Psychotherapy practice and research. Repairing a strained alliance

An Evaluation of Cognitive Behavioral Therapy for Insomnia: A Systematic Review and Application of Tolin's Criteria for Empirically Supported Treatments

The American Psychological Association's Society of Clinical Psychology recently adopted the "Tolin Criteria" to evaluate empirically supported treatments. These criteria better account for strength and quality of rapidly accumulating evidence bases for various treatments. Here we apply this framework to cognitive behavioral therapy for insomnia (CBT-I). Following procedures outlined by Tolin, McKay, et al. (2015), Step 1 included an examination of quantitative systematic reviews; nine met inclusion criteria. Step 2 evaluated review quality and effect size data. We found high-quality evidence that CBT-I produces clinically and statistically significant effects on insomnia and other sleep-related outcomes. Based on the Tolin Criteria, the literature merits a "strong" recommendation for CBT-I. This report is a working model for subsequent applications of the Tolin Criteria.

Control Conditions That Are Neither Usual Care Nor No Treatment in Randomized Trials of Psychoeducational Palliative Care Interventions: A Systematic Review

BACKGROUND:

Determining intervention efficacy depends as much on the control group as on the intervention, but little attention has been given to the control condition in psychoeducational trials in palliative care.

OBJECTIVES:

To examine (1) research practice regarding control conditions that are neither usual care nor no-treatment controls in randomized trials of psychoeducational palliative care interventions and (2) the rationale and completeness of the descriptions of control conditions in trial reports.

METHODS:

PubMed, EMBASE, PsycINFO, and Web of Science were searched. After screening 1603 articles, 70 full-text articles were assessed for eligibility. The final sample included 9 trial reports. We used the Delphi list for quality assessment and the modified intervention taxonomy checklist to assess active intervention and control conditions.

RESULTS:

Four trials used an attention control designed to be equivalent to the structure of the active intervention. In another 4, the control condition included some aspects of attention control such that the mode of contact was similar to that in the active intervention, but either the amount or the intensity of attention was not similar. Only 3 trial reports explicitly stated the rationale for the choice of control condition. Although most reports contained delivery mode, materials, duration, frequency, and sequence, none described the qualifications or training required to deliver the control condition. Only 1 report mentioned the fidelity monitoring method, and none included fidelity data.

CONCLUSION:

Our review of psychoeducational trials in palliative care calls for researchers' attention to appropriate selection, design, conduct and report of control conditions.

The effect of alliance-focused training on a cognitive-behavioral therapy for personality disorders

OBJECTIVE

To improve success rates in psychotherapy, we developed and evaluated an alliance-focused training (AFT) protocol with regard to patient-therapist interpersonal behavior in a 30-session protocol of cognitive-behavioral therapy (CBT) for outpatients comorbid with Axis I and II conditions.

METHOD

Participants included 40 patients treated by 40 therapists in a multiple baseline design in which novice therapists trained to fidelity standards in CBT were introduced to AFT at different time intervals (after either 8 or 16 sessions) during a 30-session CBT protocol. Interpersonal behaviors were assessed with a simplified version of the Structural Analysis of Social Behavior (SASB) on videotaped sessions sampled from the early (between Sessions 6 through 8), mid (Sessions 14 through 16), and late (Sessions 22 through 24) phases of therapy.

RESULTS

As predicted, several significant interactions were observed between within-subject interpersonal change and between-groups differences in exposure to AFT. Specifically, there were decreases in patient dependence and in therapist control (including criticism), plus increases in patient expressiveness and in therapist affirmation and expressiveness, all of which could be attributed to AFT. The predictive relationship of several of these variables to session-level and overall treatment outcome was also demonstrated.

CONCLUSIONS

This study demonstrates that novice CBT therapists can be trained to improve their interpersonal process with patients who present with comorbid diagnoses, including a personality disorder. (PsycINFO Database Record

Using decision trees to characterize verbal communication during change and stuck episodes in the therapeutic process

Methods are needed for creating models to characterize verbal communication between therapists and their patients that are suitable for teaching purposes without losing analytical potential. A technique meeting these twin requirements is proposed that uses decision trees to identify both change and stuck episodes in therapist-patient communication. Three decision tree algorithms (C4.5, NBTree, and REPTree) are applied to the problem of characterizing verbal responses into change and stuck episodes in the therapeutic process. The data for the problem is derived from a corpus of 8 successful individual therapy sessions with 1760 speaking turns in a psychodynamic context. The decision tree model that performed best was generated by the C4.5 algorithm. It delivered 15 rules characterizing the verbal communication in the two types of episodes. Decision trees are a promising technique for analyzing verbal communication during significant therapy events and have much potential for use in teaching practice on changes in therapeutic communication. The development of pedagogical methods using decision trees can support the transmission of academic knowledge to therapeutic practice.

