Toward a more clinically valid approach to therapy research

Life Is About Change: A Professional Memoir

Receiving my doctorate in 1961 just as John F. Kennedy was inaugurated president of the United States, I was inspired by his sentiment that any person can make a difference, and every person should try. In this memoir I review my professional journey of trying to make a difference in researching, teaching, supervising, and practicing clinical psychology and psychotherapy. I began my career by working on an evidence base for projective techniques. Upon joining the Stony Brook faculty, I shifted my efforts to research on and practice of behavior therapy, and then to the incorporation of cognition in developing cognitive behavioral therapy. Further work on integration consisted of closing the gap between research and practice, lowering the barriers that existed across schools of therapy, and incorporating lesbian, gay, bisexual, and transgender issues into mainstream psychology.

Toward a synthesis of cognitive behaviour therapy via component analysis of self-regulation

The cognitive behavioural therapies (CBTs) are the choice psychotherapies for many clinicians treating a wide range of adult psychological disorders including various anxieties, mood, substance use, eating, schizophrenia and personality-related. Empirical research in the CBTs is ever increasing, and the accumulating evidence supporting efficacious treatments is substantial and well documented. However, with prolific research comes a seemingly accelerating and worrying trend of purportedly different therapies, and numerous hybrids and combinations of therapies and techniques. For many clinicians this is increasingly confusing and not helpful in clinical practice. This article is a critique of current trends and directions in clinical research, which show signs of limited effectiveness, fragmentation, and obfuscation. An alternative strategy is proposed-examining transdiagnostic therapeutic effects, which appear related to treating pervasive dysregulated emotions, with component analyses of four principal self-regulation components (viz., self-monitoring; functional analysis; identifying values, goals and treatment-plans; and feedback). Such a strategy is likely to lead to a more coherently synthesized and effective CBT.

Mentalization-oriented psychodynamic group therapy for patients with personality disorders: a naturalistic prospective cohort study

OBJECTIVES

Patients with personality disorders (PDs) are often treated with non-manualized psychodynamic group therapy (PDT) lasting for several years. Non-manualized PDT often combines a variety of therapeutic approaches from different PDT traditions, including mentalization-based therapy. Currently, little is known about the effect of this long-term, costly treatment. This study investigated the extent to which patients with different PDs benefit from mentalization-oriented PDT as it is implemented in clinical practice in terms of symptom severity, interpersonal problems, and general functioning.

METHODS

The design was a naturalistic, prospective cohort study. Seventy-five consecutive PD patients were assessed before treatment with the Symptom Checklist-90 Revised (SCL-90-R) as the primary outcome measure and the Inventory of Interpersonal Problems (IIP) and Global Assessment of Functioning (GAF) as secondary outcome measures. The sample was repeatedly assessed every 12 months for up to 36 months. Paired t-tests were applied to examine the effectiveness of the intervention.

RESULTS

Among completers (n = 42; 56%), improvement was observed on the SCL-90-R: Global Severity Index (mean change = -0.45 [95% CI = -0.72, -0.19]; Cohen's d = -0.55), Positive Symptom Distress Index (-0.40 [-0.63, -0.17]; -0.56); Positive Symptoms Total (-10.70 [-17.31, -4.09]; -0.52). Secondary outcomes also improved: IIP-total (mean change = -0.50 [95%CI = -0.74, -0.25]; Cohen's d = -0.66); GAF-Functioning (8.79 [6.32, 11.27]; 1.15); and GAF-Symptoms (10.67 [8.09, 13.25]; 1.34).

CONCLUSIONS

Completers improved on symptom severity, interpersonal problems, and general functioning, with within-group effect sizes ranging from medium to large. Approximately half the sample dropped out, suggesting that mentalization-oriented PDT spanning several years may be unrealistic for many patients with PD. Significant outcomesThere are no clear guidelines for psychological interventions targeting personality disorders (PDs), and currently eclectic and non-manualized psychodynamic approaches lasting for up to 3 years are prevailing in some clinical practices.Although this treatment approach may have an effect on compliant patients, the high drop-out rate indicates that it may not be suitable for a large proportion of PD patients since it requires long-term commitment. Furthermore, it is difficult to identify the content of the non-manualized psychodynamic therapy and what helps the patients.More specific clinical guidelines emphasizing the application of evidence-based treatments or at least manualized treatments are warranted for the treatment of emotionally unstable PDs and other PDs. LimitationsThe naturalistic study design, without any control group, limits conclusions about mechanisms of action of the intervention.Since the intervention was not manualized, it is unknown exactly which treatment was actually administered, which reduces external validity.The outcomes are based on completer data of a relatively small sample size with high drop-out rate.

