONCLUSIONS

The clinical implications and the limitations of these findings are discussed, together with the relevance of a good case formulation for clinicians' optimal responsiveness.

How much time does psychoanalysis take? The duration of psychoanalytic treatments from Freud's cases to the Swedish clinical practice of today

The starting point for this paper is Freud's thinking about the length of psychoanalysis and the conditions for ending it. His psychoanalytic treatments were intense, but varied greatly in length. Freud's assertion that deep psychological changes take time is still topical; however, the length of time has gradually increased. Available documentation from psychoanalytic training institutes, and findings from empirical studies, indicate that the mean length of psychoanalysis ranges from between three to seven years, and varies between different countries and periods. A recent survey among Swedish psychoanalysts found a mean length of 5.7 years and a wide variation in length from 1.5 to 12 years. Discussions in a seminar group on endings and the qualitative follow-up survey showed that a unique combination of factors determined the duration of psychoanalysis in each individual case. We briefly review the potential determinants of the treatment length and the different meanings of time in open-ended psychoanalytic treatments. To conclude, we stress the need for systematic clinical and empirical studies of determinants and the underlying processes behind the different lengths of psychoanalyses.

Learning clinical skills: an ecological perspective

The pedagogy underpinning clinical psychology training is often reliant upon the acquisition and transmission of knowledge and the practice of skills. The dominant paradigm in the training of clinical psychologists emphasises competence-based training drawing upon a scientist practitioner model of practice, often underpinned by knowledge of evidence-based interventions. Little has changed over the past 40 years. Training is predicated upon the assumption that effective therapy is attributed to the therapist's skills to implement specific therapeutic processes and her or his capacity to form an effective working alliance with the client or patient. We provide an argument for an alternative paradigm in which ecological principles are privileged with a view to enhancing clinical training of psychologists in health settings responsive to the trainee as well as the broader societal context in which they practice, by adopting a pedagogy which prioritizes the relationship between the person and the environment. The proposed approach brings an ecological set of assumptions to the learning experience in clinical contexts. Key principles, drawn from an ecological perspective includes: affordances, the emergence of self-organisation in clinical learning, constraints and rate limiters. The approach is supported by examples applied to clinical learning contexts. Implications for clinical training are discussed. The ways in which an ecological approach may contribute to more effective learning outcomes through the use of representative learning contexts may inform learning design, how learning is actioned in clinical psychology as well as future research on the pedagogy of clinical training.

Stability and flexibility in psychotherapy process predict outcome

Ten good outcome and ten poor outcome psychotherapy cases were compared to investigate whether or not the temporal stability and flexibility of their process variables can predict their outcomes. Each participant was monitored daily using the Therapy Process Questionnaire (TPQ), which has 43 items and seven sub-scales, and responses over time were analyzed in terms of correlation robustness and correlation variability across the TPQ sub-scales. "Correlation robustness" and "correlation variability" are two basic characteristics of any correlation matrix: the first is calculated as the sum of the absolute values of Pearson correlation coefficients, the second as the standard deviation of Pearson correlation coefficients. The results demonstrated that the patients within the poor outcome group had lower values on both variables, suggesting lower stability and flexibility. Furthermore, a higher number of cycles of increase and decrease in correlation robustness and variability of the TPQ sub-scales was observed within good outcome psychotherapies, suggesting that, these cycles can be considered as process-markers of good-outcomes. These results provide support for the validity of these quantitative process-parameters, correlation robustness and variability, in predicting psychotherapeutic outcomes. Moreover, the results lend support to the common clinical experience of alternating periods of flexibility and integration being beneficial to good psychotherapeutic processes.

Communication strategies to facilitate the implementation of new clinical practices: a qualitative study of community mental health therapists

Although communication is widely observed to be central to the implementation process, the field of implementation science has largely overlooked the details of how communication may best be utilized to facilitate implementation. This paper draws on relevant insights from Rogers' Diffusion of Innovations Theory, which laid the foundation for explicitly attending to the role of communication as a mechanism for implementation strategies to exert their effects. To offer empirically-derived and theory-informed recommendations regarding communication processes to support the effective introduction of new clinical practices. This investigation leverages data from 61 therapists poised to undergo implementation of measurement-based care (MBC) for depressed adults receiving psychotherapy in community mental health settings. Data were collected via focus groups across 12 sites. Themes emergent in the data analysis suggest five practices to facilitate effective communication in the introduction of new clinical practices like MBC: the communication of a clear rationale for the new practice; the provision of necessary procedural knowledge; communication about the change via multiple methods; sufficient lead time to prepare for the change; and the opportunity for bidirectional engagement. In addition to indicating several best practices to improve communication prior to implementation, our results suggest that the current conceptualization of implementation strategies may not yet be complete. Components and/or methods of effective communication about new practices should be included among the growing set of implementation strategies. Existing implementation strategies might also benefit from more temporal specificity, with more attention to the exploration and preparation phases. (Trial Registration: Clinicaltrials.gov NCT02266134. Registered 12 October 2014.).

