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Fjermestad KW, Wallin MH, Naujokat F, McLeod BD, Silverman WK, Öst LG, Lerner MD, Heiervang ER, Wergeland GJ. Group cohesion and alliance predict cognitive-behavioral group treatment outcomes for youth with anxiety disorders. Cogn Behav Ther 2024:1-19. [PMID: 39105346 DOI: 10.1080/16506073.2024.2385906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 07/24/2024] [Indexed: 08/07/2024]
Abstract
Knowledge about how to enhance group cognitive behavioral therapy (GCBT) outcomes is needed. In a randomized controlled effectiveness trial, we examined group cohesion (the bond between group members) and the alliance (the client-clinician bond) as predictors of GCBT outcomes. The sample was 88 youth (M age 11.7 years, SD = 2.1; 54.5% girls; 90.7% White) with anxiety disorders. Observers rated group cohesion and alliance in 32 sessions from 16 groups. We examined early group cohesion and alliance (r = .50, p < .001) and group cohesion and alliance change from early to late in treatment in relation to outcomes using generalized estimation equations accounting for nesting within groups (ICCs .31 to .55). The outcomes were diagnostic recovery, clinical severity, and parent- and youth-reported anxiety symptoms, each at post-treatment, 12-months, and 4-years follow-up. There were more significant associations with 4-years follow-up than earlier outcomes. Clinical severity and parent-reported anxiety symptoms were more frequently predicted than diagnostic recovery. Clinician- and parent-reported outcomes were far more frequently significantly predicted by cohesion and alliance than youth-rated outcomes. We conclude that group cohesion and alliance are related but distinct variables, both associated with some GCBT outcomes for as long as 4 years after treatment.
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Affiliation(s)
| | - Malin H Wallin
- Department of Psychology, University of Oslo, Oslo, Norway
| | | | - Bryce D McLeod
- Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA
| | - Wendy K Silverman
- Child Study Center, School of Medicine, Yale University, New Haven, CT, USA
| | - Lars-Göran Öst
- Department of Psychology, Stockholm University, Stockholm, Sweden
| | - Matthew D Lerner
- Department of Psychology, Stony Brook University, Stony Brook, NY, USA
| | - Einar R Heiervang
- Tynset Child and Adolescent Mental Health Clinic, Innlandet Hospital Trust, Lillehammer, Norway
| | - Gro Janne Wergeland
- Department of Child and Adolescent Psychiatry, Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway
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Fjermestad KW, Naujokat F, Wallin M, Wergeland GJ. Mediation Effects of Group Cohesion in Group-Based Cognitive Behavioral Therapy for Youth Anxiety Disorders. Int J Group Psychother 2024:1-13. [PMID: 38976589 DOI: 10.1080/00207284.2024.2365718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
There is limited research on group cohesion as a potential outcome facilitator in group-based cognitive-behavioral treatment (GCBT) for youth. We examined if group cohesion mediated the relation between the temperamental trait behavioral inhibition and posttreatment outcomes following GCBT for youth with anxiety disorders. The sample comprised 88 youth (M age = 11.2 years) from a randomized controlled effectiveness trial. The outcomes were posttreatment clinical severity and treatment satisfaction. Group cohesion fully mediated the relation between behavioral inhibition and posttreatment severity. Higher group cohesion was associated with lower posttreatment clinical severity. There was no significant association between behavioral inhibition and treatment satisfaction, hence no mediation. We conclude that group cohesion is a factor that can be targeted by clinicians to potentially enhance GCBT outcomes.
