Individual psychotherapy outcome and process research: challenges leading to greater turmoil or a positive transition?

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.

Client Perspectives on what Contributes to Symptom Relief in Psychotherapy: A Qualitative Outcome Study

Assessing psychotherapy outcome with post-therapy questionnaires and self-report instruments does not adequately capture the richness and complexity of change during psychotherapy and relies too heavily on quantitative analysis. This qualitative study explored the lived experience of symptom relief in psychotherapy as perceived by client participants and treats their subjective accounts as credible data. The scientific phenomenological method developed by A. Giorgi was used to conduct in-depth interviews with 3 participants who experienced symptom relief during the course of psychotherapy.

A Cluster-Analytic Investigation of Subtypes of Adult Career Counseling Clients: Toward a Taxonomy of Career Problems

Two hundred and seventy-eight adults who ranged in age from 18 to 69 years and were voluntarily in career counseling completed measures pre- and postcounseling to assess career-related variables (e.g., vocational identity) and psychological issues that may affect career concerns (e.g., level of psychological distress). Participant-clients received 1 to 14 sessions of individual career counseling, according to the need of each participant. The counselors were trained to use a holistic method of career counseling that emphasized the importance of considering career and psychosocial concerns together in working with the client. Using cluster analysis, four distinct types of career counseling clients were identified that provides an initial taxonomy of career problems with adult career clients. Pre- and postcounseling differences among clusters were examined. Implications of the findings for career counseling practice and further research are discussed.

Is reduction in pain catastrophizing a therapeutic mechanism specific to cognitive-behavioral therapy for chronic pain?

Mechanisms underlying favorable outcomes of psychosocial interventions for chronic pain are unclear. Theory suggests changes in maladaptive cognitions represent therapeutic mechanisms specific to cognitive-behavioral therapy (CBT). We illustrate the importance of examining whether treatments work either uniquely via mechanisms specified by theory or via mechanisms common to different treatments. Secondary data analysis was conducted to examine the effects of reduction in pain catastrophizing on outcomes following CBT and Pain Education. Generally, reductions in pain catastrophizing were significantly related to outcome improvements irrespective of CBT or Pain Education condition. Results underscore the need to assess whether mechanisms presumed to operate specifically in one treatment do indeed predict outcomes and illustrate the importance of broadening the assessment of mechanisms beyond those specified by theory. Theory-specific, competing, and common mechanisms must all be assessed to determine why our treatments work.

Cell phone-supported cognitive behavioural therapy for anxiety disorders: a protocol for effectiveness studies in frontline settings

Background

Reviews of randomized controlled trials (RCTs) of cognitive behavioural therapy (CBT) for anxiety disorders have reported large pre- to post-treatment within-group effect sizes on measures of anxiety when supplied in therapist consultations and in technology-supported settings. However, the stringent experimental control of RCTs results in a lack of external validity, which limits the generalizability of findings to real-world frontline clinical practice. We set out to examine the specification of a protocol for study of the effectiveness of cell phone-supported CBT for in situ management of anxiety disorders.

Methods and design

Nominal group methods were used for requirements analysis and protocol design. Making a distinction between different forms of technology-supported therapy, examination of therapists' role, and implementing trials in existing organizational and community contexts were found to be the central requirements in the protocol.

Discussion

The resulting protocol (NCT01205191 at clinicaltrials.gov) for use in frontline clinical practice in which effectiveness, adherence, and the role of the therapists are analyzed, provides evidence for what are truly valuable cell phone-supported CBT treatments and guidance for the broader introduction of CBT in health services.

Culture and Empirically Supported Treatments: On the Road to a Collision?

The dual influence of culturally sensitive therapies (CSTs) and empirically supported treatments (ESTs) on clinical practitioners has grown quickly in the United States. While CST advocates have been driven by the need to provide culturally diverse populations with services that are consistent with their cultural characteristics, practitioners of ESTs have striven to empirically demonstrate the benefits of psychotherapy. However, as EST's influence grows, it may increasingly threaten CST's advances. Some assumptions underlying the development of ESTs are not culturally sensitive and can be detrimental to the well-being of culturally diverse patients. This article highlights these assumptions in four interrelated areas and provides suggestions to overcome these shortcomings. Cultural assumptions and methodological implications of ESTs are presented, as well as some suggestions on how to broaden their cultural understandings. To conclude, some general recommendations on how to start bridging the gap between ESTs and CSTs are proposed.

Some methodological and statistical issues in the study of change processes in psychotherapy

As the number of psychotherapies with demonstrated efficacy accumulates, an important task is to identify principles and processes of change. This information can guide treatment refinement, integration, and future development. However, the standard randomized control trial (RCT) design can limit the questions that can be asked and the statistical analyses that can be conducted. We discuss the importance of examining the shape of change, in addition to the importance of identifying mediators and moderators of change. We suggest methodological considerations for longitudinal data collection that can improve the kinds of therapy process questions that can be examined. We also review some data analytic approaches that are being used in other areas of psychology that have the potential to capture the complexity and dynamics of change in psychotherapy.