Minding our Minds: Obsessive-Compulsiveness, Psychiatry, and Psychology

Obsessive-compulsive features are commonly found in high-achieving people including psychiatrists, psychologists, and scientists. These traits have a substantial but unrecognized cultural influence on psychiatric and psychological science and practice. This article reviews obsessive-compulsive mechanisms and discusses the ways they both promote and impede psychiatric and psychological science and practice. It examines them in relation to two of the dominant psychiatric and psychological paradigms of our era, the Diagnostic and Statistical Manual (DSM), and Cognitive-Behavioral Therapy. Finally, the article suggests that better awareness of our collective obsessive-compulsive tendencies can facilitate a cultural shift toward a broader, more useful science of mind and brain, as well as therapies informed by more comprehensive scientific understanding.

Mental health progress requires causal diagnostic nosology and scalable causal discovery

Nine hundred and seventy million individuals across the globe are estimated to carry the burden of a mental disorder. Limited progress has been achieved in alleviating this burden over decades of effort, compared to progress achieved for many other medical disorders. Progress on outcome improvement for all medical disorders, including mental disorders, requires research capable of discovering causality at sufficient scale and speed, and a diagnostic nosology capable of encoding the causal knowledge that is discovered. Accordingly, the field's guiding paradigm limits progress by maintaining: (a) a diagnostic nosology (DSM-5) with a profound lack of causality; (b) a misalignment between mental health etiologic research and nosology; (c) an over-reliance on clinical trials beyond their capabilities; and (d) a limited adoption of newer methods capable of discovering the complex etiology of mental disorders. We detail feasible directions forward, to achieve greater levels of progress on improving outcomes for mental disorders, by: (a) the discovery of knowledge on the complex etiology of mental disorders with application of Causal Data Science methods; and (b) the encoding of the etiological knowledge that is discovered within a causal diagnostic system for mental disorders.

Il ruolo della terapia psicodinamica e gli ostacoli alla sua diffusione

Dalle ricerche emerge che la terapia psicodinamica è efficace in modo specifico per pazienti con disturbi di personalità, disturbi cronici d'ansia e depressivi e anche disturbi cronici complessi. Inoltre, la frequenza settimanale e la durata della terapia hanno effetti positivi indipendenti tra loro. Uno degli ostacoli alla diffusione della terapia psicodinamica è il fatto che vengono preferiti i trattamenti brevi, in particolar modo la terapia cognitivo-comportamentale (CBT), considerata spesso il gold standard (cioè la terapia migliore che ci sia) nonostante i problemi che sono stati rilevati nelle metodologie delle ricerche sperimentali, nella validità dei risultati in suo favore, nella generalizzabilità dei risultati e nei metodi diagnostici utilizzati. Un altro ostacolo all'erogazione della terapia psicodinamica risiede nei protocolli delle compagnie assicurative vigenti in molti Paesi, che guardano al contenimento dei costi anziché fornire ai pazienti un trattamento ottimale; negli Stati Uniti, ad esempio, tradiscono il mandato del Mental Health Parity Act, la legge che obbliga che i limiti massimi di copertura assicurativa per i disturbi mentali non seguano criteri diversi da quelli per i trattamenti ottimali dei problemi medici o chirurgici.

Integration of Cognitive and Emotional Processing Predicts Poor and Good Outcomes of Psychotherapy

Abstract

With the aim of investigating analogies and differences between psychotherapeutic processes, ten good-outcome and ten poor-outcome cases were selected from a sample of patients treated at the University Hospital of Psychiatry, Salzburg, Austria, and the Department of Psycho-Traumatology of the Clinic St. Irmingard, Prien am Chiemsee, Germany. They were monitored daily using the Therapy Process Questionnaire (TPQ), and their evolution over time was analyzed by means of Principal Components Analysis and Linear Discriminant Analysis. The results highlight that poor-outcome patients show a separation between cognitive processes (Principal Component 1) and relational-emotional processes (Principal Component 2) (r = − 0.25; p = n.s.), while in the good-outcome patients these aspects are well integrated (r = 0.70; p = 0.02). These results corroborate the validity of the daily monitoring procedure and also indicate the need for greater attention to the relational and emotional aspects of the patients rather than merely to their cognitive functioning and well-being.