A computational approach to measure the linguistic characteristics of psychotherapy timing, responsiveness, and consistency

Although individual psychotherapy is generally effective for a range of mental health conditions, little is known about the moment-to-moment language use of effective therapists. Increased access to computational power, coupled with a rise in computer-mediated communication (telehealth), makes feasible the large-scale analyses of language use during psychotherapy. Transparent methodological approaches are lacking, however. Here we present novel methods to increase the efficiency of efforts to examine language use in psychotherapy. We evaluate three important aspects of therapist language use - timing, responsiveness, and consistency - across five clinically relevant language domains: pronouns, time orientation, emotional polarity, therapist tactics, and paralinguistic style. We find therapist language is dynamic within sessions, responds to patient language, and relates to patient symptom diagnosis but not symptom severity. Our results demonstrate that analyzing therapist language at scale is feasible and may help answer longstanding questions about specific behaviors of effective therapists.

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."

Introducing SYPRENE: An International Practice Research Network for Strategic and Systemic Therapists and Researchers

SYPRENE, a new international Systemic Practice Research Network (PRN), has been established to fill the gap in practice-based research on the effectiveness and efficiency of strategic therapies. This article presents the rationale for the creation of SYPRENE and describes data collection methods, and the encoding system implemented within this PRN. More developments are expected in the recruitment of practitioners, the types of data collected, findings, and the implementation of SYPRENE in supervision, trainings, and professional schools.

Beyond linear mediation: Toward a dynamic network approach to study treatment processes

Few clinical scientists would disagree that more research is needed on the underlying mechanisms and processes of change in psychological therapies. In the dominant current approach, processes of change are studied through mediation. The study of mediation has been largely structured around a distinction between moderation and mediation first popularized by Baron and Kenny's (1986) seminal article, which is based on a nomothetic and cross-sectional framework. In this article, we argue that this approach is unable to adequately address change processes in psychological therapies, because it falsely assumes that treatment change is a linear, unidirectional, pauci-variate process and that the statistical assumptions are met to study processes of change in an individual using a nomothetic approach. In contrast, we propose that treatment is a dynamic process involving numerous variables that may form bi-directional and complex relationships that differ between individuals. Such relationships can best be studied using an individual dynamic network approach connected to nomothetic generalization methods that are based on a firm idiographic foundation. We argue that our proposal is available, viable, and can readily be integrated into existing research strategies. We further argue that adopting an individual dynamic network approach combined with experimental analyses will accelerate the study of treatment change processes, which is necessary as the field of evidence-based care moves toward a process-based model. We encourage future research to gather empirical evidence to examine this approach.

Effectiveness of Brief Psychodynamic Therapy With Children and Adolescents: An Outcome Study

Studies on the effectiveness of child and adolescent psychotherapy treatments provided by the Italian National Health Service lag behind, while the scientific community has rather focused on the value of cognitive-behavioral psychotherapeutic approaches. This paper evaluates the effectiveness of a one year psychodynamically-oriented intervention with children and adolescents-aged between 6 and 18 years (M = 12.08, SD = 3.7)-and their parents, carried out in a Child and Adolescent Neuropsychiatric Service (SCIAF), part of the Italian National Health System. Following a psychodiagnostic assessment, two types of therapeutic intervention were offered: children and adolescents allocated to Group 1 (N = 26) were offered individual psychodynamic psychotherapy alone, whilst youths in Group 2 (N = 31) were offered individual psychotherapy, accompanied by parental support. This study examines the effects of this time-limited (12 month) psychodynamically-oriented psychotherapy in terms of improvements in patients' symptoms (measured on the Achenbach's questionnaires: Child Behavior Checklist and Youth Self-Report 11-18). This study also examines the effects of treatment on parents' perception of their family empowerment. This domain is measured on the Family Empowerment Scale (FES). Our findings seem to be partly in line with published studies according to which poor parenting (i.e., characterized by lack of warmth, a rigid and/or negative parenting style, poor monitoring of the children, etc.) would be positively associated with Externalizing problems in childhood. Our preliminary findings suggest that brief psychodynamic therapy seemed to show positive outcomes in both "Internalizing" and "Externalizing" difficulties, accounting for age-related differences, ICD-10 (1) diagnoses, and the types of treatment offered. However, no statistically significant changes were detected in the parents' perceptions of empowerment at 12 months.

Clinical and cost-effectiveness of guided internet-based interventions in the indicated prevention of depression in green professions (PROD-A): study protocol of a 36-month follow-up pragmatic randomized controlled trial

BACKGROUND

People in green professions are exposed to a variety of risk factors, which could possibly enhance the development of depression. Amongst possible prevention approaches, internet- and mobile-based interventions (IMIs) have been shown to be effective and scalable. However, little is known about the effectiveness in green professions. The aim of the present study is to examine the (cost-)effectiveness of a tailored IMI program for reducing depressive symptoms and preventing the onset of clinical depression compared to enhanced treatment as usual (TAU+).

