An apprenticeship model in the training of psychotherapy students. Study protocol for a randomized controlled trial and qualitative investigation

Background

One approach towards advancing the quality of mental health care is to improve psychotherapists’ skills through education and training. Recently, psychotherapy training has benefitted from adapting training methods from other professions (e.g., deliberate practice). The apprenticeship model has a long history in skill trades and medicine, but has yet to be adopted in training mental health professionals. This study aims to investigate the impact of apprenticeship training on clinical psychology students’ skills.

Methods

In a pragmatic mixed-methods trial, 120 first year students in a Master’s degree clinical psychology program will be randomized to either training-as-usual or training-as-usual plus psychotherapy apprenticeship. In the intervention group, students will participate, over a period of 10 weeks, in weekly treatment sessions together with licensed therapists at outpatient mental health and substance use treatment clinics. Outcomes are assessed post-intervention and at two-year follow-up. The main outcome measure is the Facilitative Interpersonal Skills (FIS) performance test. Additional self-report measures tap self-efficacy, self-compassion, worry, rumination, and stress. Weekly reflection log entries written by the students will be qualitatively analyzed in order to gain an in-depth understanding of the learning process. Students’ and therapists’ experiences with the intervention will be explored in focus group interviews.

Discussion

To the best of our knowledge, this is the first controlled study to investigate the impact of apprenticeship as an isolated training component in the education of clinical psychologists. The study is designed so as to yield a comprehensive understanding of an approach which could prove to be a valuable supplement to the existing educational methods in this field and ultimately, contribute to improve the quality of mental health care.

Early maladaptive schemas impact on long-term outcome in patients treated with group behavioral therapy for obsessive-compulsive disorder

BACKGROUND

Some studies have previously found that certain elevated early maladaptive schemas (EMSs) are negative predictors for outcome for patients with obsessive-compulsive disorder (OCD) treated with Cognitive-Behavioral Therapy (CBT) or Exposure and Response Prevention (ERP). The current study explores whether EMS were related to reductions in OCD symptom severity at long-term follow-up (Mean = 8 years) after group ERP for patients with OCD. The central hypothesis was that patients with no response to treatment or patients who relapsed during the follow-up period were more likely to have elevated pre-treatment EMSs compared to those who responded to initial treatment and maintained gains over time. We also investigated whether there were any differences in change over time of overall EMS between patients who were recovered versus patients who were not recovered at extended follow-up.

METHODS

Young Schema Questionnaire -Short Form (YSQ-SF), Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Beck Depression Inventory (BDI) were measured in 40 OCD patients in a general outpatient clinic before and after group ERP, after 12-months and at extended follow-up. To analyze the predictors, a multiple regression analyses was conducted. Changes in overall EMS was analyzed by mixed models procedures.

RESULTS

The major finding is that patients with high pre-treatment YSQ-SF total scores were less likely to respond to initial treatment or were more likely to relapse between post-treatment and the extended follow-up. The YSQ-SF total score at pre-treatment explained 10.5% of the variance of extended long-term follow-up outcome. The entire sample experienced a significant reduction in overall EMS over time with largest reduction from pre- to post-test. There were no statistically significant differences in total EMS change trajectories between the patients who were recovered at the extended follow-up compared to those who were not.

CONCLUSION

The results from the present study suggest that patients with higher pre-treatment EMSs score are less likely to recover in the long-term after receiving group ERP for OCD. A combined treatment that also targets early maladaptive schemas may be a more effective approach for OCD patients with elevated EMS who don't respond to standard ERP.

Three-Week Inpatient Treatment of Obsessive-Compulsive Disorder: A 6-Month Follow-Up Study

Background: Specialized inpatient or residential treatment might be an alternative treatment approach for patients with obsessive-compulsive disorder (OCD) that do not respond satisfactorily to the standard outpatient treatment formats.

