Study Protocol: Pegasus: psychotherapy incorporating horses for 'therapy-resistant' adolescents with autism spectrum disorders, a study with series of randomised, baseline controlled n-of-1 trials

BACKGROUND

For people with autism spectrum disorder (ASD), daily life can be highly stressful with many unpredictable events that can evoke emotion dysregulation (ED): a strong difficulty with appropriately negative affect regulation. For some of the patients with ASD, treatment as usual does not prove to be effective for ED. They may be at risk of life-long impairment, development of other disorders and loss of motivation for most regular forms of therapy. A highly promising method that may prove effective for therapy-resistant individuals with ASD is Psychotherapy incorporating horses (PIH). PIH uses the interactions of the horse and the patients on the ground and does not include horseriding. While often met with prejudgment and scepticism, reports from parents and therapists as well as a recent systematic review suggest that PIH may have beneficial effects on youths with ASD. Therefore, we examine clinical outcomes both in the short and in the long terms of PIH offered to adolescents with ASD and severe ED despite regular therapy.

METHODS

A total of 35 adolescents aged 11-18 years with ASD will receive PIH during 15 sessions once a week with randomization to five different groups differentiating in baseline phase from 2 to 6 weeks. PIH uses horses to promote social awareness and self-awareness as well as relationship management and self-management. The primary outcome is the response to treatment on the Emotion Dysregulation Index (EDI). The secondary outcome measures include ASD symptom severity, quality of life, self-esteem, global and family functioning, and goal attainment. Assessments take place at the baseline (T0), at the end of baseline phase A (T1), after completion of intervention phase B (T2), after the end of post-measurement phase C (T3) and after one year (T4). Qualitative interviews of participants, parents and therapists will be held to reveal facilitators and barriers of PIH and a cost-effectiveness study will be performed.

DISCUSSION

This study aims at contributing to clinical practice for adolescents with ASD and persistent emotion regulation problems despite 1.5 year of treatment by offering Psychotherapy incorporating horses in a study with series of randomised, baseline controlled n-of-1 trials.

TRIAL REGISTRATION

www.

CLINICALTRIALS

gov NCT05200351, December 10th 2021.

Brief individual experiential schema therapy in adult outpatients with cluster C personality disorders: Does it work?

This study investigated the effectiveness of brief individual experiential schema therapy (ST) in 12 adult outpatients with cluster C personality disorders (PD) using randomised multiple baseline design. Waitlist period was followed by five explorative sessions, 18 experiential ST sessions, two treatment follow-up (FU) booster sessions and a 6-month FU assessment. Overall well-being (ORS), behavioural treatment goals and negative core beliefs were assessed 60-91 times, global symptomatic distress (BSI) six times. PD severity (SCID-5-PD) was pre-post-analysed. Randomisation and non-parametric tests showed large significant effects (d = 1.08-2.38, r = .53-.66) on all outcomes at treatment-FU and 6-month FU assessment. This is the first study providing preliminary evidence of effectiveness of brief individual experiential ST for patients with cluster C PD, tentatively challenging the common tenet that long treatment duration is required. Due to limitations, replication is recommended.

Measuring personal recovery in a low-intensity community mental healthcare setting: validation of the Dutch version of the individual recovery outcomes counter (I.ROC)

BACKGROUND

Measuring progress in treatment is essential for systematic evaluation by service users and their care providers. In low-intensity community mental healthcare, a questionnaire to measure progress in treatment should be aimed at personal recovery and should require little effort to complete.

METHODS

The Individual Recovery Outcome Counter (I.ROC) was translated from English into Dutch, and psychometric evaluations were performed. Data were collected on personal recovery (Recovery Assessment Scale), quality of life (Manchester Short Assessment of Quality of Life), and symptoms of mental illness and social functioning (Outcome Questionnaire, OQ-45) for assessing the validity of the I.ROC. Test-retest reliability was evaluated by calculating the Intraclass Correlation Coefficient and internal consistency was evaluated by calculating Cronbach's alpha. Exploratory factor analysis was performed to determine construct validity. To assess convergent validity, the I.ROC was compared to relevant questionnaires by calculating Pearson correlation coefficients. To evaluate discriminant validity, I.ROC scores of certain subgroups were compared using either a t-test or analysis of variance.

