Common factors aren't so common: The common factors dilemma

Sampaio TP, Marçal L, Burdmann EA, Neto FL, Bernik MA. Inflammatory markers changes following acceptance-based behavioral psychotherapy in generalized anxiety disorder patients: Evidence from a randomized controlled trial

Introduction

Generalized anxiety disorder (GAD) has been associated with elevated levels of C-reactive protein (CRP) and proinflammatory cytokines. Despite robust evidence as an effective treatment for GAD, research on the effects of cognitive-behavioral therapies (CBT) in the inflammatory profile of patients with clinical anxiety has presented mixed results.

Objective

The present study aimed to investigate the effect of an acceptance-based behavior therapy (ABBT) on inflammatory biomarkers and their association with anxiety levels in GAD patients in comparison to supportive therapy as an active control.

Methods

Peripheral inflammatory biomarkers (CRP, IL-1β, IL-4, IL-6, IL-10, TNF-α) were measured in 77 GAD patients who participated in a 14-week 10-session randomized clinical trial of group ABBT (experimental, n = 37) or supportive group therapy (ST: active control group, n = 40).

Results

The concentrations of IL-1β decreased in the control group and the concentrations of IL-6 increased in the experimental group from baseline to post-treatment, whereas no difference was identified in IL-4, IL-10, TNF, or CRP. Although anxiety and depression levels decreased in both treatment conditions, no correlation with inflammation markers was found for most clinical and biological variables. A negative correlation between changes in IL-6 and IL-10 and anxiety symptom score changes was identified.

Conclusions

The present study results found that a short trial of acceptance-based behavior therapy did not change the proinflammatory profile which may be associated with GAD. Additional research is needed to evaluate the influence of other inflammation-related variables, longer periods of follow-up as well as the effect of supportive therapy on peripheral inflammatory biomarkers in GAD patients.

Waiting for a digital therapist: three challenges on the path to psychotherapy delivered by artificial intelligence

Growing demand for broadly accessible mental health care, together with the rapid development of new technologies, trigger discussions about the feasibility of psychotherapeutic interventions based on interactions with Conversational Artificial Intelligence (CAI). Many authors argue that while currently available CAI can be a useful supplement for human-delivered psychotherapy, it is not yet capable of delivering fully fledged psychotherapy on its own. The goal of this paper is to investigate what are the most important obstacles on our way to developing CAI systems capable of delivering psychotherapy in the future. To this end, we formulate and discuss three challenges central to this quest. Firstly, we might not be able to develop effective AI-based psychotherapy unless we deepen our understanding of what makes human-delivered psychotherapy effective. Secondly, assuming that it requires building a therapeutic relationship, it is not clear whether psychotherapy can be delivered by non-human agents. Thirdly, conducting psychotherapy might be a problem too complicated for narrow AI, i.e., AI proficient in dealing with only relatively simple and well-delineated tasks. If this is the case, we should not expect CAI to be capable of delivering fully-fledged psychotherapy until the so-called "general" or "human-like" AI is developed. While we believe that all these challenges can ultimately be overcome, we think that being mindful of them is crucial to ensure well-balanced and steady progress on our path to AI-based psychotherapy.

Patients' Experiences of Using an eHealth Pain Management Intervention Combined With Psychomotor Physiotherapy: Qualitative Study

Background

Chronic pain is a major health challenge to those affected. Blended care with psychomotor physiotherapy (PMP) combined with eHealth self-management might be beneficial.

Objective

This study aims to explore how patients with chronic pain experience the combination of PMP and the use of EPIO, an eHealth self-management intervention for chronic pain.

Methods

Individual semistructured interviews were conducted with 5 adult patients with chronic pain (ie, participants) who used EPIO in combination with PMP over a period of 10 to 15 weeks. Interviews explored participants’ experiences using this treatment combination in relation to their pain and analyzed their experiences using systematic text condensation.