METHODS

A pragmatic randomized controlled trial (RCT) will be conducted to evaluate a tailored and therapeutically guided preventive IMI program in comparison to TAU+ with follow-ups at post-treatment (9 weeks), 6-, 12-, 24-, and 36-months. Entrepreneurs in green professions, collaborating spouses, family members and pensioners (N = 360) with sufficient insurance status and at least subthreshold depression (PHQ-9 ≥ 5) are eligible for inclusion. Primary outcome is depressive symptom severity (QIDS-SR16). Secondary outcomes include incidence of depression (QIDS-SR16), quality of life (AQoL-8D) and negative treatment effects (INEP). A health-economic evaluation will be conducted from a societal perspective. The IMI program is provided by psychologists of an external service company and consists of six guided IMIs (6-8 modules, duration: 6-8 weeks) targeting different symptoms (depressive mood, depressive mood with comorbid diabetes, perceived stress, insomnia, panic and agoraphobic symptoms or harmful alcohol use). Intervention choice depends on a screening of participants' symptoms and individual preferences. The intervention phase is followed by a 12-months consolidating phase with monthly contact to the e-coach.

DISCUSSION

This is the first pragmatic RCT investigating long-term effectiveness of a tailored guided IMI program for depression prevention in green professions. The present trial builds on a large-scale strategy for depression prevention in green professions. The intended implementation of the IMI program with a nationwide rollout has the potential to reduce overall depression burden and associated health care costs in case of given effectiveness.

TRIAL REGISTRATION

German Clinical Trial Registration: DRKS00014000 . Registered on 09 April 2018.

What helps in self-help? A qualitative exploration of interactions within a borderline personality disorder self-help group

Background: Self-help groups can have a large impact on individuals well-being and could reduce costs for healthcare services. Previous research supports the effectiveness of self-help groups, but explanations for this are lacking. Identifying the active ingredients which encourage positive change could inform effectiveness of these groups producing the best outcomes for members.Aim: This research investigated how members and facilitators of a borderline personality disorder self-help group (BPD SHG)interacted and made sense of their experiences in group meetings, to determine what aspects of interaction were helpful.Method: Naturalistic data was collected from 10 participants via audio recording and analysed using interpretative phenomenological analysis.Results: Three emergent themes are discussed: humour, praise and experiential knowledge.Conclusion: These are suggested to be active ingredients which are critical for the effectiveness of this BPD SHG, with particular focus on the facilitator's contribution.

Training Psychiatry Residents in Psychotherapy: The Role of Manualized Treatments

Evidence-based treatment and manualized psychotherapy have a recent but rich history. As interest and research have progressed, defining the role of treatment manuals in resident training and clinical practice has become more important. Although there is not a universal definition of treatment manual, most clinicians and researchers agree that treatment manuals are an essential piece of evidence-based therapy, and that despite several limitations, they offer advantages in training residents in psychotherapy. Requirements for resident training in psychotherapy have changed over the years, and treatment manuals offer a simple and straightforward way to meet training requirements. In a search limited to only depression, two treatment manuals emerged with the support of research regarding both clinical practice and resident training. In looking toward the future, it will be important for clinicians to remain updated on further advances in evidence based manualized treatment as a tool for training residents in psychotherapy, including recent developments in online and smartphone based treatments.

Towards the recovery of a sense of self: An interpretative phenomenological analysis of patients' experience of body-oriented psychotherapy for schizophrenia

OBJECTIVE

Increasing evidence supports the efficacy of body-oriented psychotherapy (BPT) for schizophrenia. Yet, so far no research has investigated outcome in relation to therapy process: Why and how BPT is effective. In this study, we qualitatively explore participants' experience of a manualized BPT for schizophrenia to shed light on the process of therapeutic change.

METHOD

We conducted in-depth interviews with 6 participants who completed a 10-week BPT group intervention. Interviews explored participants' experience of change and helpful aspects of therapy and were analysed using interpretative phenomenological analysis.

FINDINGS

We identified six master themes across the interviews: (i) Being a whole: body-mind connection; (ii) Being agentic and being able; (iii) Being unique and worthy: Being accepted for who one is; (iv) Changing interactions: Engaging in authentic interpersonal contact; (v) Being part of a group: Feeling integrated; and (vi) Hope and investing in the future.