Key Message

In poor-outcome cases, burdensome emotions and interpersonal experiences on the one hand and cognitive/well-being aspects of the mental processing on the other, stay unrelated. Successful therapeutic processing, as in good-outcome cases, requires an integration of cognitive and affective components.

The Research-Practice Psychotherapy Wars: The Case of Group Psychotherapy in the Treatment of PTSD

In light of two recent meta-analyses of the efficacy of group psychotherapy in treating posttraumatic stress disorder (PTSD), this article critically reviews the randomized control trial (RCT) generated findings as well as two of its outgrowths-the production of a variety of clinical practice guidelines for treating PTSD and the dissemination efforts to transfer laboratory findings to clinical practice. All three of these activities have received considerable pushback from experienced clinicians and Boulder-identified scientist practitioners, creating an ongoing and entrenched gap or split between researcher and clinician. The article also reviews the various suggestions that have been offered to heal this gap and ending the hegemony of RCT outcome research as the only game in town for declaring what constitutes evidence. Specifically, the literature suggests two primary strategies for helping to realize the scientist-practitioner model and thus advancing the cause of psychotherapy, in general, and group psychotherapy, in particular: (a) leveling the playing field so that both researcher and practitioner have real authority and voices for shaping the field; and (b) shifting the research priority away from a purely outcome focus, asking only does it work, and moving to a more sophisticated, theoretically guided empirical study of process-outcome, examining the how, why, when, and for whom it works.

Clinical Hypnosis as an Adjunct to Cognitive Behavior Therapy: An Updated Meta-Analysis

In 1995, Kirsch and colleagues published an influential meta-analysis (k = 20, N = 577) which found that CBT enhanced with hypnosis (CBTH) was superior to CBT alone by at least d = .53. However, a lack of full replication and the emergence of new empirical studies prompted this updated analysis. A total of 48 post- (N = 1,928) and 25 follow-up treatments (N = 1,165) were meta-analyzed. CBTH achieved small to medium but statistically significant advantages over CBT at posttreatment (d_IGPP/d = .25 to .41), and specifically in the management of depressed mood and pain. At follow-up, there was a medium sized advantage for CBTH (d_IGPP/d = .54 to .59), and specifically for the treatment of obesity. These results further support the adjunctive use of hypnosis as an enhancer of CBT's efficaciousness and endurance as a treatment.

Moving Forward While Standing Still: A Case of Mental Health Advocacy Evolving in the Time of COVID-19

There have been shifts over time in the value placed on long-term psychotherapeutic modalities even though they can be life-saving. For example, the province of Ontario in Canada has been dealing with a government proposal put forward in 2019 to limit the length of psychotherapy treatment. In response, stakeholders from numerous groups came together to advocate for the importance of continuing unrestricted access to long-term psychotherapy. Approaches to this advocacy then had to unexpectedly adapt to the Coronavirus Disease 2019 (COVID-19) pandemic that came to the forefront in 2020 and will continue to develop in response to this changing landscape.

Trends in Psychiatric Residency Education and Practice From 1944 to 2019: A Loving, Informal, and Highly Personal Review Served With Gently Roasted Sacred Cow

In celebration of the American Psychiatric Association's 175th anniversary, the author presents an overview of major trends in psychiatric residency education over the past 75 years, from 1944 to 2019, using narrative review and personal perspectives infused with occasional irreverence. In both 1944 and today in 2020, psychiatric educators have been challenged by having too many patients, too few clinicians, too few teachers, and too little knowledge. Over the course of these years, psychiatric residency training has adapted and evolved in response to major ongoing shifts in psychiatric practice patterns shaped by economic, social, and cultural forces, academic regulations and processes, roles for psychiatry vis-à-vis other health and mental health professions, diagnostic and scientific models, psychotherapeutic, psychosocial, and biological treatment paradigms, methods of education, and methods of educational evaluation. Trends in psychiatric education have moved from loosely and irregularly structured clinical and didactic curricula to much more highly regulated and bureaucratized program requirements and processes, from faith-based beliefs and practices to increasing reliance on evidence-based faith, from the availability of Federal funds directly supporting stipends and teachers to the disappearance of those funds, from few to increasing numbers of women entering psychiatry (and all of medicine), and persistent concerns about recruiting excellent and diverse US medical school graduates into residency. Psychiatric educators will continue to help generate, synthesize, sustain, and disseminate meaningful narratives and to prepare future generations of psychiatric residents armed with iteratively better myths and conceptualizations about human nature, purpose, and our place in the universe-and about how to better confront and reduce psychiatric suffering through psychotherapeutic, psychosocial, and biological treatment strategies. Trends are onward and upward.