RESULTS

There were 764 participants in this study who mostly completed more than one I.ROC (total n = 2,863). The I.ROC aimed to measure the concept of personal recovery as a whole, which was confirmed by a factor analysis. The test-retest reliability was satisfactory (Intraclass Correlation Coefficient is 0.856), as were the internal consistency (Cronbachs Alpha is 0.921) and the convergent validity. Sensitivity to change was small, but comparable to that of the OQ-45.

CONCLUSIONS

The Dutch version of the I.ROC appears to have satisfactory psychometric properties to warrant its use in daily practice. Discriminant validity and sensitivity to change need further research.

Spanish Versions of the Outcome Rating Scale and the Session Rating Scale: Normative Data, Reliability, and Validity

Routine outcome monitoring (ROM) uses standardized measures to both track and inform mental health service delivery. Use of ROM has been shown to improve the outcome of psychotherapy when applied to different types of patients. The present research was designed to determine the reliability and validity of the Outcome Rating Scale (ORS) and the Session Rating Scale (SRS) in a sample of Spanish patients. After a controlled process of translation into the Spanish that is spoken and written in Spain (i.e., in Europe, as distinct from, e.g., Latin American Spanish), both measures were completed by patients of an outpatient mental health unit during eight sessions of psychotherapy. Sixty mental health patients filled out the ORS and 59 the SRS. In addition, the ORS was completed by 33 people who constituted the non-clinical sample. The cut-off of the ORS was 24.52 points, and the Reliable Change Index (RCI) was 9.15 points. ORS and SRS scores exhibited excellent internal consistency. The temporal stability of the SRS was adequate. The convergent and discriminant validity of the two measures were adequate. Regarding the factorial validity of the ORS and the SRS, in the third psychotherapy session, confirmatory factor analyses evidenced the existence of a unifactorial model. The predictive validity of SRS was acceptable. The ORS was sensitive to changes in patients’ symptoms. In conclusion, compared to the original English versions of the ORS and SRS measures, the Spanish versions of the measures are also reliable and valid.

The Alliance-Outcome Association in Couple Therapy: A Common Fate Model

The working alliance has been shown to be a robust predictor of couple therapy outcomes. However, there are still questions regarding the best way to conceptualize and analyze the association between the alliance and outcomes in the couple therapy context. This study presents results from a relatively novel analytic approach for evaluating the alliance and therapy outcomes via the shared influence model (i.e., common fate statistical methodology) with 93 couples who had at least three sessions. Examining the alliance in couple therapy this way allows for nuance in conceptualizing the process of the alliance among partners and the therapist in couple therapy. Empirically, the question that remains is whether the shared experience of the alliance between partners is a stronger predictor of therapy outcome as compared to the unique individual experiences of the alliance. This approach has not yet been utilized to model the couple alliance-outcome association. Results revealed that the shared influence model demonstrated a significant association between the alliance and therapy outcome. Specifically, the couple-level alliance construct was adequately represented from the partners' alliance ratings with the therapist, and couples that report higher shared alliance experiences were also likely to have better therapy outcomes. These findings suggest that conceptualizing and analyzing the alliance at the couple level may be strongly advantageous. Implications for research and practice are provided.

Development of the Therapeutic Alliance and its Association With Internet-Based Mindfulness-Based Cognitive Therapy for Distressed Cancer Patients: Secondary Analysis of a Multicenter Randomized Controlled Trial

Background

Mindfulness-based cognitive therapy (MBCT) is an evidence-based group-based psychological treatment in oncology, resulting in reduction of depressive and anxiety symptoms. Internet-based MBCT (eMBCT) has been found to be an effective alternative for MBCT. The therapeutic alliance (the bond between therapist and patient,) is known to have a significant impact on psychological treatment outcomes, including MBCT. A primary concern in the practice of eMBCT is whether a good therapeutic alliance can develop. Although evidence for the beneficial effect of therapist assistance on treatment outcome in internet-based interventions (IBIs) is accumulating, it is still unclear whether the therapeutic alliance is related to outcome in IBIs.