Results

Participants described having benefited from using EPIO in combination with PMP in terms of increased awareness of bodily signals and how pain was related to stress and activity. They also described changes in the relationship to themselves in terms of increased self-acceptance, self-assertion, and hope and their relationship to their pain in terms of seeing pain as less harmful and engaging in more active coping strategies.

Conclusions

Results indicate that a blended care approach combining eHealth self-management interventions such as EPIO with PMP may be of value to patients living with chronic pain.

Trial Registration

ClinicalTrials.gov NCT03705104; https://clinicaltrials.gov/ct2/show/NCT03705104

Expert clinicians' prototypes of an adolescent treatment: Common and unique factors among four treatment models

To investigate (1) whether expert clinicians within psychodynamic therapy (PDT), mentalization-based treatment (MBT), cognitive-behavioral therapy (CBT), and interpersonal psychotherapy (IPT) agree on the essential adolescent psychotherapy processes using the Adolescent Psychotherapy Q-Set (APQ); (2) whether these four session prototypes can be empirically distinguished; and (3) whether mentalization is a shared component in expert clinicians' conceptualizations of these four treatment models.

Thirty-nine raters with expertize in PDT, MBT, CBT, and IPT provided ratings of the 100 APQ items to characterize a prototypical session that adheres to the principles of their treatment model. A Q-factor analysis with varimax rotation was conducted.

Expert clinicians reached a high level of agreement on their respective session prototypes, which loaded onto five independent factors. The PDT session prototype straddled two different factors, suggesting more variability in PDT expert clinicians' understanding of PDT process for adolescents than in the views of the expert clinicians representing the other treatment models. Mentalization process was shared among all four session prototypes; however, the correlation between the CBT and IPT session prototypes remained significant after controlling for the MBT session prototype.

Researchers can now assess adherence to four adolescent treatments and identify change processes beyond these labels.

Patients responses to diagnoses of mental disorders: Development and validation of a reliable self-report measure

OBJECTIVES

Psychiatric patients are regularly informed about diagnoses. Treatment guidelines assume that informing patients fosters functional coping processes, but few research exists on how patients respond. Thus, the objective was to develop a standardized self-report measure to assess patients reactions to diagnoses.

METHODS

Fifty nine items were generated based on a qualitative study. The process of item selection and determination of the factor structure were performed on a sample of 252 patients: Results of an explorative factor analysis with a randomly split sub-sample 1 were cross-validated by confirmatory factor analysis on sub-sample 2. The revised 26-item instrument was revaluated using data from an independent sample of 1.271 patients with different diagnoses.

RESULTS

Three functional and three dysfunctional processing styles emerged from the analyses and provided good model fit in the revaluation study (TLI = 0.935; CFI = 0.943; RMSEA = 0.051; SRMR = 0.048). Variance-analytical calculations and post hoc analyses revealed significant differences among diagnoses with regard to coping styles, such as schizophrenia was associated with self-stigmatization and anorexia nervosa showed pronounced over-identification. Overall, various diagnosis-dependent specifics were found.

CONCLUSIONS

As patients reactions to diagnoses vary substantially, their formation, impact on treatment and overall cause should be investigated in further studies.

MAGIC: a Proposed Model Based on Common Factors

The author offers an initial formulation of what an approach integrating common factors and the processes of change would look like. The dodo-verdict has been extant in the psychology literature for almost 100 years, and it is time to acknowledge the veracity of the dodo-bird verdict as we move toward therapeutic approaches focusing on factors the empirical approaches have in common. Although we now have hundreds of different theoretical models, no one model appears to be superior to any other. However, certain presenting conditions may be more suited to certain interventions. The MAGIC approach introduced here incorporates client motivation, the therapeutic alliance, goal-setting, implementation, and commitment. This gives us a basic structure of commonalities around which we will be able to build comprehensive psychotherapeutic strategies drawing on intervention techniques from many different models. After a brief consideration of historical factors, I will present one idea for an integrated approach followed by a discussion of some assumptive processes which are at work in the therapeutic cadre as well as a consideration of cultural diversities.