Psy Wars : le tsunami cognitivocomportemental en Grande-Bretagne

Cet article propose une analyse critique de l’évolution des prises en charge psychothérapiques en Grande-Bretagne à partir des réflexions de Farhad Dalal (2019) dans un ouvrage intitulé CBT: the Cognitive Behavioural Tsunami. Après avoir souligné les affinités idéologiques qui associent néolibéralisme et thérapies cognitivocomportementales (TCC), nous décrivons la manière dont ces dernières ont construit un mythe de leurs origines reposant sur l’idée, mensongère et démentie par la recherche empirique, de leur supposée meilleure efficacité par rapport aux autres approches. Ce discours idéologique s’inscrit plus largement dans le contexte actuel des PsyWars du développement de la psychiatrie biologique ayant mené aux évolutions contemporaines du DSM. Nous décrivons ensuite la mise en place de l’Increasing Access to Psychological Therapies (IAPT) en Grande-Bretagne, un large programme censé améliorer les prises en charge psychothérapiques à partir d’une libéralisation de ce secteur, National institute for health and care Excellence. Ce programme s’appuie sur les recommandations du NICE qui a favorisé l’utilisation quasi exclusive des TCC. Après avoir présenté comment un patient est suivi grâce à l’IAPT, nous soulignons les dérives et les échecs de ce système. Nous proposons ensuite une synthèse des principales formes de corruptions scientifiques associées aux TCC en prenant pour exemple deux études publiées dans ce champ. Ces dérives rendent intelligible l’écart observé actuellement entre les résultats empiriques des recherches en ce domaine et le manque d’efficacité des TCC dans la prise en charge effective des patients. L’ensemble de ces éléments, qui découlent des dérives idéologiques et scientifiques de certains tenants des TCC, apparaissent essentiels à connaître afin de ne pas reproduire en France les mêmes erreurs que la Grande-Bretagne dans la mise en place des futures politiques de santé publique concernant les psychothérapies.

Therapeutic Chaos

The conventional view on interventions as mechanistically causing interchangeable clients to get better has come under attack. Group-based and linear approaches fall short in adequately describing the idiosyncratic and dynamic nature of treatment processes. Non-linear dynamic system theories in contrast hold great potential to better conceptualize and understand the generalities and idiosyncrasies of psychotherapeutic change processes. The aim of this study was to examine whether we can detect markers of complex dynamical systems behavior in two single-case therapies. All sessions from both therapies were coded with sequential plan analysis using a 10s sampling frequency. The coding system incorporates verbal and non-verbal behaviors and allows for the representation of contextualized interactive behaviors. The high sampling frequency results in long time series, which allowed us to apply non-linear analysis techniques. We found strong support for complex behavior and the existence of a butterfly effect, i.e., a relatively short prediction horizon in which reliable predictions about the system's future behavior could be made. Further, critical fluctuations as a marker for phase-transitions were detected that were accompanied with different interactional patterns in both therapies. Finally, there was strong support for self-organized pattern formation, with a few interactional patterns dominating the interaction. Considering that we are intervening on complex dynamical systems means that we have to (1) acknowledge the principal individuality of change processes, (2) accept the fundamental limitations of the mechanistic input-output model of treatment effects and (3) appreciate the impossibility of long-term predictions of treatment responses.