CONCLUSION

We discuss the clinical implications for each theme and bring the findings together by describing therapeutic change in schizophrenia as a recovery of sense of self at different but interlocked levels. Moreover, we put forward recommendations for both specific and common factors for schizophrenia therapy. Clinical or methodological significance of this article: The clinical significance of this study is twofold. On the one hand, the findings of this analysis might inform the theory and practice of BPT and might directly feedback into a further development of the manual guidelines. On the other hand, common helpful factors have been identified thatmight also be relevant for the more general clinical practice concerning patients with schizophrenia. Here, we summarize our key messages for the clinical practitioner emerging from the findings: The inclusion of bodily aspects and a focus on pre-reflective experience in psychotherapy can help persons with schizophrenia recover the sense of being a body-mind unity. Empowering persons with schizophrenia, instead of instructing them, seems to foster a sense of agency and self-confidence, which are crucial to the recovery process. A twofold therapeutic stance characterized by openness towards the other and authenticity was experienced by patients as facilitating the rapport building. This might help persons with schizophrenia engage in the relation. Social inclusion might enhance therapeutic change and recovery in schizophrenia. Group therapy might be helpful for fostering a feeling of social belonging, but the inclusion in the wider social and community context remains a critical issue. The experience of joyful moments in psychotherapy might positively contribute to therapeutic change in that it fosters a sense of hope for the future. Overall our paper contributes to the literature aiming at expanding the range of therapeutic modalities, focussing on the creation and use of mixed models of therapy within and beyond talking practices.

Developing an obesity-cancer intervention for workplaces: Indigenous, Native American, Māori and other minority occupational settings

There is growing evidence for links between obesity and certain types of cancer. Studies done within Native American, Māori, and other Indigenous populations suggest the need to promote healthier lifestyles, including the maintenance of optimal body weight through nutrition and physical activity, to lower the risk factors of obesity-related cancers. What is missing is a program that combines culturally attuned workplace interventions that deal with obesity reduction as it relates to cancer prevention. The main purpose of this project was to discuss the process of developing an employee assistance program module to reduce the risk for obesity-related cancers. Expert curriculum developers specialising in workplace disease management assisted with the creation of a unique obesity and cancer prevention program. Several national leaders in Indigenous and minority health were consulted for feedback. The completed intervention included a six-session model with cultural features wrapped around topics of obesity-related cancer warning signs, diet and physical activity guidance, stress management, goal-setting, and resource linkage. A Native American workplace was selected for feasibility and pilot testing. Preliminary results are also discussed. Ultimately, this paper presents a novel intervention approach to address health issues for Native Americans, with indicators for use in other Indigenous populations globally.

A Program Evaluation Strategy in a Community-Based Behavioral Health and Education Services Agency for Children and Families

Evaluation research and outcomes measurement in the arena of behavioral health services for children must be adapted for the community agency setting. Through evaluation research, it is possible to address service goals as well as more traditional academic research goals. This article examines a variety of activities that have been implemented to evaluate children’s behavioral and educational services in a Northern California non-profit community agency. It is noted that there are multiple formats for collecting information from and providing comments to children’s parents, their clinicians, and program administration staff, all of which can be used to effectively address service-focused evaluation research goals. Challenges to doing scientifically rigorous research in a community setting require additional considerations regarding organizational culture and structure. Based on the experiences of the authors and the experiences of others, the article describes general principles that can guide evaluation research and outcomes measurement with children and their families in the community health agency setting.

Assessment of Change after Long-Term Psychoanalytic Group Treatment: Presentation of a Field Study of Outpatients from Private Psychiatric Practice

The main purpose of this article is to underline the importance of doing clinical research on long-term, dynamic group psychotherapy as it is carried out in practice (effectiveness study). After a review of the outcome literature, which mainly consists of experimental studies (efficacy studies), an effectiveness study from a private practice will be described with some preliminary results. Experiences from implementation of a research project in clinical practice are presented and the strengths and limitations of the two research methods are discussed.

Mental Health Smartphone Apps: Review and Evidence-Based Recommendations for Future Developments

BACKGROUND

The number of mental health apps (MHapps) developed and now available to smartphone users has increased in recent years. MHapps and other technology-based solutions have the potential to play an important part in the future of mental health care; however, there is no single guide for the development of evidence-based MHapps. Many currently available MHapps lack features that would greatly improve their functionality, or include features that are not optimized. Furthermore, MHapp developers rarely conduct or publish trial-based experimental validation of their apps. Indeed, a previous systematic review revealed a complete lack of trial-based evidence for many of the hundreds of MHapps available.

OBJECTIVE

To guide future MHapp development, a set of clear, practical, evidence-based recommendations is presented for MHapp developers to create better, more rigorous apps.

METHODS

A literature review was conducted, scrutinizing research across diverse fields, including mental health interventions, preventative health, mobile health, and mobile app design.

RESULTS

Sixteen recommendations were formulated. Evidence for each recommendation is discussed, and guidance on how these recommendations might be integrated into the overall design of an MHapp is offered. Each recommendation is rated on the basis of the strength of associated evidence. It is important to design an MHapp using a behavioral plan and interactive framework that encourages the user to engage with the app; thus, it may not be possible to incorporate all 16 recommendations into a single MHapp.

CONCLUSIONS

Randomized controlled trials are required to validate future MHapps and the principles upon which they are designed, and to further investigate the recommendations presented in this review. Effective MHapps are required to help prevent mental health problems and to ease the burden on health systems.

