Lessons learned from psychotherapy research

Internet Gaming Disorder in Adolescents: Personality, Psychopathology and Evaluation of a Psychological Intervention Combined With Parent Psychoeducation

Internet Gaming Disorder is an increasingly prevalent disorder, which can have severe consequences in affected young people and in their families. There is an urgent need to improve existing treatment programs; these are currently hampered by the lack of research in this area. It is necessary to more carefully define the symptomatic, psychosocial and personality characterization of these patients and the interaction between treatment and relevant variables. The objectives of this study were three: (1) to analyze the symptomatic and personality profiles of young patients with Internet Gaming Disorder in comparison with healthy controls; (2) to analyze the effectiveness of a cognitive behavioral treatment on reducing symptomatology; and (3) to compare the results of that treatment with or without the addition of a psychoeducational group offered to the parents. The final sample consisted of 30 patients consecutively admitted to a specialized mental health unit in Spain, and 30 healthy controls. The experimental group received individual cognitive-behavioral therapy. The experimental group was divided into two subgroups (N = 15), depending on the addition or not of a psychoeducational group for their parents (consecutively admitted). Scores on the Millon Adolescent Personality Inventory (MACI), the Symptom Checklist-Revised (SCL-90-R), the State-Trait Anxiety Index (STAI), and other clinical and psychopathological measures were recorded. The patients were re-assessed post treatment (except for the MACI questionnaire). Compared with healthy controls, patients did not differ in symptomatology at baseline, but scored significantly higher in the personality scales: Introversive and Inhibited, and in the expressed concerns scales: Identity Confusion, Self-Devaluation, and Peer Insecurity and scored significantly lower in the Histrionic and Egotistic scale. In the experimental group, pre-post changes differed statistically on SCL-90-R scales Hostility, Psychoticism, and Global Severity Index and on the diagnostic criteria for Internet Gaming Disorder, regardless of the addition of a psychoeducational group for parents. Pre-post changes did not differ between experimental subgroups. However, the subgroup without psychoeducation for parents presented statistically higher drop-out rates during treatment. The results of this study are based on a sample of patients seeking treatment related to problems with online gaming, therefore, they may be of value for similar patients.

Advancing Analytic Approaches to Address Key Questions in Mechanisms of Behavior Change Research

OBJECTIVE

Interest in studying mechanisms of behavior change (MOBCs) in substance use disorder (SUD) treatments has grown considerably in the past two decades. Much of this work has focused on identifying which variables statistically mediate the effect of SUD treatments on clinical outcomes. However, a fuller conceptualization of MOBCs will require greater understanding of questions that extend beyond traditional mediation analysis, including better understanding of when MOBCs change during treatment, when they are most critical to aiding the initiation or maintenance of change, and how MOBCs themselves arise as a function of treatment processes.

METHOD

In the present study, we review why these MOBC-related questions are often minimally addressed in empirical research and provide examples of data analytic methods that may address these issues. We highlight several recent studies that have used such methods and discuss how these methods can provide unique theoretical insights and actionable clinical information.

RESULTS

Several statistical approaches can enhance the field's understanding of the timing and development of MOBCs, including growth-curve modeling, time-varying effect modeling, moderated mediation analysis, dynamic systems modeling, and simulation methods.

CONCLUSIONS

Adopting greater diversity in methods for modeling MOBCs will help researchers better understand the timing and development of key change variables and will expand the theoretical precision and clinical impact of MOBC research. Advances in research design, measurement, and technology are key to supporting these advances.

Client experiences of motivational interviewing: An interpersonal process recall study

OBJECTIVES

To explore clients' experience of the therapy process in motivational interviewing (MI) for alcohol abuse.

DESIGN

A qualitative study using grounded theory.

METHODS

Interviews with nine clients were conducted using interpersonal process recall (IPR), a methodology which utilizes a video recording as a cue to aid memory recall. Clients watched a videotape of their MI session and were asked to identify and describe the important moments in the therapy session. The transcribed interviews were then analysed using grounded theory.