Objective

This study aimed to (1) explore whether early therapeutic alliance predicts treatment dropout in MBCT or eMBCT, (2) compare the development of the therapeutic alliance during eMBCT and MBCT, and (3) examine whether early therapeutic alliance is a predictor of the reduction of psychological distress and the increase of mental well-being at posttreatment in both conditions.

Methods

This study was part of a multicenter randomized controlled trial (n=245) on the effectiveness of MBCT or eMBCT for distressed cancer patients. The therapeutic alliance was measured at the start of week 2 (ie, early therapeutic alliance), week 5, and week 9. Outcome measures were psychological distress, measured with the Hospital Anxiety and Depression Scale, and mental well-being, measured with the Mental Health Continuum-Short Form.

Results

The strength of early therapeutic alliance did not predict treatment dropout in MBCT or eMBCT (B=−.39; P=.21). Therapeutic alliance increased over time in both conditions (F_2,90=16.46; Wilks λ=0.732; P<.001). This increase did not differ between eMBCT and MBCT (F_1,91=0.114; P=.74). Therapeutic alliance at week 2 predicted a decrease in psychological distress (B=−.12; t₁₁₄=−2.656; P=.01) and an increase in mental well-being (B=.23; t₁₁₃=2.651; P=.01) at posttreatment. The relationship with reduction of psychological distress differed between treatments: a weaker early therapeutic alliance predicted higher psychological distress at posttreatment in MBCT but not in eMBCT (B=.22; t₁₁₃=2.261; P=.03).

Conclusions

A therapeutic alliance can develop in both eMBCT and MBCT. Findings revealed that the strength of early alliance did not predict treatment dropout. Furthermore, the level of therapeutic alliance predicted reduced psychological distress and increased mental well-being at posttreatment in both conditions. Interestingly, the strength of therapeutic alliance appeared to be more related to treatment outcome in group-based MBCT than in eMBCT.

Trial Registration

ClinicalTrials.gov NCT02138513; https://clinicaltrials.gov/ct2/show/NCT02138513

Therapeutic alliance-not therapist competence or group cohesion-contributes to reduction of psychological distress in group-based mindfulness-based cognitive therapy for cancer patients

Mindfulness‐based cognitive therapy (MBCT) is an innovative evidence‐based intervention in mental and somatic health care. Gaining knowledge of therapeutic factors associated with treatment outcome can improve MBCT. This study focused on predictors of treatment outcome of MBCT for cancer patients and examined whether group cohesion, therapeutic alliance, and therapist competence predicted reduction of psychological distress after MBCT for cancer patients. Moreover, it was examined whether therapist competence facilitated therapeutic alliance or group cohesion. Multilevel analyses were conducted on a subsample of patients collected in a larger randomized controlled trial on individual internet‐based versus group‐based MBCT versus treatment as usual in distressed cancer patients. The current analyses included the 84 patients who completed group‐based MBCT out of 120 patients who were randomized to group‐based MBCT. Group cohesion and therapist competence did not predict reduction in psychological distress, whereas therapeutic alliance did. In addition, therapist competence did not predict therapeutic alliance but was associated with reduced group cohesion. Our findings revealed that therapeutic alliance significantly contributed to reduction of psychological distress in MBCT for cancer patients. Elaborating the clinical implications of the predictive significance of therapeutic alliance might be of added value to enhance the potential effect of MBCT.