An opportunity to bridge the gap between clinical research and clinical practice: implications for clinical training

Clinical researchers and clinical practitioners share a goal of increasing the integration of research and clinical practice, which is reflected in an evidence-based practice (EBP) approach to psychology. The EBP framework involves the integration of research findings with clinical expertise and client characteristics, values, and preferences, and consequently provides an important foundation for conducting clinically relevant research, as well as empirically based and clinically sensitive practice. Given the critical role that early training can play in the integration of science and practice and in promoting the future of the field, the present article addresses predoctoral training programs as a context for adopting an EBP approach to clinical work. We address training in the three components of EBP and provide suggestions for curriculum development and practicum training that we hope will contribute to bridging the gap between research and practice.

A Legacy Neglected: Restating the Case for Single-case Research in Cognitive-Behaviour Therapy

The dominant research tradition in psychology, including much of cognitive-behaviour therapy, requires that large numbers of subjects be allocated randomly to form treatment groups. Treatment effects typically are assessed by testing a null hypothesis about group mean differences. This paradigm seriously thwarts the development of a science of individual behaviour, inhibits the implementation of the scientist–practitioner model, stifles innovation, impairs accountability, and precludes the scientific investigation of the exceptional or novel case. Single-case research designs, first systematically expounded by Sidman (1960), make it possible to draw scientifically valid conclusions from the investigation and treatment of individuals. Criticisms of the between-groups research paradigm are summarised, the key elements of single-case designs are outlined, and their consistent adoption strongly recommended.

A Commentary on Psychosocial Interventions and Evidence-Based Practice: Time for Reflection About What an ‘Ideal’ Psychosocial Intervention Would Look Like in Clinical Psychology?

Controlled efficacy/effectiveness trials throughout the world have reached a high standard from a methodological stance, but what do we regard as the ideal or elegant intervention in clinical psychology? This article presents six key points as the gold standards of psychosocial interventions by which treatment efficacy/effectiveness research with children, adolescents and adults might be evaluated: (1) theoretical rationale and conceptualisation of clinical dysfunction, (2) clear problem identification and target client group, (3) program features such as realistic goal setting, flexibility, and time-limited interventions, (4) manual-based treatments, (5) research support including clinically significant outcomes, and (6) acceptability/social validation of clients and society. Finally, we discuss the usefulness of such a framework for mental health professionals and clinical researchers.

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.

Some methodological and statistical issues in the study of change processes in psychotherapy

As the number of psychotherapies with demonstrated efficacy accumulates, an important task is to identify principles and processes of change. This information can guide treatment refinement, integration, and future development. However, the standard randomized control trial (RCT) design can limit the questions that can be asked and the statistical analyses that can be conducted. We discuss the importance of examining the shape of change, in addition to the importance of identifying mediators and moderators of change. We suggest methodological considerations for longitudinal data collection that can improve the kinds of therapy process questions that can be examined. We also review some data analytic approaches that are being used in other areas of psychology that have the potential to capture the complexity and dynamics of change in psychotherapy.

Closing the Research-Practice Gap: Factors Affecting Adoption and Implementation of a Children's Mental Health Program

Despite the availability of effective interventions, they are not widely used in community mental health centers. This study examined the adoption and implementation of The Arson Prevention Program for Children (TAPP-C), a program for juvenile firesetters developed at a teaching hospital and disseminated to community settings. Questionnaire data from mental health professionals were used to evaluate the roles of adopter, innovation, and dissemination characteristics in TAPP-C adoption and implementation. Results indicate that different factors are important at different diffusion stages. Moreover, they suggest that innovation characteristics may be particularly important to adoption, whereas adopter and dissemination characteristics may be more influential in implementation.

Individual psychotherapy outcome and process research: challenges leading to greater turmoil or a positive transition?

Psychotherapy is facing challenges that relate to the emergence of managed health care, the possibility of a national health care system, and advances in biological psychiatry. These situations have created pressure to achieve a more accurate assessment of psychotherapeutic effectiveness. Psychotherapy has been proven to be generally effective; however, there is uncertainty as to why. The field is currently experiencing apparent turmoil in three areas: (a) theory development for psychotherapeutic effectiveness, (b) research design, and (c) treatment technique. This chapter reviews the dynamics within each of the areas and highlights the progress made in treating mental disorders. We conclude that recent advances in research design may provide a transition that will bring psychotherapy closer to becoming a unified paradigm with an acceptable theory of effectiveness.