RESULTS

A single session of MI is seen by the clients in this study as a complex interpersonal interaction between client and therapist, which impacts on the client's cognitive and affective intrapersonal processes.

CONCLUSIONS

The themes which emerged partly confirm processes of MI previously hypothesized to be important, but also highlight the importance of factors common to all therapeutic approaches.

PRACTITIONER POINTS

The aspects of therapy which clients in this study felt were important are similar to those hypothesized to underlie the effectiveness of MI, including a non-confrontational approach, affirmation, and developing discrepancies between beliefs and behaviour. These were embedded in aspects common to all therapies, including the qualities of the therapist and the therapeutic relationship. Client's perspectives on therapeutic processes are an important area of research, and IPR is a particularly suitable method.

Telephone-based continuing care counseling in substance abuse treatment: Economic analysis of a randomized trial

PURPOSE

To investigate whether telephone-based continuing care (TEL) is a promising alternative to traditional face-to-face counseling for clients in treatment for substance abuse.

METHODS

Patients with alcohol and/or cocaine dependence who had completed a 4-week intensive outpatient program were randomly assigned through urn randomization into one of three 12-week interventions: standard continuing care (STD), in-person relapse prevention (RP), or telephone-based continuing care (TEL). This study performed cost, cost-effectiveness, and cost-benefit analyses of TEL and RP compared to STD, using results from the randomized clinical trial with two years of follow up (359 participants). In addition, the study examined the potential moderating effect of baseline patient costs on economic outcomes.

RESULTS

The study found that TEL was less expensive per client from the societal perspective ($569) than STD ($870) or RP ($1684). TEL also was also significantly more effective, with an abstinence rate of 57.1% compared to 46.7% for STD (p<0.05). Thus TEL dominated STD, with a highly favorable negative incremental cost-effectiveness ratio (-$1400 per abstinent year). TEL also proved favorable under a benefit-cost perspective.

CONCLUSIONS

TEL proved to be a cost-effective and cost-beneficial contributor to long-term recovery over two years. Because TEL dominated STD care interventions, wider adoption should be considered.

"It sounds like...": A natural language processing approach to detecting counselor reflections in motivational interviewing

The dissemination and evaluation of evidence-based behavioral treatments for substance abuse problems rely on the evaluation of counselor interventions. In Motivational Interviewing (MI), a treatment that directs the therapist to utilize a particular linguistic style, proficiency is assessed via behavioral coding-a time consuming, nontechnological approach. Natural language processing techniques have the potential to scale up the evaluation of behavioral treatments such as MI. We present a novel computational approach to assessing components of MI, focusing on 1 specific counselor behavior-reflections, which are believed to be a critical MI ingredient. Using 57 sessions from 3 MI clinical trials, we automatically detected counselor reflections in a maximum entropy Markov modeling framework using the raw linguistic data derived from session transcripts. We achieved 93% recall, 90% specificity, and 73% precision. Results provide insight into the linguistic information used by coders to make ratings and demonstrate the feasibility of new computational approaches to scaling up the evaluation of behavioral treatments.

Active Ingredients of Treatment and Client Mechanisms of Change in Behavioral Treatments for Alcohol Use Disorders: Progress 10 Years Later

BACKGROUND

The current review revisits the article entitled: "Active Ingredients: How and Why Evidence-Based Alcohol Behavioral Treatment Interventions Work" published in Alcoholism: Clinical and Experimental Research. This work summarized proceedings from a 2004 Symposium of the same name that was held at the Annual Meeting of the Research Society on Alcoholism (RSA). A decade has passed, which provides occasion for an evaluation of progress. In 2014, an RSA symposium titled Active Treatment Ingredients and Client Mechanisms of Change in Behavioral Treatments for Alcohol Use Disorders: Progress 10 Years Later did just that.

METHODS

The current review revisits state-of-the-art research on the 3 treatments examined 10 years ago: cognitive behavioral therapy, alcohol behavior couples therapy, and 12-step facilitation. Because of its empirically validated effectiveness and robust research agenda on the study of process outcome, motivational interviewing has been selected as the fourth treatment modality to be discussed. For each of these 4 treatments, the reviewers provide a critical assessment of current theory and research with a special emphasis on key recommendations for the future.