Group Interventions for Patients with Cancer and HIV Disease: Part I: Effects on Psychosocial and Functional Outcomes at Different Phases of Illness

Group interventions for individuals facing cancer or HIV disease have drawn considerable attention among researchers and clinicians over the past 20 years. There is growing evidence that group services may be helpful, but which interventions are most effective for participants at which phases in the trajectory of disease has been less clear. Moreover, professionals working in different intervention settings (e.g., primary prevention vs. clinical care) and different disease sites (cancer vs. HIV disease) often have little awareness of relevant advances in other fields. Efforts to integrate findings in the literature may accelerate research and advance the standard of clinical care. The current article, the first in a series of four special reports, critically evaluates the efficacy of group interventions led by professional or trained facilitators for individuals confronted by cancer or HIV, across the spectrum of illness from elevated risk through advanced disease. We examine psychosocial and functional outcomes for different interventions directed toward different patient subgroups, trace common themes, highlight limitations, and offer recommendations for further research.

Implications of RDoC for the research and practice of psychotherapy

The field of psychotherapy is at an important juncture. Recent changes in the field include (a) the skeptical reception of the fifth edition of the Diagnostic and Statistical Manual and (b) NIMH's prioritization of an alternative classification system to guide translational and intervention research. Moreover, (c) the field continues to be held accountable to governmental agencies and third-party payers to demonstrate its empirical basis. Thus, psychological research as it relates to the practice of psychotherapy is at a crossroads. In this article, we provide a brief overview of several generations of psychotherapy outcome research, including the consequences that followed in the 1980s as psychotherapy research moved toward randomized controlled trials for clinical disorders. We delineate the inherent strengths and limitations of this movement and address how the NIMH has recently responded with the Research Domain Criteria (RDoC). We then address philosophical and practical implications of the emphasis on a neuroscientific conceptualization of psychological problems. Finally, we discuss opportunities for a next generation of convergent science that incorporates, rather than replaces, psychosocial variables across stages of translational research and treatment development.

Integrating education, research, and practice in gerontological social work: lessons learned from the reclaiming joy peer support program

The practice-to-research gap has been attributed to many factors, including differing goals and priorities, differing knowledge bases and skill sets, and lack of recognition of limits of agency and community resources. Although many scholars have called for more collaboration between educators, researchers, and practitioners, these challenges can make collaboration difficult. The authors illustrate how the application of the strengths perspective, by acknowledging and building on the strengths and goals of researchers, practitioners, and educators, can help to mitigate some of the barriers that contribute to the research--practice gap and to create more relevant research. The Reclaiming Joy Peer Support Program is offered as a case study in gerontological social work to demonstrate how the strengths perspective can be applied in a real-life research setting.

From parent to 'peer facilitator': a qualitative study of a peer-led parenting programme

BACKGROUND

Peer-led interventions are increasingly common in community health settings. Although peer-led approaches have proven benefits for service users, relatively little is known about the process and outcomes of participation for peer leaders. This study investigated experiences of parents who had participated as 'peer facilitators' in Empowering Parents, Empowering Communities (EPEC), a peer-led programme designed to improve access to evidence-based parenting support in socially disadvantaged communities.

METHOD

A qualitative cross-sectional design was used. Semi-structured interviews were conducted with 14 peer facilitators and scrutinized using thematic analysis.

RESULTS

Peer facilitators developed their knowledge and skills through personal experience of receiving parenting support, participation in formal training and supervised practice, access to an intervention manual, and peer modelling. Peer facilitators described positive changes in their own families, confidence and social status. Transformative personal gains reinforced peer facilitators' role commitment and contributed to a cohesive 'family' identity among EPEC staff and service users. Peer facilitators' enthusiasm, openness and mutual identification with families were seen as critical to EPEC's effectiveness and sustainability. Peer facilitators also found the training emotionally and intellectually demanding. There were particular difficulties around logistical issues (e.g. finding convenient supervision times), managing psychosocial complexity and child safeguarding.

CONCLUSIONS

The successful delivery and sustained implementation of peer-led interventions requires careful attention to the personal qualities and support of peer leaders. Based on the findings of this study, support should include training, access to intervention manuals, regular and responsive supervision, and logistical/administrative assistance. Further research is required to elaborate and extend these findings to other peer-led programmes.

Toward a cognitive-behavioral classification system for mental disorders

As is true for its predecessors, the recently published DSM-5 uses arbitrary criteria and cutoffs to define categories of mental disorders that are of questionable validity and that provide no guidance for treatment. Recently, the NIMH introduced an alternative classification system, the Research Domain Criteria (RDoC). Both the DSM-5 and the RDoC initiative make the strong assumption that psychological problems are expressions of specific latent disease entities. In contrast, the complex causal network approach conceptualizes psychological problems as mutually interacting, often reciprocally reinforcing, elements of a complex causal network. The cognitive behavioral model offers a classification framework that is compatible with the complex causal network approach and provides a treatment-relevant alternative to the latent disease model that is the basis for the DSM-5 and the RDoC initiative.