The effect of patients' feedback on treatment outcome in a child and adolescent psychiatric sample: a randomized controlled trial

The systematic use of feedback from patients on treatment progress and treatment satisfaction is a promising method to increase treatment effectiveness. The extent to which this also applies to the treatment of children with severe psychiatric problems is not clear. We conducted a Randomized Controlled Trial (RCT) to study the effect of adding Feedback Informed Treatment (FIT) to care as usual in a child psychiatric sample. Quality of Life (QoL) was used as the primary outcome measure and symptom severity as the second. Fifty-one therapists from eight Autism Care Teams in a multi-center facility for Child and Adolescent Psychiatry (Karakter) participated and were cluster randomized to the FIT condition (n = 4 teams) or the Care as Usual (CAU) condition (n = 4 teams). Children aged 6-18 years, mainly with an Autism Spectrum Disorder (ASD) and treated in one of the Autism Care Teams were allocated to the FIT condition (n = 86) or the CAU condition (n = 80). Results indicated that adding FIT leads to an increased QoL [F (2,165) = 3.16, p = 0.045]. No additional effects were observed for symptom severity decrease [F (2,158) = 0.19, p = 0.825]. No interaction with time was found for QoL nor symptom severity. Adding FIT in a child psychiatric setting may increase QoL, but does not appear to decrease symptom severity as compared with CAU. It is suggested that FIT positively changes parents' expectations. Results should be replicated in other child psychiatric samples and with an extended theoretical model.

Psychometric Properties of the Outcome Rating Scale (ORS) in a Spanish Clinical Sample

The Outcome Rating Scale (ORS) is an ultra-brief measure of well-being designed to track outcome in psychotherapy. This research studied the psychometric properties of the ORS in a Spanish clinical sample. One-hundred and sixty-five adult participants from different primary care centers of the city of Barcelona were recruited. The psychometric properties of the ORS in the sample were explored and described, comparing them to the properties of other instruments already validated in Spain. Our results showed good reliability (α = .91 [.88, .93]; α = .96; test re-test correlations from .61 to .84), good validity (convergent validity correlations with distress and symptoms measures from -.32 to -.76), and good sensitivity to change (pre-post comparison through Wilcoxon signed-rank test, Mdnpre = 31.0, Mdnpost = 19.6, z = -7.38, p < .05, r = .42). These results are consistent with previous findings in other countries. We conclude suggesting that the instrument can be applied to monitor outcome in psychotherapy and to test the effectiveness of treatments imparted with Spanish speaking clients. However, further research with the ORS in Spanish could provide more evidence of its psychometric properties.

Recovering Process from Child Sexual Abuse During Adulthood from an Integrative Approach to Solution-Focused Therapy: A Case Study

In recent times, strengths-based recovery approaches that focus on the present and build strategies that look toward the future have become popular. However, some cases require the consideration of experiences from previous stages of the clients' development. This single-case study explores the psychotherapeutic process of a middle-aged woman who presented with a history of child sexual abuse (incest) and a long-term adult diagnosis of depression that was treated in public health services. This psychotherapy involved an integrative approach to solution-focused therapy; specifically, the approach proposed by Yvonne Dolan to work with adult survivors of sexual abuse, in conjunction with techniques and strategies from the transtheoretical model. Measures incorporating therapeutic working alliance and outcomes were administered over sessions. Results showed positive outcomes from this therapeutic intervention, which remained at 3-month and 12-month follow-ups. Implications for practitioners' specialist practice in health services are discussed, given the complexity of comorbid mental health conditions with a history of child sexual abuse.

Cognitive remediation therapy (CRT) as a treatment enhancer of eating disorders and obsessive compulsive disorders: study protocol for a randomized controlled trial

BACKGROUND

Anorexia nervosa (AN) and Obsessive Compulsive Disorder (OCD) are among the most incapacitating and costly of mental disorders. Cognitive Behaviour Therapy (CBT), medication, and combination regimens, to which in AN personalised guidance on weight control is added, are moderately successful, leaving room for more effective treatment algorithms. An underlying deficit which the two disorders share is cognitive inflexibility, a trait that is likely to impede treatment engagement and reduce patients' ability to benefit from treatment. Cognitive remediation therapy (CRT) is an easy-to-use intervention aimed at reducing cognitive inflexibility and thereby enhancing treatment outcome, which we aim to test in a controled study.

METHODS

In a randomized-controlled multicenter clinical trial 64 adult patients with AN and 64 with OCD are randomized to 10 bi-weekly sessions with either CRT or a control condition, after which Treatment As Usual (TAU) is started. All patients are evaluated during single-blind assessments at baseline, post-CRT/control intervention, and after 6 months. Indices of treatment effect are disorder-specific symptom severity, quality of life, and cost-effectivity. Also, moderators and mediators of treatment effects will be studied.