Socially transmitted placebo effects

Medical treatments typically occur in the context of a social interaction between healthcare providers and patients. Although decades of research have demonstrated that patients' expectations can dramatically affect treatment outcomes, less is known about the influence of providers' expectations. Here we systematically manipulated providers' expectations in a simulated clinical interaction involving administration of thermal pain and found that patients' subjective experiences of pain were directly modulated by providers' expectations of treatment success, as reflected in the patients' subjective ratings, skin conductance responses and facial expression behaviours. The belief manipulation also affected patients' perceptions of providers' empathy during the pain procedure and manifested as subtle changes in providers' facial expression behaviours during the clinical interaction. Importantly, these findings were replicated in two more independent samples. Together, our results provide evidence of a socially transmitted placebo effect, highlighting how healthcare providers' behaviour and cognitive mindsets can affect clinical interactions.

Mindfulness-Based Cognitive Therapy Experiences in Youth With Inflammatory Bowel Disease and Depression: Protocol for a Mixed Methods Qualitative Study

BACKGROUND

Mindfulness-based programs are increasingly used as a part of integrated treatment for inflammatory bowel disease (IBD). However, the majority of research has been quantitative with limited qualitative exploration of patients' experiences of mindfulness programs and no studies among adolescents and young adults with IBD. Furthermore, there has been a paucity of research exploring the role of common psychotherapy and group factors within mindfulness programs.

OBJECTIVE

This study aims to explore the experiences of adolescents and young adults with IBD and depression who completed a mindfulness-based cognitive therapy (MBCT) group program, as well as the role of therapeutic alliance, group affiliation, and other common psychotherapy and group factors.

METHODS

This mixed methods qualitative study, nested within a randomized controlled trial (RCT) of MBCT for adolescents and young adults with IBD, will obtain qualitative data from focus groups and open-ended survey questions. The study aims to conduct three to four focus groups with 6-8 participants in each group. It will employ data and investigator triangulation as well as thematic analysis of the qualitative data.

RESULTS

The study was approved by the Mater Hospital Human Research Ethics Committee and recruitment commenced in May 2019; study completion is anticipated by early 2020.

CONCLUSIONS

The study will contribute to the assessment of acceptability and feasibility of the MBCT program for adolescents and young adults with IBD. It will also elucidate the role of previously unexplored common psychotherapy and group factors within mindfulness training and help inform the design of a future large-scale RCT of MBCT in this cohort.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12617000876392; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373115.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/14432.

Are Complex Psychotherapies More Effective than Biofeedback, Progressive Muscle Relaxation, or Both? A Meta-Analysis

A meta-analysis of 26 studies was conducted to assess whether more complex forms of psychotherapy would be superior to control treatments of either biofeedback, progressive muscle relaxation, or both. Consistent with hypotheses, more complex treatments provided a small, significant improvement over biofeedback and progressive muscle relaxation ( r = .09). A subset of the more complex behavioral treatments accounted for most of this small incremental effectiveness of more complex treatments ( r = .15). Possible sources of this incremental effectiveness are discussed.

Evidence-Based Practice:

A consensus has long existed that the scientist-practitioner model has failed to reflect what was envisioned by the Boulder Conference participants and endorsed by counseling psychology at the Greyston and Georgia Conferences. Counseling psychology's commitment, however, to the scientist-practitioner model has not faltered. Furthermore, developments within the health care system (e.g., managed care, empirically validated treatments, treatment guidelines) demand from psychologists increasing levels of scientific knowledge and a wider range of research skills. Psychology's current commitment to positivist explanation , scientific knowledge characterized by law-governed causal processes, is at the core of the scientist-practitioner split. To integrate scientist-practitioner ideals into a comprehensive approach to counseling psychology training, research, and practice, counseling psychologists should embrace an identity as evidence- based practitioners. Inherent in this framework is a philosophical, scientific, political, and social shift toward an expanded view of what constitutes scientific evidence.