Exploring the impact of parental psychopathology and emotion regulation on evidence-based parenting interventions: a transdiagnostic approach to improving treatment effectiveness

Parenting interventions, particularly those categorized as parent management training (PMT), have a large evidence base supporting their effectiveness with most families who present for treatment of childhood behavior problems. However, data suggest that PMTs are not effective at treating all families who seek services. Parental psychopathology has been identified as one important factor moderating their effectiveness, yet few PMTs pay explicit attention to the role of parental psychopathology in treatment. Given growing support for a transdiagnostic model of psychopathology, which posits that disruptions in emotions and emotion regulation (ER) may underlie various forms of psychopathology, one way to address the impact of parental psychopathology on PMT may be by targeting parental ER. This paper will review the available literature on PMT and parental psychopathology, as well as existing evidence on relations between ER and both parental psychopathology and parenting behaviors. The limited research on PMTs that include explicitly parent-focused components will be reviewed, and suggestions for augmenting existing PMT curricula by including intervention around parental ER will be presented.

Clinical experiences in using cognitive-behavior therapy to treat panic disorder

Although there is a growing body of research to support the use of psychological treatments for specific disorders, there has been no way for practitioners to provide feedback to researchers on the barriers they encounter in implementing these treatments in their day-to-day clinical work. In order to provide practitioners a means to give researchers information about their clinical experience, the Society of Clinical Psychology and the Division of Psychotherapy of the American Psychological Association collaborated on an initiative to build a two-way bridge between practice and research. A questionnaire was developed on the therapist, patient, and contextual variables that undermine the effective use of CBT in reducing the symptoms of panic disorder, a clinical problem that occurs frequently in clinical practice and has an extensive research base. An Internet-based survey was advertised internationally in listservs and professional newsletters, asking clinicians to indicate all aspects of CBT that they used in treating panic disorder, and to respond to a series of questions with variables that presumably limited successful symptom reduction in clinical work using CBT to treat panic disorder. The final database included responses from 338 participants who varied in experience in applying CBT to the treatment of panic disorders. Participants identified a wide range of patient factors that were barriers to symptom reduction, including symptoms related to panic, motivation, social system, and the psychotherapy relationship, in addition to specific problems with implementing CBT for the treatment of panic disorder.

The acceptability and efficacy of a group cognitive behavioural therapy programme in a community mental health setting

This paper presents data on a patient evaluation of a group cognitive behavioural therapy programme in an applied setting and its efficacy for reducing generalised anxiety and or depression, and distress. Patients (n=14) participated in one of two 8-week group cognitive behavioural therapy programmes for generalised anxiety or depression, within a mental health service. Patients’ perceptions of the programme were collected via an evaluation questionnaire, and data on clinical outcomes were sourced from patients’ case notes. Most patients who were invited to participate in the programme (n=14 of 17), and their evaluations were generally favourable. Almost all participants (93%) indicated that the programme either met or exceeded their expectations. The clinical outcomes of the intervention were similar to those found in efficacy studies reported in the published literature (approximately half to threequarters of one standard deviation improvement in anxiety, depression, and distress scores).

What should we expect from psychotherapy?

In addressing the very general question of what we should expect from psychotherapy, this article begins by discussing what constitutes relevant evidence on which to base the efficacy and effectiveness of psychotherapy. In this context, an important distinction is made between empirically supported treatments and evidence-based practice. Although there is evidence that psychotherapy does indeed work, there are also findings that there are times when our patients are harmed by our interventions. It is noted that the therapeutic alliance plays an extremely important role in the change process, and that ruptures in the alliance can contribute to our therapeutic failures. In pointing to directions for the future, modifications of how we investigate the outcome of treatment, as well as how to close the gap between research and practice, are offered.

The biomedical model of mental disorder: a critical analysis of its validity, utility, and effects on psychotherapy research

The biomedical model posits that mental disorders are brain diseases and emphasizes pharmacological treatment to target presumed biological abnormalities. A biologically-focused approach to science, policy, and practice has dominated the American healthcare system for more than three decades. During this time, the use of psychiatric medications has sharply increased and mental disorders have become commonly regarded as brain diseases caused by chemical imbalances that are corrected with disease-specific drugs. However, despite widespread faith in the potential of neuroscience to revolutionize mental health practice, the biomedical model era has been characterized by a broad lack of clinical innovation and poor mental health outcomes. In addition, the biomedical paradigm has profoundly affected clinical psychology via the adoption of drug trial methodology in psychotherapy research. Although this approach has spurred the development of empirically supported psychological treatments for numerous mental disorders, it has neglected treatment process, inhibited treatment innovation and dissemination, and divided the field along scientist and practitioner lines. The neglected biopsychosocial model represents an appealing alternative to the biomedical approach, and an honest and public dialog about the validity and utility of the biomedical paradigm is urgently needed.