RESULTS

Noteworthy progress has been made in identifying active ingredients of treatments and mechanisms of behavior change in these 4 behavioral interventions for alcohol and other drug use disorders. Not only have we established some of the mechanisms through which these evidence-based treatments work, but we have also uncovered some of the limitations in our existing frameworks and methods.

CONCLUSIONS

Further progress in this area will require a broader view with respect to conceptual frameworks, analytic methods, and measurement instrumentation.

Does exposure and response prevention improve the results of group cognitive-behavioural therapy for male slot machine pathological gamblers?

INTRODUCTION

Cognitive-behavioural therapy (CBT) seems to offer effective treatment for pathological gambling (PG). However, it has not yet been established which techniques yield the best results, or whether exposure and response prevention (ERP) techniques are of additional use.

OBJECTIVES

To evaluate clinical and socio-demographic characteristics of a PG sample at baseline, comparing cognitive-behavioural group intervention, with and without exposure, with response prevention (CBT + ERP vs. CBT), to compare the results of therapy and to assess pre-post changes in psychopathology between both groups.

DESIGN

We applied a quasi-experimental design comprising intervention on the independent variable, but without random assignment.

METHODS

The sample comprised 502 males with PG, consecutively admitted to a specialist unit, who received standardized outpatient CBT group therapy in 16 weekly sessions. Scores on the Symptom Checklist-Revised (SCL-90-R), the Temperament and Character Inventory-Revised (TCI-R), the South Oaks Gambling Screen (SOGS), and other clinical and psychopathological scales were recorded.

RESULTS

Pre-post changes did not differ between groups, except for SCL paranoid ideation, being greater in the CBT therapy group. The risk of relapse during treatment was similar in the CBT + ERP and CBT patients. However, compliance with treatment was poorer in the CBT + ERP group, who presented higher drop-out rates during treatment. Drop-out during therapy was associated with shorter disorder duration and higher scores on the TCI-R novelty seeking scale.

CONCLUSIONS

Although the two CBT programs elicited similar therapy responses, patients receiving CBT alone showed higher adherence to therapy and lower drop-out rates.

From in-session behaviors to drinking outcomes: a causal chain for motivational interviewing

Client speech in favor of change within motivational interviewing sessions has been linked to treatment outcomes, but a causal chain has not yet been demonstrated. Using a sequential behavioral coding system for client speech, the authors found that, at both the session and utterance levels, specific therapist behaviors predict client change talk. Further, a direct link from change talk to drinking outcomes was observed, and support was found for a mediational role for change talk between therapist behavior and client drinking outcomes. These data provide preliminary support for the proposed causal chain indicating that client speech within treatment sessions can be influenced by therapists, who can employ this influence to improve outcomes. Selective eliciting and reinforcement of change talk is proposed as a specific active ingredient of motivational interviewing.

[Addiction and brief-systemic therapy: working with compulsion]