Reaffirming the Unique Identity of Counseling Psychology:

Chwalisz's (2003 [this issue])call to adopt the evidence-based practice model provides an opportunity for counseling psychologists to reexamine both their commitment to the scientist-practitioner model and their unique professional identity. In this reaction, the author offers her critique of several assumptions underlying the evidence-based approach and presents her position that a shift to the evidence-based worldview would move the field further away from its roots as a specialty, including its particular commitment to prevention, multiculturalism, and social justice. A set of standards or competencies to advance counseling psychologists' commitments to a prevention-oriented, social justice approach is needed to guide counseling training, practice, and research. In addition, significant barriers to the implementation of a prevention-oriented agenda in counseling psychology will need to be overcome.

Expert clinicians' prototypes of an ideal child treatment in psychodynamic and cognitive-behavioral therapy: Is mentalization seen as a common process factor?

OBJECTIVE

To investigate (a) whether expert clinicians within psychodynamic therapy (PDT) and cognitive-behavioral therapy (CBT) agree on key features of child psychotherapy process using the Child Psychotherapy Process Q-Set (CPQ); (b) whether these two prototypes can be empirically distinguished; and (c) whether promoting mentalization (operationalized as reflective functioning [RF]) is a shared component of the way expert clinicians conceptualize these two treatment models.

METHOD

Thirty-one raters with expertise in PDT, CBT, and RF provided ratings of the 100 CPQ items to describe an ideal prototype session that adheres to the principles of their treatment model. Two Q-factor analyses with varimax rotation were conducted.

RESULTS

Expert clinicians reached a high level of agreement on their respective PDT and CBT prototypes. These prototypes loaded onto two independent factors. The RF process prototype loaded onto both factors.

CONCLUSIONS

From the theoretical perspective of expert clinicians representing PDT and CBT, a focus on RF appears to be a common process factor in the way both treatment models are conceptualized. The CPQ can also be a useful instrument in teaching psychotherapy process from different theoretical perspectives and training future clinicians in their application. Future researchers can use these prototypes to explore process in actual sessions.

A longitudinal study of the working relationship and return to work: perceptions by clients and occupational therapists in primary health care

BACKGROUND

The working relationship between client and therapist can be important to enhance outcomes from vocational rehabilitation for women with stress-related disorders in primary health care. The aim was to investigate the working relationship, as perceived by clients and therapists in the Redesigning Daily Occupations (ReDO™) program, and its relationships to return to work and satisfaction with the rehabilitation. Another aim was to compare the ReDO™ group and a "care-as-usual" (CAU) group regarding perceptions of the working relationship with the social insurance officer.

METHOD

Forty-two ReDO™ clients and 42 matched controls receiving CAU participated. The study included four measurements (baseline, after 16 weeks rehabilitation and follow-ups after 6 and 12 months). 37 + 37 clients completed. Return to work data was obtained from the Social Insurance Offices (SIO), and the working relationship and client satisfaction were assessed by self-report questionnaires.

RESULTS

The clients rated the working relationship higher than the therapists (mean rating 101.1 vs. 93.9; p < 0.001). The therapists' rating showed a statistically significant association with return to work at the 12-month follow-up, and the clients' perceptions were statistically significantly related to how they rated satisfaction with the rehabilitation received. The ReDO™ and the CAU groups did not differ regarding how they rated the relationship with the SIO officer (mean ratings 83.9 vs. 77; p = 0.189). The working relationship with the SIO officer was not related to return to work, but an association (rs = 0.70, p < 0.001) to client satisfaction at 16 weeks appeared in the CAU group alone.