DISCUSSION

To our knowledge, this is the first randomized controlled trial using an control condition evaluating the efficacy and effectiveness of CRT as a treatment enhancer preceding TAU for AN, and the first study to investigate CRT in OCD, moreover taking cost-effectiveness of CRT in AN and OCD into account.

TRIAL REGISTRATION

The Netherlands Trial Register NTR3865 . Registered 20 february 2013.

Patient-Rated Outcome Assessment With the German Version of the Outcome Questionnaire 45 in People With Severe Mental Illness

Abstract. The purpose of this study was to assess the feasibility and psychometric properties of the German version of the Outcome Questionnaire (Ergebnisfragebogen; EB-45) in people with severe mental illness (N = 294). Reliability and sensitivity to change were assessed. Convergent validity was examined through correlations with the measures Health of the Nation Outcome Scales (HoNOS-D) and Global Assessment of Functioning (GAF), and predictive validity through correlation with length of inpatient stay. The EB-45 showed good reliability and sensitivity to change, as well as good internal consistency for the total score and the subscale “symptom distress.” The EB-45 was found to be acceptable and feasible for use within inpatient psychiatric settings. Also predictive validity was good. However, psychometric properties of the subscales “interpersonal relations” and “social role” were equivocal. Thus, interpreting subscale scores only is not advisable. Also low convergent validity is a concern. Taken together, the EB-45 can be recommended for outcome assessment in a wide range of mental health service settings including inpatient psychiatric services. However, treatment planning and evaluation of effectiveness of services for people with severe mental illness should not be based on EB-45 data alone.

Feedback-informed treatment in emergency psychiatry; a randomised controlled trial

BACKGROUND

Immediate patient feedback has been shown to improve outcomes for patients in mild distress but it is unclear whether psychiatric patients in severe distress benefit equally from feedback. This study investigates the efficacy of an immediate feedback instrument in the treatment of patients with acute and severe psychosocial or psychiatric problems referred in the middle of a crisis.

METHODS

A naturalistic mixed diagnosis sample of patients (N = 370) at a Psychiatric Emergency Centre was randomised to a Treatment-as-Usual (TAU) or a Feedback (FB) condition. In the FB condition, feedback on patient progress was provided on a session-by-session basis to both therapists and patients. Outcomes of the two treatment conditions were compared using repeated measures MANCOVA, Last Observation Carried Forward and multilevel analysis.

RESULTS

After 3 months, symptom improvement in FB (ES 0.60) did not significantly differ from TAU (ES 0.71) (p = 0.505). After 6 weeks, FB patients (ES 0.31) actually improved less than TAU patients (0.56) (p = 0.019).

CONCLUSIONS

Patients with psychiatric problems and severe distress seeking emergency psychiatric help did not benefit from direct feedback.

TRIAL REGISTRATION

Dutch Trial Register, NTR3168 , date of registration 1-9-2009.

Improving the efficiency of cognitive-behavioural therapy by using formal client feedback

OBJECTIVE

Feedback from clients on their view of progress and the therapeutic relationship can improve effectiveness and efficiency of psychological treatments in general. However, what the added value is of client feedback specifically within cognitive-behavioural therapy (CBT), is not known. Therefore, the extent to which the outcome of CBT can be improved is investigated by providing feedback from clients to therapists using the Outcome Rating Scale (ORS) and Session Rating Scale (SRS).

METHOD

Outpatients (n = 1006) of a Dutch mental health organization either participated in the "treatment as usual" (TAU) condition, or in Feedback condition of the study. Clients were invited to fill in the ORS and SRS and in the Feedback condition therapists were asked to frequently discuss client feedback.

RESULTS

Outcome on the SCL-90 was only improved specifically with mood disorders in the Feedback condition. Also, in the Feedback condition, in terms of process, the total number of required treatment sessions was on average two sessions fewer.