Method: The aim of this open trial was to investigate the 6-month effectiveness of a 3-week inpatient treatment of OCD, where exposure with response prevention (ERP) was the main treatment intervention. The sample consisted of 187 adult patients with OCD, all with previous treatment attempts for OCD.

Results: The sample showed significant reductions in symptoms of OCD and depression. The effect sizes were large for obsessive-compulsive symptoms and moderate to large for depressive symptoms. At discharge, 79.7% of the intent-to-treat (ITT) group were classified as treatment responders (≥35% reduction in Y-BOCS scores). However, some participants experienced relapse, as 61.5% of the ITT group were classified as treatment responders at 6-month follow-up. Antidepressant use appeared not to influence the outcome. Only pre-treatment levels of obsessive-compulsive symptoms emerged as a significant predictor of relapse.

Conclusion: The 3-week inpatient programme produced similar treatment effects as previous inpatient and residential studies of longer duration (2 – 3 months). The results suggest that patients with severe OCD can be treated efficiently using this brief inpatient format. However, better relapse prevention interventions are needed.

Explaining depression symptoms in patients with social anxiety disorder: Do maladaptive metacognitive beliefs play a role?

Social anxiety disorder (SAD) is a major risk factor for developing symptoms of depression. Severity of social anxiety has previously been identified as a risk factor, and cognitive models emphasize dysfunctional schemas and self-processing as the key vulnerability factors underlying general distress in SAD. However, in the metacognitive model, depressive and other symptoms are related to metacognitive beliefs. The aim of this study was therefore to test the relative contribution of metacognitions when controlling for SAD severity and factors postulated in cognitive models. In a cross-sectional design, 102 patients diagnosed with primary SAD were included. We found that negative metacognitive beliefs concerning uncontrollability and danger and low confidence in memory emerged as the only factors explaining depressive symptoms in the regression model, suggesting that metacognitive beliefs are associated with increased depressive symptoms in SAD patients.

Paroxetine, Cognitive Therapy or Their Combination in the Treatment of Social Anxiety Disorder with and without Avoidant Personality Disorder: A Randomized Clinical Trial

BACKGROUND

The most efficacious treatments for social anxiety disorder (SAD) are the SSRIs and cognitive therapy (CT). Combined treatment is advocated for SAD but has not been evaluated in randomized trials using CT and SSRI. Our aim was to evaluate whether one treatment is more effective than the other and whether combined treatment is more effective than the single treatments.

METHODS

A total of 102 patients were randomly assigned to paroxetine, CT, the combination of CT and paroxetine, or pill placebo. The medication treatment lasted 26 weeks. Of the 102 patients, 54% fulfilled the criteria for an additional diagnosis of avoidant personality disorder. Outcomes were measured at posttreatment and 12-month follow-up assessments.

RESULTS

CT was superior to paroxetine alone and to pill placebo at the end of treatment, but it was not superior to the combination treatment. At the 12-month follow-up, the CT group maintained benefits and was significantly better than placebo and paroxetine alone, whereas there were no significant differences among combination treatment, paroxetine alone, and placebo. Recovery rates at 12 months were much higher in the CT group (68%) compared to 40% in the combination group, 24% in the paroxetine group, and 4% in the pill placebo group.

CONCLUSIONS

CT was the most effective treatment for SAD at both posttreatment and follow-up compared to paroxetine and better than combined treatment at the 12-month follow-up on the Liebowitz Social Anxiety Scale. Combined treatment provided no advantage over single treatments; rather there was less effect of the combined treatment compared to CT alone.

Psychotic and schizotypal symptoms in non-psychotic patients with obsessive-compulsive disorder

BACKGROUND

Research is scarce with regard to the role of psychotic and schizotypal symptoms in treatment of obsessive-compulsive disorder (OCD). The aim of the current study was to investigate the occurrence and specificity of psychotic and schizotypal symptoms among non-psychotic OCD patients, and to examine whether such symptoms was associated with response to exposure and response prevention (ERP), and whether ERP for OCD had an impact on psychotic and schizotypal symptoms.