CONCLUSION

The working relationship as perceived by clients and therapists seemed to be partly separate phenomena, the client perceptions being linked with satisfaction with the rehabilitation and the therapist perceptions with the clients' return to work. The relationship to the SIO officers was of no importance to return to work but was of some significance for satisfaction with the rehabilitation among the CAU clients. Therapists should strive to improve the relationship with clients to whom they feel the relationship is fragile since that might enhance the chances for those clients to return to work.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov (identifier NCT01234961) 2 November 2010.

Universal Preventive Interventions for Children in the Context of Disasters and Terrorism

This review addresses universal disaster and terrorism services and preventive interventions delivered to children before and after an event. The article describes the organization and structure of services used to meet the needs of children in the general population (practice applications), examines screening and intervention approaches (tools for practice), and suggests future directions for the field. A literature search identified 17 empirical studies that were analyzed to examine the timing and setting of intervention delivery, providers, conditions addressed and outcomes, and intervention approaches and components.

Dimensions of personality and personality pathology: factor structure of the Shedler-Westen assessment procedure-II (SWAP-II)

Researchers have proposed replacing the current system for diagnosing personality disorders with a dimensional trait model. Proposed trait models have been derived primarily from data provided by untrained lay informants (often via self-report questionnaires) using item sets derived from lay conceptions of personality. An alternative is to derive personality trait dimensions from data provided by clinically expert informants using an instrument that includes personality features salient to clinicians who treat personality dysfunction. The authors report the factor structure of the latest edition of the Shedler-Westen Assessment Procedure (SWAP-II) using a normative clinical sample of 1,201 North American patients assessed by experienced psychologists and psychiatrists. Factor analysis identified 14 clinically and empirically coherent factors. The findings highlight dimensions of personality and personality pathology that have not emerged in personality item sets designed for lay personality description.

Mental health interventions for children exposed to disasters and terrorism

OBJECTIVE

The purpose of this review is to describe interventions used with children who are exposed to disasters and terrorism and to present information about the potential benefits of these interventions.

METHODS

A literature search conducted in January 2013 using relevant databases and literature known to the authors that was not generated by the search yielded a total of 85 studies appropriate for review.

RESULTS

Intervention approaches used with children exposed to disasters and terrorism included preparedness interventions, psychological first aid, psychological debriefing, psychoeducation, cognitive behavioral techniques, exposure and narrative techniques, eye movement desensitization and reprocessing, and traumatic grief interventions. The investigation of these interventions is complex, and studies varied in methodological rigor (e.g., sample size, the use of control groups, outcomes measured).

CONCLUSIONS

Given the limitations in the currently available empirical information, this review integrates the literature, draws tentative conclusions about the current state of knowledge, and suggests future directions for study.

Research methodology used in studies of child disaster mental health interventions for posttraumatic stress

OBJECTIVE

In the last decade, the development of community-based and clinical interventions to assist children and adolescents after a disaster has become an international priority. Clinicians and researchers have begun to scientifically evaluate these interventions despite challenging conditions. The objective of this study was to conduct a systematic review of the research methodology used in studies of child disaster mental health interventions for posttraumatic stress.

METHOD

This scientifically rigorous analysis used standards for methodological rigor of psychosocial treatments for posttraumatic stress disorder (PTSD) to examine 29 intervention studies.

RESULTS

This analysis revealed that further refinement of methodology is needed to determine if certain intervention approaches are superior to other approaches and if they provide benefit beyond natural recovery. Most studies (93.1%) clearly described the interventions being tested or used manuals to guide application and most (89.7%) used standardized instruments to measure outcomes, and many used random assignment (69.0%) and provided assessor training (65.5%). Fewer studies used blinded assessment (44.8%) or measured treatment adherence (48.3%), and sample size in most studies (82.8%) was not adequate to detect small effects generally expected when comparing two active interventions. Moreover, it is unclear what constitutes meaningful change in relation to treatment especially for the numerous interventions administered to children in the general population.