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Kangaslampi S, Zijlmans J. MDMA-assisted psychotherapy for PTSD in adolescents: rationale, potential, risks, and considerations. Eur Child Adolesc Psychiatry 2023:10.1007/s00787-023-02310-9. [PMID: 37814082 DOI: 10.1007/s00787-023-02310-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 09/25/2023] [Indexed: 10/11/2023]
Abstract
3,4-Methylenedioxymetamphetamine(MDMA)-assisted psychotherapy (MDMA-AP) is a proposed treatment for posttraumatic stress disorder (PTSD) that may be approved for adults soon. PTSD is also common among trauma-exposed adolescents, and current treatments leave much room for improvement. We present a rationale for considering MDMA-AP for treating PTSD among adolescents. Evidence suggests that as an adjunct to therapy, MDMA may reduce avoidance and enable trauma processing, strengthen therapeutic alliance, enhance extinction learning and trauma-related reappraisal, and hold potential beyond PTSD symptoms. Drawing on existing trauma-focused treatments, we suggest possible adaptations to MDMA-AP for use with adolescents, focusing on (1) reinforcing motivation, (2) the development of a strong therapeutic alliance, (3) additional emotion and behavior management techniques, (4) more directive exposure-based methods during MDMA sessions, (5) more support for concomitant challenges and integrating treatment benefits, and (6) involving family in treatment. We then discuss potential risks particular to adolescents, including physical and psychological side effects, toxicity, misuse potential, and ethical issues. We argue that MDMA-AP holds potential for adolescents suffering from PTSD. Instead of off-label use or extrapolating from adult studies, clinical trials should be carried out to determine whether MDMA-AP is safe and effective for PTSD among adolescents.
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Affiliation(s)
- Samuli Kangaslampi
- Faculty of Social Sciences/Psychology, Tampere University, Tampere, Finland.
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands.
| | - Josjan Zijlmans
- Department of Child and Adolescent Psychiatry & Psychosocial Care, Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam University Medical Center, Mental Health, Amsterdam, The Netherlands
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de Soet R, Vermeiren RRJM, Bansema CH, van Ewijk H, Nijland L, Nooteboom LA. Drop-out and ineffective treatment in youth with severe and enduring mental health problems: a systematic review. Eur Child Adolesc Psychiatry 2023:10.1007/s00787-023-02182-z. [PMID: 36882638 DOI: 10.1007/s00787-023-02182-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 02/27/2023] [Indexed: 03/09/2023]
Abstract
Youth with severe and enduring mental health problems (SEMHP) tend to drop out of treatment or insufficiently profit from treatment in child and adolescent psychiatry (CAP). Knowledge about factors related to treatment failure in this group is scarce. Therefore, the aim of this systematic review was to thematically explore factors associated with dropout and ineffective treatment among youth with SEMHP. After including 36 studies, a descriptive thematic analysis was conducted. Themes were divided into three main categories: client, treatment, and organizational factors. The strongest evidence was found for the association between treatment failure and the following subthemes: type of treatment, engagement, transparency and communication, goodness of fit and, perspective of practitioner. However, most other themes showed limited evidence and little research has been done on organizational factors. To prevent treatment failure, attention should be paid to a good match between youth and both the treatment and the practitioner. Practitioners need to be aware of their own perceptions of youth's perspectives, and transparent communication with youth contributes to regaining their trust.
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Affiliation(s)
- R de Soet
- LUMC Curium-Department of Child and Adolescent Psychiatry, Leiden University Medical Center, Post Box 15, 2300 AA, Leiden, The Netherlands.
