The assessment of cognitive errors using an observer-rated method

Cognitive heuristics in borderline personality disorder across treatment: A longitudinal non-parametric analysis

OBJECTIVE

The development of a constructive therapeutic alliance may represent an important feature of interpersonal adaptation in clients with Borderline Personality Disorder (BPD). The present study explores cognitive heuristics as dynamic features of change in relationship with the therapeutic alliance in the treatment of BPD.

METHOD

In total, N = 60 clients with BPD, are included in the present study. In the context of brief therapy, the therapeutic alliance (WAI) is assessed from the client and the therapist perspectives after each therapy session; cognitive heuristics are assessed three times (CERS). The data analyses are on the basis of non-parametric clusters (kml3d) linked with the therapeutic alliance.

RESULTS

The results showed that clusters of cognitive heuristics trajectories are linked with the client's therapeutic alliance (t(55) = 2.30, p = .03), but they remained unrelated with the evolution of the therapist's alliance.

CONCLUSIONS

These results are discussed with regard to the interpersonal adaptiveness of cognitive heuristics in the context of BPD undergoing treatment.

The role of cognitive biases in short-term psychodynamic psychotherapy

The concept of biased thinking - or cognitive biases - is relevant to psychotherapy research and clinical conceptualization, beyond cognitive theories. The present naturalistic study aimed to examine the changes in biased thinking over the course of a short-term dynamic psychotherapy (STDP) and to discover potential links between these changes and symptomatic improvement. This study focuses on 32 self-referred patients consulting for Adjustment Disorder according to DSM-IV-TR. The therapists were experienced psychodynamically oriented psychiatrists and psychotherapists. Coding of cognitive biases (using the Cognitive Errors Rating Scale; CERS) was made by external raters based on transcripts of interviews of psychotherapy; the reliability of these ratings on a randomly chosen 24% of all sessions was established. Based on the Symptom Check List SCL-90-R given before and after, the Reliable Change Index (RCI) was used. The assessment of cognitive errors was done at three time points: early (session 4-7), mid-treatment (session 12-17), and close to the end (after session 20) of the treatment. The results showed that the total frequency of cognitive biases was stable over time (p = .20), which was true both for positive and for negative cognitive biases. In exploring the three main subscales of the CERS, we found a decrease in selective abstraction (p = .02) and an increase in personalization (p = .05). A significant link between RCI scores (outcome) and frequency of positive cognitive biases was found, suggesting that biases towards the positive might have a protective function in psychotherapy.

PRACTITIONER POINTS

Therapists may be attentive to changes in biased thinking across short-term dynamic psychotherapy for adjustment disorder. Therapists may foster the emergence of positive cognitive biases at mid-treatment for adjustment disorder.

Change in Biased Thinking in a Treatment Based on the Motive-Oriented Therapeutic Relationship for Borderline Personality Disorder

Biased thinking is a common feature of patients presenting with borderline personality disorder (BPD). For the treatment of BPD, it was shown that the individualizing of the treatment, by using the motive-oriented therapeutic relationship (MOTR), had a beneficial short-term effect on process and outcome. So far, it remains unclear what the role of early change in biased thinking is in these treatments. The present study aims to assess whether there is a link between the MOTR, change in biased thinking, and outcome. The sample (N = 60) is based on a randomized controlled trial with two conditions: (a) 30 patients in a 10-session version of psychiatric management, and (b) 30 patients in a 10-session version of psychiatric management augmented with the MOTR. For each patient, three sessions (intake, middle, late) were selected, transcribed, and rated using the Cognitive Errors Rating Scale (CERS). An overall decrease of negative cognitive errors during 10 sessions of treatment was observed, independently of the treatment condition. No specific effect related to change in biased thinking may be attributed to the individualizing of the treatment. These results are discussed with regard to mechanisms of change in treatments for BPD, in particular with regard to the central role that biased thinking, as well as the MOTR, might play early in treatment.

Predictive validity of an observer-rated adherence protocol for multisystemic therapy with juvenile drug offenders

OBJECTIVE

Multisystemic therapy (MST) is perhaps the best validated treatment for youth who engage in serious and chronic antisocial behavior (Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 2009). Despite evidence suggesting that high treatment adherence is needed to achieve optimal MST outcomes, this research is limited because past studies have relied on adherence reports derived solely from treatment participants (i.e., caregivers, youth, and therapists). To address this gap in the literature, the present study assessed the reliability and predictive validity of an observational protocol for rating adherence to MST.

METHOD

The sample was drawn from a randomized clinical trial of juvenile drug offenders (77.5% male, 65% African American) referred to one of four treatment conditions (Henggeler et al., 2006). Audiotaped sessions of youth and their families were selected from the first month of MST and trained undergraduate students independently rated therapist adherence to the nine MST treatment principles. We assessed the validity of MST adherence in predicting outcomes at post-recruitment and 12-month follow-up.

RESULTS

Good interrater reliability (ICC=0.642) was found across all raters for our composite index of adherence. High adherence to MST during the first month of therapy predicted decreases in externalizing behavior at post-recruitment and decreases in youth alcohol consumption at 12-month follow-up.

CONCLUSIONS

These results provide independent support for the link between treatment fidelity and behavioral outcomes in the context of MST. Further, this study demonstrates the feasibility of using novice, undergraduate judges to reliably code therapist adherence.

A Randomized Controlled Trial of a Brief Intervention for Delayed Psychological Effects in Snakebite Victims

BACKGROUND

Snakebite results in delayed psychological morbidity and negative psycho-social impact. However, psychological support is rarely provided to victims.

AIM

To assess the effectiveness of a brief intervention which can be provided by non-specialist doctors aimed at reducing psychological morbidity following snakebite envenoming.

METHOD

In a single blind, randomized controlled trial, snakebite victims with systemic envenoming [n = 225, 168 males, mean age 42.1 (SD 12.4) years] were randomized into three arms. One arm received no intervention (n = 68, Group A), the second received psychological first aid and psychoeducation (dispelling prevalent cultural beliefs related to snakebite which promote development of a sick role) at discharge from hospital (n = 65, Group B), while the third received psychological first aid and psychoeducation at discharge and a second intervention one month later based on cognitive behavioural principles (n = 69, Group C). All patients were assessed six months after hospital discharge for the presence of psychological symptoms and level of functioning using standardized tools.

RESULTS

At six months, there was a decreasing trend in the proportion of patients who were positive for psychiatric symptoms of depression and anxiety from Group A through Group B to Group C (Chi square test for trend = 7.901, p = 0.005). This was mainly due to a decreasing trend for symptoms of anxiety (chi-square for trend = 11.256, p = 0.001). There was also decreasing trend in the overall prevalence of disability from Group A through Group B to Group C (chi square for trend = 7.551, p = 0.006), predominantly in relation to disability in family life (p = 0.006) and social life (p = 0.005). However, there was no difference in the proportion of patients diagnosed with depression between the three groups (chi square for trend = 0.391, p = 0.532), and the intervention also had no effect on post-traumatic stress disorder.

CONCLUSIONS

A brief psychological intervention, which included psychological first aid and psychoeducation plus cognitive behavioural therapy that can be provided by non-specialist doctors appeared to reduce psychiatric symptoms and disability after snakebite envenoming, but not depression or post-traumatic stress disorder.

TRIAL REGISTRATION

Sri Lanka Clinical Trials Registry: SLCTR/2011/003.