CONCLUSIONS

Overall, the results are inconclusive about which children, what settings, and what approaches are most likely to be beneficial.

The role of therapist activity in psychodynamic psychotherapy

The teaching of psychodynamic psychotherapy is a critical component of psychiatric residency training programs. The authors argue that encouraging our residents to become active while providing psychodynamic psychotherapy is a skill that can be taught. By helping residents to understand how to actively help patients focus on their internal world, identify and work with the defenses, and develop and maintain a treatment alliance, psychodynamic educators can enable psychiatric residents to feel far more competent when working in this paradigm. Such a stance inevitably leads to greater excitement and enjoyment for trainees, as well as better outcomes for patients.

Wirkfaktoren der Psychotherapie – eine Übersicht und Standortbestimmung

Zusammenfassung.Psychotherapie wirkt. Wie, ist weitgehend unklar. Vor dem Hintergrund der Kontroverse über die unterschiedliche Wirksamkeit verschiedener Psychotherapieansätze haben sich zwei gegensätzliche Vorstellungen darüber entwickelt, was Psychotherapie wirksam macht: Vertreter der Sichtweise, dass zwischen verschiedenen Psychotherapierichtungen nur geringe Wirkunterschiede bestehen, führen die Wirksamkeit von Psychotherapie auf allgemeine Wirkfaktoren zurück. Befürworter empirisch fundierter Psychotherapieansätze gehen dagegen von verfahren- oder störungsspezifischen Wirkfaktoren aus. Mit dem Wirkfaktorenbegriff sowie der dichotomen Gegenüberstellung der zwei Arten von Wirkfaktoren sind jedoch eine Reihe terminologischer und konzeptueller Schwierigkeiten verbunden: Es liegt keine klare und einheitliche Definition des Wirkfaktorenbegriffs vor; Wirkfaktoren können außerdem verschiedensten Ebenen des Therapieprozesses zugeordnet werden. Die begrifflichen Unklarheiten, das Ebenenproblem sowie die Befundlage stellen die Dichotomie in Frage. Konzeptuell angemessener erscheint eine Perspektive, die spezifische und allgemeine Wirkfaktoren in ihrer synergistischen Wirkung sowie ihrem Zusammenspiel mit Störungsparametern und individuellen Patientenmerkmalen betrachtet.

Experimentelle Konstruktion eines Kurzfragebogens zur direkten Veränderungsmessung psychotherapeutischer Effekte im Befinden

Zusammenfassung. Befunde aus zwei Studien zur Entwicklung eines Kurzinstruments zur direkten Veränderungsmessung psychotherapeutischer Effekte werden dargestellt. Die Fragebogenkonstruktion fokussiert Veränderungen im Bereich des Befindens. An Studie I waren 150 Patienten von 14 niedergelassenen Psychotherapeuten beteiligt. Sie wurden nach dem Zufall einer Therapie- oder einer Wartelistekontrollgruppe zugewiesen. Nach dreimonatiger Psychotherapie bzw. Wartezeit beantworteten alle den aus zwölf Komparativaussagen bestehenden „Veränderungsfragebogen zum Entspannungserleben und Befinden – Psychotherapie” (VFE-PT). Die Änderungssensivität des Kurzfragebogens für Psychotherapieeffekte wird im Vergleich zur unbehandelten Kontrollgruppe auf Item- und Skalenniveau empirisch bestätigt. Studie II folgt einem naturalistischen Design, nach dem 275 erwachsene ambulante Patienten den VFE-PT 12 bis 20 Wochen nach Therapiebeginn ausgefüllt haben. Die Befunde bestätigen die guten Itemparameter und interne Konsistenz des Verfahrens. Die konvergente Validität des VFE-PT wird durch bedeutsame Korrelationen zu Indikatoren klinisch relevanter Veränderungen aus der indirekten Veränderungsmessung bestätigt.