| | - R R J M Vermeiren
- LUMC Curium-Department of Child and Adolescent Psychiatry, Leiden University Medical Center, Post Box 15, 2300 AA, Leiden, The Netherlands
- Youz, Parnassia Group, The Hague, The Netherlands
| | - C H Bansema
- LUMC Curium-Department of Child and Adolescent Psychiatry, Leiden University Medical Center, Post Box 15, 2300 AA, Leiden, The Netherlands
| | - H van Ewijk
- LUMC Curium-Department of Child and Adolescent Psychiatry, Leiden University Medical Center, Post Box 15, 2300 AA, Leiden, The Netherlands
| | - L Nijland
- LUMC Curium-Department of Child and Adolescent Psychiatry, Leiden University Medical Center, Post Box 15, 2300 AA, Leiden, The Netherlands
| | - L A Nooteboom
- LUMC Curium-Department of Child and Adolescent Psychiatry, Leiden University Medical Center, Post Box 15, 2300 AA, Leiden, The Netherlands
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Becker KD, Chorpita BF. Future Directions in Youth and Family Treatment Engagement: Finishing the Bridge Between Science and Service. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY : THE OFFICIAL JOURNAL FOR THE SOCIETY OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY, AMERICAN PSYCHOLOGICAL ASSOCIATION, DIVISION 53 2023; 52:284-309. [PMID: 36787342 DOI: 10.1080/15374416.2023.2169926] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
The field has spent more than 50 years investing in the quality of youth mental healthcare, with intervention science yielding roughly 1,300 efficacious treatments. In the latter half of this period, concurrent efforts in implementation science have developed effective methods for supporting front-line service organizations and therapists to begin to bridge the science to service gap. However, many youths and families still do not benefit fully from these strategic investments due to low treatment engagement: nearly half of youths in need of services pursue them, and among those who do, roughly another half terminate prematurely. The negative impact of low engagement is substantial, and is disproportionally and inequitably so for many. We contend that to build a robust and "finished" bridge connecting science and service, the field must go beyond its two historical foci of designing interventions and preparing therapists to deliver them, to include an intentional focus on the youths and families who participate in these interventions and who work with those therapists. In this paper, we highlight the significance of treatment engagement in youth mental healthcare and discuss the current state of the literature related to four priorities: conceptualization, theory, measurement, and interventions. Next, we offer an example from our own program of research as one illustration for advancing these priorities. Finally, we propose recommendations to act on these priorities.
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Adherence, Competence, and Alliance as Predictors of Long-term Outcomes of Cognitive Behavioral Therapy for Youth Anxiety Disorders. Res Child Adolesc Psychopathol 2023; 51:761-773. [PMID: 36692616 DOI: 10.1007/s10802-023-01028-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2023] [Indexed: 01/25/2023]
Abstract
The present study investigated therapist adherence, therapist competence, and patient-therapist alliance as predictors of long-term outcomes of cognitive behavioral therapy (CBT) for anxiety disorders in youth. Potential differential effects for group versus individual CBT, for therapists with or without formal CBT training, and based on youth symptom severity were examined. Videotapes (n = 181) from treatment sessions in a randomized controlled effectiveness trial comprising youth (N = 170, M age = 11.6 years, SD = 2.1) with anxiety disorders were assessed for therapist adherence and competence. Alliance was rated by therapists and youth. Participants completed a diagnostic interview and an anxiety symptom measure at pre-treatment, post-treatment, one-year follow-up, and long-term follow-up (M = 3.9 years post-treatment, SD = 0.8, range = 2.2-5.9 years). The change in anxiety symptoms or diagnostic status from pre-treatment to long-term follow-up was not significantly related to any predictor variables. However, several interaction effects were found. For loss of principal diagnosis, therapist competence predicted positive outcome when therapist adherence also was high. Adherence was found to predict positive outcome if CBT was provided individually. Therapist-rated alliance was related to both loss of principal diagnosis and loss of all diagnoses when CBT was provided in groups. Interaction effects suggested that therapists displaying both high adherence and high competence produced better long-term outcomes. Further, the alliance may be particularly important for outcomes in group CBT, whereas adherence may be particularly important for outcomes in individual CBT.