The clinical effectiveness of evidence-based interventions for depression: a pragmatic trial in routine practice

BACKGROUND

Controversy persists about how effectively empirically-supported treatments for major depression work in actual clinical practice as well as how patients choose among them. We examined the acute phase effectiveness of cognitive therapy (CT), interpersonal psychotherapy (IPT), and combined psychotherapy-pharmacotherapy (PHT) in a naturalistic setting, allowing patients their choice of treatment.

METHODS

The study compared CT (n=63), IPT (n=56), CT-PHT (n=34), and IPT-PHT (n=21) for 174 subjects with major depression in a secondary care mood disorders clinic. Patient preference, rather than randomization, determined treatment selection. The Beck Depression Inventory-II (BDI) was the primary outcome variable. Exclusion criteria were minimal.

RESULTS

All treatments were associated with a reduction in depressive symptoms, with a 35% remission rate by week 26. Overall improvement was well within ranges reported in efficacy trials. On average, treatment effects of the different interventions straddled the same range, but moderation analyses revealed that BDI scores dropped faster in the first 16 weeks in patients who received CT alone than patients who received CT and pharmacotherapy, a pattern not found in patients who received IPT (with or without pharmacotherapy).

LIMITATIONS

Limitations consist of a modest sample size, choice of treatment was made by participants which may have been influenced by many sources, and the absence of a non-active control group.

CONCLUSIONS

This study supports the effectiveness of empirically-supported antidepressant treatments selected by patients in routine settings, and provides an indication that speed of therapeutic response may vary amongst treatments.

Cognitive-Behavioral Group Therapy for Heterogeneous Anxiety and Mood Disorders in a Psychiatric Hospital Outpatient Clinic

Recent literature has shown that group cognitive-behavioral therapy (CBT) is effective for individuals with heterogeneous anxiety disorders. However, these studies have used a narrow range of outcome measures, and have not included global measures such as quality of life. In addition, heterogeneous mood disorders have not been well researched. The aim of this study was to replicate and extend on previous studies by assessing the effectiveness of group CBT treatment programs designed for use with heterogeneous anxiety or depressive disorders. Global outcome measures of quality of life and social functioning were assessed in addition to outcome measures of anxiety and mood symptoms. There were 173 patients who completed either group CBT for anxiety disorders or for depressive disorders. Symptom measures and quality of life measures were used to determine treatment effectiveness. Results demonstrated that the treatments were effective in reducing overall symptom severity and improving quality of life. Treatment gains were maintained to 12 month follow-up. However, the degree of change was considerably lower than that found in comparable trials with diagnostically homogenous samples. Overall, group CBT for heterogeneous diagnostic populations was effective but requires further investigation and refinement.

Cognitive behaviour therapy and supportive therapy for bipolar disorders: relapse rates for treatment period and 2-year follow-up

BACKGROUND

The efficacy of adjunctive psychosocial interventions such as cognitive behaviour therapy (CBT) for bipolar disorder (BD) has been demonstrated in several uncontrolled and controlled studies. However, these studies compared CBT to either a waiting list control group, brief psycho-education or treatment as usual (TAU). Our primary aim was to determine whether CBT is superior to supportive therapy (ST) of equal intensity and frequency in preventing relapse and improving outcome at post-treatment. A secondary aim was to look at predictors of survival time.

METHOD

We conducted a randomized controlled trial (RCT) at the Department of Psychology, University of Tübingen, Germany (n=76 patients with BD). Both CBT and ST consisted of 20 sessions over 9 months. Patients were followed up for a further 24 months.

RESULTS

Although changes over time were observed in some variables, they were not differentially associated with CBT or ST. CBT showed a non-significant trend for preventing any affective, specifically depressive episode during the time of therapy. Kaplan-Meier survival analyses revealed that 64.5% of patients experienced a relapse during the 33 months. The number of prior episodes, the number of therapy sessions and the type of BD predicted survival time.

CONCLUSIONS

No differences in relapse rates between treatment conditions were observed, suggesting that certain shared characteristics (e.g. information, systematic mood monitoring) might explain the effects of psychosocial treatment for BD. Our results also suggest that a higher number of prior episodes, a lower number of therapy sessions and a diagnosis of bipolar II disorder are associated with a shorter time before relapse.

Treating patients who strain the research psychotherapy paradigm

Clinical trials of psychotherapy require diagnostic homogeneity, which implies a convergence of clinical presentations. Yet research study patients present diversely, and patients who do not fit a treatment paradigm may greatly complicate delivery of the study psychotherapy. The research literature has not addressed this issue. The authors use case illustrations of three psychotherapies--Prolonged Exposure, Relaxation Therapy, and Interpersonal Psychotherapy--from an ongoing psychotherapy outcome trial of posttraumatic stress disorder to describe psychotherapeutic responses to complex, "atypical" patients who strain standard treatment paradigms. Therapists required flexibility, and occasionally deviations from strict protocol, in treating heterodox patients. Such heterogeneity of presentation may have implications for psychotherapy outcome in research trials. Despite lack of discussion in the literature, many trials may face such issues.