Braking the bandwagon: scrutinizing the science and politics of empirically supported therapies

Proponents of empirically supported therapies (ESTs) argue that because manualized ESTs have demonstrated efficacy in treating a range of psychological disorders, they should be the treatments of choice. In this article, the author uses a hypothetical treatment for obesity to highlight numerous flaws in EST logic and argues for common factors as a more clinically relevant but empirically challenging approach. The author then explores how political variables may be contributing to the expansion of EST and the resulting restriction of practitioner autonomy. Last, the author argues that EST is best viewed as 1 component of a more comprehensive evidence-based practice framework. The author concludes with some cautionary statements about the perils of equating the EST paradigm with the scientist-practitioner ideal.

A qualitative study of the acceptability of an intensive format for the delivery of cognitive-behavioural therapy for obsessive-compulsive disorder

OBJECTIVES

An intensive format may be both useful and effective for the delivery of cognitive-behavioural therapy (CBT) for obsessive-compulsive disorder (OCD). However, the acceptability of an intensive treatment format from the perspective of service users is unknown. This study examines service user perspectives on the acceptability of an intensive versus a standard weekly treatment format.

DESIGN

The study comprises a detailed comparative qualitative analysis of the perspectives of service users who have completed either intensive or weekly CBT for OCD.

METHODS

Six treatment completers in each format (matched for age, gender, and symptom changeover the course of treatment) were asked to reflect on helpful and problematic aspects of their treatment format, and to consider the differences between treatment formats. The interviews were transcribed and analysed in detail using thematic analysis.

RESULTS

Individual differences were apparent in preference for treatment format. Weekly treatment completers were concerned that intensive treatment could be overwhelming or too brief for real change to take place. However, intensive treatment completers valued the high pressure and pace and felt that it improved motivation, engagement, and eventual outcome.

CONCLUSION

An intensive treatment format for the delivery of CBT for OCD can be highly motivating and acceptable to service users who have chosen to undertake it. Good quality follow-up and crisis support may be particularly important following intensive treatment.

Psychotherapy research at the start of the 21st century: the persistence of the art versus science controversy

This article offers an overview of prominent general trends in the field of psychotherapy research. We consider 3 areas of the literature: metaanalytic reviews addressing the effectiveness of psychotherapy, the movement to identify empirically supported treatments (EST), and research on the "common factor" or "contextual" models of psychotherapy. We present narrative reviews of selected literature associated with each area. The reviews highlight several issues currently confronting the field. Metaanalytic reviews underscore 2 conclusions: psychotherapy is superior to the absence of treatment, and different approaches to psychotherapy yield equivalent effects. In counterpoint to these findings, the EST movement emphasizes the empirical demonstration that specific psychotherapies have efficacy for specific disorders. Misinterpretation of EST findings has led to considerable controversy. Although EST research can identify causal effects of therapy, it has less capacity to explain how these effects come about. We suggest an appropriate perspective on EST findings. Considerable evidence supports the importance of common factors as mechanisms of change; at present, however, this evidence is predominantly correlational. We conclude that a blending of EST studies and research on the common factors represents the greatest potential for advancing the field. Studies to identify specific ESTs are key to validating the efficacy of psychotherapy approaches and need to be undertaken with the psychodynamic and experiential therapies. Greater emphasis on common factors in research, training, and practice can advance understanding about change processes in efficacious therapies, facilitate the development of sensitive clinicians, and increase the effectiveness of mental health services.

Four eras of study of college student suicide in the United States: 1920-2004

Studies of college student suicide can be grouped into the following 4 eras: 1920-1960, 1960-1980, 1980-1990, and 1990-2004. The suicide rate for students has declined monotonically across these 4 eras, from 13.4 to 8.0 to 7.5 and, most recently, to 6.5. The decreasing proportion of men in the student populations studied largely accounts for this decline. Since 1960, the suicide rate for students has consistently been about half the rate of the general US population, matched for age and gender. This highly favorable relative suicide rate is the result of firearms having been effectively banned from campuses. Additional population-oriented approaches warrant implementation to further reduce student-suicide rates. Approaches focused on high-risk groups also hold promise. These findings are based upon and may be most valid for the 70% of all students who attend 4-year colleges and universities full time.