In our daily practice in public hospitals, we are regularly confronted with the paradox of helping patients, who do not ask for help. Although the French law is clearly defined to allow us to treat patients suffering from psychiatric conditions, who are unable to give their consent, it is not the case for those with addictive disorders. In fact, their disorder does not always (or does not yet) justify treatment without their consent, according to the 1990 law (psychiatric treatment without the patient's consent). However, many of them are referred to us because a third party has forced them (spouse, general practitioner, treatment order) and even though some patients consult spontaneously, they often do so more "for others" than for themselves. Because of this, the therapist (doctor, psychologist or nurse), in addition to the paradox of treating patients who do not ask for treatment, find themselves in a situation with two-fold compulsion, fixed by the social (or family) setting, both as a helper and as a coercive agent, thus, putting the fundamental concepts of treatment into question. A therapeutic agreement, free-will and motivation are in jeopardy when the pressure is strong, which removes the therapist from his mission of treating. Although we would not question the necessity for psychiatric treatment in patients who do not ask for it (addictions are a major public-health problem), we should not forget that motivation is one of the essential elements for making any changes in behavior. Although compulsion (external or internal) is recognized by everyone as a limiting factor, we would like to show here how much it can be a lever for change, as long as this compulsion is identified right from the first meeting with the patient, who consults in an addiction centre. Brief systemic therapy may be of interest for these patients, since it reinforces the motivating approach, which is recommended today and since the compulsive nature of the request for treatment is not an obstacle for such treatment to be started. We try to outline here how the therapist can get out of this two-fold compulsion and help the patient to become the instigator of this change, often imposed on him. Two elements are fundamental to understand the function of brief systemic therapy. First of all, "systemic" means "interaction". A systemic approach to treatment requires working in clinical situations, particular attention being paid to interactions. Second, brief therapy does not mean short therapy, but rather therapy with an objective in view. The objective is determined by the patient together with the therapist and they work out together how to reach it, with or without the family's help. Because of this, we use a five-point assessment to offer a concrete response to the patients in these psychotherapeutic consultations. Firstly, is the patient the one who has asked for treatment? We know that in addictive behavior, it is not always the one with symptoms who asks for help (many couples consult who are persuaded that the other one needs to change). Once we know who has asked for treatment, we clarify (with the patient's help) that his/her objectives are not the same as someone who asks for treatment and we can then redefine them (first step in the therapeutic agreement). Once the request for treatment is clarified, we can clearly define what the problem is, the objectives that the patient fixes for him/herself and how to reach them. A large proportion of therapeutic failures result from the request for treatment being unclear. In this way, we define the problem in concrete terms, without using classifications and the previous attempts to solve it (third point). In fact, we often find that the problem itself is the solution, which is chosen to try to resolve it. Knowing which solutions have been tried (and failed) allows the patient to realize what is effective and what is not. The role of the therapist is to help the family and the patient to find other types of solution to their problem. The therapist only offers concrete tasks, which can be done in the near future (minimal changes). Finally, the therapist takes into account the patient's beliefs, values and personal priorities, to which they are attached and which have determined up to now, how they react to the problem. To work with a patient suffering from addiction, it is important, first of all, to find the elements of compulsion, which are hiding behind each request for treatment. This is because, if the patient does not follow the initial therapeutic objectives, there is always the underlying complaint, which should motivate the patient to improve the situation. An individual patient only has a few possibilities for adapting to this type of situation (agreeing, refusal or negotiation) and the role of the therapist is first of all to help him to realize this. This helps to avoid resistance developing, by underlying the compulsive aspect, which originates from the family's request for treatment. We offer a way for setting up the first meeting: working on the role of the patient in the treatment. Three types of patients consult: patients who are "not concerned" (sent by a third party; their main problem is with the person who asked for them to be treated), "victims" (they complain and consult because they put the responsibility of their problem on someone else) and "clients" (they consult because they consider that their problem depends on themselves and they want help to solve it actively). In fact, changing is not easy and does not happen without making an effort. Change comes from a complex cycle of interactions, for which it is often impossible to find a single origin for the situation in question. The psychological world tends towards homeostasis, just like all human systems, and so, suggesting making changes can only be experienced as an intrusion. Pathology begins when an individual can no longer choose what he/she needs to do. We do not consider that a brief-concrete approach is better than any other approach, but its pragmatic nature seems to fit in with the new conception of addiction therapy, with earlier intervention. However, is it possible to make changes outside of a crisis situation? We are unable to answer this question, except to say that the best time for change is that chosen by the patient.

Perspectives and future directions

BACKGROUND

Mechanisms of behavior change (MOBC) in treating drinking problems is a topic of growing importance.

METHODS

This article identifies salient themes presented in talks during the first Annual RSA Satellite on Mechanisms of Behavior Change in Alcoholism Treatment.

RESULTS

Themes focused on the need to move beyond a passive approach to identifying MOBC in alcoholism treatment and a number of conceptual and methodological advances were proposed.

CONCLUSIONS

While a consensus has emerged that more attention should be paid to MOBC in alcoholism treatment research, a subgroup of experts are calling for MOBC to be the primary focus in future efforts.