Evidence-Based Services in a Statewide Public Mental Health System: Do the Services Fit the Problems?

This study examined the degree to which a literature review of evidence-based services identified services appropriate for the actual problems of youth involved in intensive public mental health services. The diagnostic profiles and specific intervention targets reported by treatment providers were coded to determine whether a relevant empirically supported treatment was identified in the literature by the Hawaii Evidence-Based Services Committee for each problem. Of the 2,197 youth with diagnostic information available, 721 youth (33%) had a pure diagnosis for which an evidence-based service was identified in the literature, and 1,953 youth (89%) had a primary diagnosis with a relevant evidence-based service. Of the 1,220 youth with treatment target information, 1,094 (90%) had 1 or more problem areas targeted for intervention with an identified evidence-based service; thus, the vast majority of youth receiving intensive public mental services experienced a mental health difficulty for which an evidence-based service was identified through a review of the empirical literature. Nevertheless, many youth had additional problems for which evidence-based services have not yet been identified through research.

Eficácia psicoterapêutica: terapia de família e o efeito "Dodô"

Este trabalho tem por objetivo rever, de modo crítico, os estudos sobre eficácia psicoterapêutica dos modelos e das escolas de terapia em geral e de terapia de família em particular, desenvolvidos sobretudo nos EUA. Discute-se o desenvolvimento do conceito de eficácia psicoterapêutica. Aborda-se o impacto da hipótese "Dodô" (Luborsky, Singer & Luborsky, 1975), que se refere à similitude de resultados dos métodos psicoterapêuticos. São revistos os resultados de estudos meta-estatísticos e discutidas suas implicações epistemológicas e metodológicas, relacionando-as com o desenvolvimento do campo da psicoterapia. Constata-se a necessidade do desenvolvimento de pesquisas que envolvam métodos mistos, quantitativos e qualitativos.

Our-component model for counseling clients with traumatic childhood abuse

To treat the effects of traumatic childhood abuse effectively, we propose a model which incorporates information from neurophysiological, psychoeducational, cognitive, and social work literature. The four components of the model reflect the broad range of explanations for pathology posed by researchers and also support the breadth of interventions available for use with survivors of childhood abuse. The model relies on individualized assessment and treatment related to the physiological response to abuse, faulty learning, cognitive and psychological problems, and social effects of abuse. This model contributes to the literature by providing a comprehensive framework complementary to many theoretical orientations, is useful across the helping disciplines, and appropriate in multidisciplinary settings.

The prevalence and impact of large sudden improvements during adolescent therapy for depression: a comparison across cognitive-behavioral, family, and supportive therapy

This study assessed the treatment specificity and impact on outcome of large, abrupt symptomatic improvements occurring prior to and during cognitive-behavioral, family, and supportive therapy. Eighty-seven depressed adolescents receiving at least 8 therapy sessions were included. Abrupt large decreases in depressive symptoms were identified by changes in weekly Beck Depression Inventory scores. Overall, 28% experienced a pretreatment gain and 39% a sudden within-treatment gain. Both types of gains were associated with superior outcome on self-report and interviewer ratings of depression. Among those participants failing to experience a pretreatment or sudden within-treatment gain, cognitive-behavioral therapy produced the superior outcomes. These findings suggest pretreatment and sudden within-treatment gains are important therapeutic events worthy of further investigation.

What kind of research can we realistically expect from the practitioner?

This article attempts to revitalize the scientist-practitioner model of psychotherapy by focusing on the research component of the model. Specifically, it takes a realistic look at the types of research that can be conducted by clinicians in an effort to motivate them to engage regularly in clinical research. Towards this end, five experienced scientist-practitioners explore the advantages, disadvantages, and potential of practitioner-initiated research. The problems and solutions for such research are discussed, and recommendations are offered.

Prediction of dose-response relations based on patient characteristics

The recent discussion of evidence-based, adaptive treatment planning highlights the need for models for the prediction of courses of treatment response. We combine a dose-response model with growth curve modeling to determine dose-response relations for well-being, symptoms, and functioning. Hierarchical linear modeling was used to model each patient's expected course of improvement. The resulting predictions were cross-validated on two samples of psychotherapy outpatients. The results give further empirical support for the dose-response model and the phase model of psychotherapy as well as for the usefulness of patient treatment response profiling for individual treatment management.

Responses to nervous breakdowns in America over a 40-year period. Mental health policy implications

The 1957 and 1976 Americans View Their Mental Health surveys from the Institute of Social Research were partially replicated in the 1996 General Social Survey (GSS) to examine the policy implications of people's responses to feeling an impending nervous breakdown. Questions about problems in modern living were added to the GSS to provide a profile of the public's view of mental health problems. Results were compared for 1957, 1976, and 1996. In 1957, 19% of respondents had experienced an impending nervous breakdown; in 1996, 26% had had this experience. Between 1957 and 1996, participants increased their use of informal social supports, decreased their use of physicians, and increased their use of nonmedical mental health professionals. These findings support policies that strengthen informal support seeking and access to effective psychosocial treatments rather than current mental health reimbursement practices, which emphasize the role of primary care physicians.