Evidence-based practice in psychology

The evidence-based practice movement has become an important feature of health care systems and health care policy. Within this context, the APA 2005 Presidential Task Force on Evidence-Based Practice defines and discusses evidence-based practice in psychology (EBPP). In an integration of science and practice, the Task Force's report describes psychology's fundamental commitment to sophisticated EBPP and takes into account the full range of evidence psychologists and policymakers must consider. Research, clinical expertise, and patient characteristics are all supported as relevant to good outcomes. EBPP promotes effective psychological practice and enhances public health by applying empirically supported principles of psychological assessment, case formulation, therapeutic relationship, and intervention. The report provides a rationale for and expanded discussion of the EBPP policy statement that was developed by the Task Force and adopted as association policy by the APA Council of Representatives in August 2005.

Treatment Expectancy Affects the Outcome of Cognitive-Behavioral Interventions in Chronic Pain

Patients' initial beliefs about the success of a given pain treatment are shown to have an important influence on the final treatment outcome. The aims of the paper are to assess determinants of patients' treatment expectancy and to examine the extent to which treatment expectancy predicts the short-term and long-term outcome of cognitive-behavioral treatment of chronic pain. This study employs the data of 2 pooled randomized clinical trials evaluating the effectiveness of cognitive-behavioral interventions for 171 patients with fibromyalgia and chronic low back pain. Pretreatment and posttreatment expectancy were measured by a short questionnaire, which was based on the procedure by Borkovec and Nau. Four composite outcome variables (pain coping and control, motoric behavior, negative affect, and quality of life) were measured before and after the intervention and at 12 months follow-up. Furthermore, several patient characteristics were taken into account. Patients with higher treatment expectancies significantly received less disability compensation and were less fearful. A regression model of 3 factors (better pain coping and control, active and positive interpretation of pain, and less disability compensation) significantly explained 10% of the variance in pretreatment expectancy. Pretreatment expectancy significantly predicted each of the 4 outcome measures immediately after treatment and at 12 months follow-up. This study corroborates the importance of treatment expectation before entering a cognitive-behavioral intervention in patients with chronic musculoskeletal pain.

The empirical status of empirically supported psychotherapies: assumptions, findings, and reporting in controlled clinical trials

This article provides a critical review of the assumptions and findings of studies used to establish psychotherapies as empirically supported. The attempt to identify empirically supported therapies (ESTs) imposes particular assumptions on the use of randomized controlled trial (RCT) methodology that appear to be valid for some disorders and treatments (notably exposure-based treatments of specific anxiety symptoms) but substantially violated for others. Meta-analytic studies support a more nuanced view of treatment efficacy than implied by a dichotomous judgment of supported versus unsupported. The authors recommend changes in reporting practices to maximize the clinical utility of RCTs, describe alternative methodologies that may be useful when the assumptions underlying EST methodology are violated, and suggest a shift from validating treatment packages to testing intervention strategies and theories of change that clinicians can integrate into empirically informed therapies.

Common factors and our sacred models

In this article we argue that much of what makes one treatment effective is common to other forms of effective treatment--both in psychotherapy generally and in marital and family therapy (MFT) specifically. Yet MFT has largely ignored the research on common factors. In this article we present a moderate view of common factors that, while repudiating the extreme position that there is no difference among treatment models, stresses that there are common factors and mechanisms of change that undergird most forms of successful treatment. These common mechanisms of change should be given more attention in our field, which has tended to emphasize the uniqueness of our sacred models. We delineate some of the major common factors, review the empirical evidence for them, and discuss implications of adapting a common factors informed approach to family therapy.