METHODS

Non-psychotic OCD patients (n = 133) and a general non-psychotic psychiatric outpatient sample (n = 110) were assessed using self-report inventories before and after psychological treatment.

RESULTS

Non-psychotic OCD patients did not report greater degree of psychotic or schizotypal symptoms than the control group. Psychotic and schizotypal symptoms were not associated with OCD symptoms before or after ERP. Psychotic and schizotypal symptom were significantly reduced following ERP.

CONCLUSIONS

Psychotic and schizotypal symptoms seem to be equally prevalent among non-psychotic OCD patients and non-psychotic psychiatric controls. These symptoms were more linked to depressive symptoms than OCD symptoms. In non-psychotic OCD patients, ERP seems sufficient in reducing OCD symptoms despite the presence of psychotic- and schizotypal symptoms, and reductions in psychotic- and schizotypal symptoms were observed following ERP.

Thought Content and Appraisals in Cognitive Behavioral Therapy for Obsessive-Compulsive Disorder

A premise for cognitive behavioral therapy (CBT) for obsessive-compulsive disorder (OCD) is that appraisal of obsessions maintains OCD symptoms whereas obsessive content is less important. The main aim of this study was therefore to explore this notion using the autogenous and reactive classification of obsessive content and by assessing changes in appraisals and symptoms following CBT for OCD. More specifically, the study investigates whether recovery from OCD is associated with changes in appraisal and explores how thought content relates to appraisal and symptoms both before and CBT. Data from 156 adults with OCD completing CBT for OCD were analyzed. Changes in appraisals were related to improvement in OCD symptoms. Slightly more participants reported reactive intrusions (47%) than autogenous (29%), but combinations of the two were common (24%). These classifications of thought content were not related to levels of appraisal or change in symptoms, with the exception of patients with autogenous thoughts who appraised their intrusions as more important than others. OCD is heterogeneous regarding thought content and strength of appraisals but can be quite homogeneous in terms of CBT treatment response. Also, and in line with cognitive theory, recovery from OCD is associated with changes in appraisals.

A pilot randomized controlled trial of videoconference-assisted treatment for obsessive-compulsive disorder

Evidence-based exposure and response prevention (ERP) treatment for obsessive-compulsive disorder (OCD) is not always easily accessible. Long distances from specialist treatment and other practical or motivational difficulties can interfere with ERP access and outcome. Delivery of ERP through telepsychology can help "fill the gap". The current study included 30 patients with OCD who were randomized to 12 weeks of either videoconference-assisted ERP (VCT; N = 10), self-help ERP (S-H, N = 10), or a wait-list condition (W-L, N = 10). The VCT format included use of tablet-based videoconferencing sessions (N = 6) or studio-based videoconference (N = 4), as well as telephone calls. Patients rated the VCT format as natural and reported strong working alliances with their therapists. VCT treatment produced significantly greater reductions in obsessive-compulsive symptoms compared to the two control conditions. Treatment outcomes were similar to that of regular face-to-face ERP and improvements in symptom scores remained stable at follow-up. The study indicated that ERP for OCD can be delivered efficiently with videoconferencing technology along with telephone calls. The use of such technology in psychological treatment is likely to become more common in the future and it holds promise as a method to make evidence-based treatment more accessible.

The role of self-image as a predictor of psychotherapy outcome

The present study examined the relationship between self-image and outcome in psychotherapy. Patients (n = 170) received treatment-as-usual at a university clinic, and met diagnostic criteria for mostly anxiety and depression related disorders. Self-image was measured with the Structural Analysis of Social Behavior (SASB-I) introject pre and post-treatment. Using multiple regression analyses, higher levels of Self-ignore and Self-blame pre-treatment predicted a poorer treatment outcome in terms of symptoms (SCL-90-R) and interpersonal problems (IIP-64), respectively. Increase in Self-love and decrease in Self-blame (pre to post) predicted reduced symptoms at post-treatment, whereas decrease in Self-attack and Self-control, as well as increase in Self-affirm, predicted reduced interpersonal problems. The results suggest that self-image improvement may be important in order to achieve a good outcome in psychotherapy.