Where is the Dialogue? A Social Constructionist View of Empirically Supported Treatments

Since the publication of the list of empirically supported treatments by the American Psychological Association in 1995 a controversy has resulted between those who view positive psychotherapeutic outcome as resulting from the use of specific (listed) techniques and those who lean towards the so-called common or relationship factors rather than particular techniques as necessary for such outcomes. This paper examines the controversy and shows that both sides follow the same objectivist/empiricist and reductionist epistemology. In contrast, the paper adopts a social constructionist perspective and shows that the idea of therapeutic outcome as linearly determined by either technical or common factors or a combination of these is a misleading oversimplification which fails to account for the dialogue which is the core of psychotherapy. Rather, positive outcome is viewed as mutually constructed in a unique dialogue which encompasses both common and technical factors. This takes the form of the conversational development of a new understanding or reframe of the problem followed by action which is deemed appropriate to the new understanding. This view is illustrated by practical examples.

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.

Context therapy: a new intervention approach for children with cerebral palsy

AIM

To describe the development of context therapy, a new intervention approach designed for a randomized controlled trial.

METHOD

Therapists were trained to change task and environmental factors to achieve parent-identified functional goals for children with cerebral palsy. Therapists did not provide any remediation strategies to change the abilities of the child. Theoretical constructs were developed using dynamic systems theory and the principles of family-centered care. A primary therapist model was used. A three-step intervention strategy was developed.

RESULTS

Therapists adhered to the treatment protocol. Parents participated in the development of both functional goals and intervention strategies.

INTERPRETATION

A therapy approach focusing on changing the task and the environment rather than children's impairments can be a viable treatment strategy and merits further investigation. The detailed description of the context therapy approach allows replication by both researchers and clinicians. Such intervention descriptions are an important methodological consideration in rehabilitation research.

Measuring clinical change in routine mental health care: differences between first time and longer term service users

OBJECTIVE

The aims were to assess the feasibility of routinely collecting outcome data in everyday mental health services across Italy and to evaluate clinical change in a cohort of patients stratified by illness duration.

METHOD

A prevalence sample of patients attending nine Italian community mental health services (CMHS) was assessed over one year with the Health of the Nation Outcome Scales (HoNOS). The patients were classified on the basis of the duration of their contact with services. Clinical outcome was evaluated taking into account parameters of reliable and clinically significant change (RCSC). Predictors of change included clinical and socio-demographic characteristics at first assessment and six month reliable improvement.

RESULTS

2059 patients were evaluated with only 3% attrition at follow up; 22% of first time and about 7% of longer term users achieved reliable improvement at one year. First contacts had a better outcome than longer term users and significant differences were seen at both group and individual level. Reliable improvement at six months was the best predictor of clinical improvement at one year for the whole cohort.

CONCLUSION

The study demonstrated the feasibility of routine outcome assessment and gave an expected and realistic picture of the one-year outcome of a representative sample of patients attending a group of Italian CMHS. RCSC showed potential utility as a means of communicating with clinicians and decision makers.

The clinical effectiveness of cognitive therapy for depression in an outpatient clinic

BACKGROUND

Cognitive therapy (CT) has been shown to be efficacious in the treatment of depression in numerous randomized controlled trials (RCTs). However, little evidence is available that speaks to the effectiveness of this treatment under routine clinical conditions.

METHOD

This paper examines outcomes of depressed individuals seeking cognitive therapy at an outpatient clinic (N=217, Center for Cognitive Therapy; CCT). Outcomes were then compared to those of participants in a large NIMH-funded RCT of cognitive therapy and medications as treatments for depression.

RESULTS

The CCT is shown to be a clinically representative setting, and 61% of participants experienced reliable change in symptoms over the course of treatment; of those, 45% (36% of the total sample) met criteria for recovery by the end of treatment. Participants at CCT had similar outcomes to participants treated in the RCT, but there was some evidence that those with more severe symptoms at intake demonstrated greater improvement in the RCT than their counterparts at CCT.

LIMITATIONS

The CCT may not be representative of all outpatient settings, and the structure of treatment there was considerably different from that in the RCT. Treatment fidelity was not assessed at CCT.

CONCLUSIONS

Depressed individuals treated with cognitive therapy in a routine clinical care setting showed a significant improvement in symptoms. When compared with outcomes evidenced in RCTs, there was little evidence of superior outcomes in either setting. However, for more severe participants, outcomes were found to be superior when treatment was delivered within an RCT than in an outpatient setting. Clinicians treating such patients in non-research settings may thus benefit from making modifications to treatment protocols to more closely resemble research settings.