Putting Suicide Policy through the Wringer: Perspectives of Military Members Who Attempted to Kill Themselves

In response to the Air Force Surgeon General, Lieutenant General Mark Ediger's call for medical services to be guided by service members' values, preferences, and experiences within the medical system, we conducted an interpretive phenomenological analysis of transcripts in which service members shared their experiences of military mental health policy and practices after being identified as suicidal. Themes of their experiences underscore nuances as it relates to intersectionality of policy when faced with unique military contextual factors and power differentials; both of which were missing in available research literature. Their experiences also illuminate further the innate "Catch 22" which happens when accessing help. Catch 22 basically means if you know you need help than you are rational; but if you actually seek help, then you are crazy and not trustworthy to do your job. Themes presented center on the lack of confidentiality of Service Members in the Workplace, effects of Unit Members' Surveillance and Command Directed Evaluations, and experiences of Military Mental Health Services. Critical discussions of policy and taken for granted assumptions that often drive narrow responses to suicide, treatment, prevention, and stigma are presented. Particular attention is given to the lived experiences of service members when placed under the demands of circumstances created by policy that may inadvertently lead in some cases to further suffering. The paper closes with recommendations from participants and the authors for policy makers and future directions in research.

Whose anxiety are we treating, anyway?

OBJECTIVES

This paper explores the ways empirically supported treatments (ESTs) help patients, therapists, and institutional administrators contain anxiety regarding complex human problems.

METHOD

The authors synthesized relevant literature with their experience as clinicians and psychotherapy researchers.

RESULTS

ESTs may manage patient anxieties by framing their symptoms in clearly stated mechanisms and relying on a therapist who is an "expert" capable of healing them quickly. ESTs allow therapists to streamline treatment decisions and minimize intersubjective aspects of treatment which reduces the complexity of therapy. ESTs assist institutional administrators in the top-down dissemination of treatments and limit concerns about malpractice and insurance reimbursement by providing assurance that interventions have been vetted.

CONCLUSIONS

While recognizing the benefits of ESTs, relying on ESTs to manage anxieties may diminish the importance of patient factors and clinical judgment, the other critical aspects of evidence-based practice, and thus limit the potential of clinical practice to reduce human distress.

The efficacy of cognitive behavioural therapy in somatoform disorders and medically unexplained physical symptoms: A meta-analysis of randomized controlled trials

BACKGROUND

This systematic review and meta-analysis aimed to update and give an overview of the evidence from published literature that focused on the efficacy of cognitive behaviour therapy (CBT) in the management of somatoform disorders and medically unexplained physical symptoms (MUPS).

METHODS

A comprehensive literature search was carried out through an electronic search of various databases on randomized controlled trials (RCTs). Primary outcome was the severity of somatic symptoms. Secondary outcomes were also measured based on severity of anxiety symptoms, severity of depressive symptoms, social functioning, physical functioning, doctor visits and the compliance with CBT, as well as follow-up visits. Effects were summarized by a random effects model using mean differences or odds ratio with 95% confidence intervals (CIs).

RESULTS

A total of 15 RCTs comprising 1671 patients with somatoform disorders or MUPS were enrolled in our systematic review and meta-analysis. The main analysis revealed that CBT could alleviate somatic symptoms: -1.31 (95% CI: -2.23 to -0.39, p = 0.005); anxiety symptoms: -1.89 (95% CI: -2.91 to -0.86; p < 0.001); depressive symptoms: -1.93 (95% CI: -3.56 to -0.31; p = 0.020); improve physical functioning: 4.19 (95% CI: 1.90 to 6.49; p < 0.001). The efficacy of CBT on alleviating somatic symptoms, anxiety and depressive symptoms were sustained on follow-up. CBT may not be effective in reducing the number of doctor visits: -1.23 (95% CI: -2.97 to 0.51; p = 0.166); and improving social functioning: 3.27 (95% CI: -0.08 to 6.63; p = 0.056). The results of subgroup analysis indicated that CBT was particularly beneficial when the duration of session was more than 50 min to reduce the severity of somatic symptoms from pre to post treatment time, when it was group based and applied affective and developed good interpersonal strategy during the treatment. Longer duration and frequency such as more than 10 sessions and 12 weeks treatments had significant effect on reduction of the comorbid symptoms including depression and anxiety, but they may underpin low level of compliance of CBT based treatments.

CONCLUSIONS

CBT is effective for the treatment of somatoform disorders and MUPS by reducing physical symptoms, psychological distress and disability.

The Neurobiological Underpinnings of Psychoanalytic Theory and Therapy

This paper sets out the neurobiological underpinnings of the core theoretical claims of psychoanalysis. These claims concern (1) innate emotional needs, (2) learning from experience, and (3) unconscious mental processing. The paper also considers the neurobiological underpinnings of the mechanisms of psychoanalytic treatment-a treatment which is based on the aforementioned claims. Lastly, it reviews the available empirical evidence concerning the therapeutic efficacy of this form of treatment.