CONCLUSION

Frequently asking feedback from clients using the ORS/SRS does not necessarily result in a better treatment outcome in CBT. However, for an equal treatment outcome significantly fewer sessions are needed within the Feedback condition, thus improving efficiency of CBT.

A systematic review of mental health outcome measures for young people aged 12 to 25 years

BACKGROUND

Mental health outcome measures are used to monitor the quality and effectiveness of mental health services. There is also a growing expectation for implementation of routine measurement and measures being used by clinicians as a feedback monitoring system to improve client outcomes. The recent focus in Australia and elsewhere targeting mental health services to young people aged 12-25 years has meant that outcome measures relevant to this age range are now needed. This is a shift from the traditional divide of child and adolescent services versus adult services with a transitioning age at 18 years. This systematic review is the first to examine mental health outcome measures that are appropriate for the 12 to 25 year age range.

METHODS

MEDLINE and PsychINFO databases were systematically searched to identify studies using mental health outcome measures with young people aged 12 to 25 years. The search strategy complied with the relevant sections of the PRISMA statement.

RESULTS

A total of 184 published articles were identified, covering 29 different outcome measures. The measures were organised into domains that consisted of eight measures of cognition and emotion, nine functioning measures, six quality of life measures, and six multidimensional mental health measures. No measures were designed specifically for young people aged 12 to 25 years and only two had been used by clinicians as a feedback monitoring system. Five measures had been used across the whole 12 to 25 year age range, in a range of mental health settings and were deemed most appropriate for this age group.

CONCLUSIONS

With changes to mental health service systems that increasingly focus on early intervention in adolescence and young adulthood, there is a need for outcome measures designed specifically for those aged 12 to 25 years. In particular, multidimensional measures that are clinically meaningful need to be developed to ensure quality and effectiveness in youth mental health. Additionally, outcome measures can be clinically useful when designed to be used within routine feedback monitoring systems.

Study protocol of a multicenter randomized controlled trial comparing the effectiveness of group and individual internet-based Mindfulness-Based Cognitive Therapy with treatment as usual in reducing psychological distress in cancer patients: the BeMind study

Background

Mindfulness-based interventions have shown to reduce psychological distress in cancer patients. The accessibility of mindfulness-based interventions for cancer patients could be further improved by providing mindfulness using an individual internet-based format. The aim of this study is to test the effectiveness of a Mindfulness-Based Cognitive Therapy (MBCT) group intervention for cancer patients in comparison with individual internet-based MBCT and treatment as usual (TAU).

Methods/Design

A three-armed multicenter randomized controlled trial comparing group-based MBCT to individual internet-based MBCT and TAU in cancer patients who suffer from at least mild psychological distress (Hospital Anxiety and Depression Scale (HADS) ≥ 11). Measurements will be conducted prior to randomization (baseline), post-treatment and at 3 months and 9 months post-treatment. Participants initially allocated to TAU are subsequently randomized to either group- or individual internet-based MBCT and will receive a second baseline measurement after 3 months. Thus, the three-armed comparison will have a time span of approximately 3 months. The two-armed intervention comparison includes a 9-month follow-up and will also consist of participants randomized to the intervention after TAU. Primary outcome will be post-treatment psychological distress (HADS). Secondary outcomes are fear of cancer recurrence (Fear of Cancer Recurrence Inventory), rumination (Rumination and Reflection Questionnaire), positive mental health (Mental Health Continuum – Short Form), and cost-effectiveness (health-related quality of life (EuroQol –5D and Short Form-12) and health care usage (Trimbos and iMTA questionnaire on Costs associated with Psychiatric illness). Potential predictors: DSM-IV-TR mood/anxiety disorders (SCID-I) and neuroticism (NEO-Five Factor Inventory) will be measured. Mediators of treatment effect: mindfulness skills, (Five-Facets of Mindfulness Questionnaire- Short Form), working alliance (Working Alliance Inventory) and group cohesion (Group Cohesion Questionnaire) will also be measured.

Discussion

This trial will provide valuable information on the clinical and cost-effectiveness of group versus internet-based MBCT versus TAU for distressed cancer patients.

Trial registration

Clinicaltrials.gov NCT02138513. Registered 6 May 2014.