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Casline E, Woodard G, Patel ZS, Phillips DA, Ehrenreich-May J, Ginsburg GS, Jensen-Doss A. Characterizing measurement-based care implementation using therapist report. EVIDENCE-BASED PRACTICE IN CHILD AND ADOLESCENT MENTAL HEALTH 2022; 8:549-559. [PMID: 38031580 PMCID: PMC10683951 DOI: 10.1080/23794925.2022.2124555] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
The effectiveness of measurement-based care (MBC), an evidence-based practice that uses regularly collected assessment data to guide clinical decision-making, is impacted by whether and how therapists use information from MBC tools in treatment. Improved characterization of how therapists use MBC in treatment sessions with youth is needed to guide implementation and understand variability in MBC effectiveness. To meet this need, this study examined therapists' sharing and discussion of MBC in treatment sessions. Thirty therapists were randomly assigned to the MBC condition as part of a comparative effectiveness trail of treatments for adolescent anxiety and depression. A qualitative content analysis was conducted on therapists' written explanations of changes made to the session based on the MBC data. Therapists reported sharing data with youth and caregivers in an average of 34.6% and 27.4% of sessions, respectively. Therapists reported incorporating MBC data in an average of 21.1% of sessions. When data were used, therapists predominately focused changes on short-term (e.g., current symptoms, treatment skill) rather than long-term (e.g., symptom progress, treatment goals) decision-making. Therapists inconsistently used MBC data, highlighting the need for improved training in and monitoring of how therapists use MBC in session to guide collaborative treatment decision-making with youth and caregivers.
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Affiliation(s)
| | - Grace Woodard
- University of Miami Department of Psychology, Coral Gables, FL, USA
| | - Zabin S. Patel
- University of Miami Department of Psychology, Coral Gables, FL, USA
| | | | | | - Golda S. Ginsburg
- University of Connecticut School of Medicine, Department of Psychiatry, Farmington, CT, USA
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Cecilione JL, Hitti SA, Vrana SR. Treating Adolescent Misophonia With Cognitive Behavioral Therapy: Considerations for Including Exposure. Clin Case Stud 2021. [DOI: 10.1177/15346501211045707] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although misophonia is not yet included in the primary diagnostic manuals used by psychologists or psychiatrists, proposed criteria suggest that this condition is characterized by a strong negative reaction to and avoidance of certain trigger sounds. Misophonic trigger sounds are largely human-made (e.g., chewing and slurping) and evoke responses such as disgust, irritation, and/or anger that are out of proportion to the situation and cause distress and/or impairment. Currently, there is no gold standard evidence-based treatment for misophonia. As the misophonia treatment literature grows, several important questions are arising: (1) should exposure to aversive sound triggers be included in treatment for misophonia and (2) how can clinicians best assess misophonia symptoms. This case offers one example of misophonia being successfully treated with a cognitive-behavioral approach to treatment (including exposures) in an adolescent girl. This case also offers an example of how clinicians may conduct a comprehensive assessment of misophonia symptoms. Theoretically and empirically derived recommendations for including exposure in misophonia treatment are presented. Information from this case may be helpful in informing future research, as there is a paucity of evidence-based assessment and treatment protocols for misophonia.
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Affiliation(s)
| | - Stephanie A. Hitti
- Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA
| | - Scott R. Vrana
- Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA
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Therapists’ Contributions to the Alliance in Home-Based Family Treatment: The Role of Alliance Building Behaviors, Personality, and Clinical Experience. CONTEMPORARY FAMILY THERAPY 2021. [DOI: 10.1007/s10591-021-09597-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AbstractAlliance is a robust contributor to the outcome of adult, youth, and family therapy, but little is known about therapists’ contributions to the alliance in conjoint family treatment. We investigated the predictive value of therapists’ personality, clinical experience and observed alliance building behaviors for mid-treatment alliance as reported by therapists and family members. Participants were 77 parents and 21 youth from 57 families receiving home-based family treatment from 33 therapists. Therapist openness to experience and agreeableness as well as therapists’ in-session engagement and emotional connection behaviors predicted more positive therapists’ and family members’ reports of the alliance. Therapist neuroticism, extraversion and conscientiousness predicted more negative alliance-reports. In-session safety behaviors also predicted more negative alliance-reports, but this finding was only significant for therapists’ and not family members’ reports of the alliance. Clinical experience did not predict quality of alliances. We conclude that training and supervision of family therapists could benefit from focusing on emotional connection with and active engagement of family members in treatment, and from increasing self-awareness of the impact of their personality on alliances with family members.
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