Videoconference- and cell phone-based cognitive-behavioral therapy of obsessive-compulsive disorder: a case series

For most patients with obsessive-compulsive disorder (OCD) the availability of exposure-based therapy is limited. In our study six outpatients with obsessive-compulsive disorder (OCD) received 15 sessions of therapy delivered only over teleconference (six sessions) and cell phones (nine sessions) over a 3-month period of time. Five of the patients were women and the average age of the participants was 31.5 (SD=8.1). Patients presented a variety of OCD symptoms which were treated with standard exposure and response prevention exercises both during treatment sessions and as a part of homework exercises. All patients rated the treatment format as acceptable and rated the quality of the working alliance as high. At the end of therapy four of the six patients were highly improved and no longer met diagnostic criteria for OCD according to the Anxiety Disorders Interview Schedule for DSM-IV and the Yale-Brown Obsessive Compulsive Scale. The same was true at 3-month follow-up although some small increases in OCD symptoms had occurred. The innovative treatment format shows promise as a method of delivery that may make treatment accessible for patients with poor access to specialty clinics.

A Norwegian version of the Obsessive-Compulsive Inventory-Revised: psychometric properties

The aims of this study were to test the psychometric properties of the Norwegian version of the Obsessive-Compulsive Inventory-Revised (OCI-R). The study included a student/community control sample (N = 1167) and a clinical sample (N = 72) with a diagnosis of obsessive-compulsive disorder (OCD). The results indicated a good fit for the six-factor structure of the OCI-R. The mean scores and standard deviations were similar to that of studies from other countries as was the internal consistency. The OCI-R scores were significantly higher in the OCD sample compared to the control sample. All the subscales, except hoarding, were significant predictors of obsessive-compulsive severity, and the OCI-R subscales seemed to be in agreement with the different subtypes of OCD according to DSM-IV. The OCI-R showed meaningful correlations with measures related to obsessive compulsive symptoms. As expected, it showed the strongest correlation with the Yale-Brown Obsessive Compulsive Scale, followed by measures of worry, anxiety, and depression. In summary, the Norwegian OCI-R showed adequate psychometric properties suggesting it could be a suitable measure of obsessive-compulsive symptoms.

[PDCA cyclus and morbidity and mortality conference as a basic tool for reduction of wound infection in colorectal surgery]

BACKGROUND

Morbidity and mortality conferences (M + M) are used for the discussion of errors and thereby further education in surgery. However, it is not clear whether this kind of quality assurance has any influence on the results of surgery.

MATERIAL AND METHODS

We investigated whether M + M as part of PDCA-cylce (plan, do, check, act) with prospectively collected quality data, fixing future goals using benchmarking data and defining a strategy to reach these goals can lead to an increase in quality.

RESULTS

Using surveillance data n = 673 colorectal resections were analysed. Between 2003 and 2008 we found a wound infection rate of 5.6 %. Comparing 2003-2005 (period of strategy development using M + M) and 2006-2008 (period of strategy conversion) the frequency decreased from 7.8 % to 3.5 % (p = 0.012). Thereby the risk factors for wound infection (ASA, wound classification, duration of surgery and wound infection score) were not different.

CONCLUSIONS

M + M as part of this PDCA cycle resulted in a clear increase in surgical quality.

An empirical test of the metacognitive model of obsessive-compulsive symptoms: replication and extension

The aim of the current study was to further investigate the role of metacognitive beliefs implicated in Wells' (1997) model of obsessive-compulsive disorder (OCD). The metacognitive domains of thought-fusion beliefs and beliefs about rituals were positively correlated with obsessive-compulsive symptoms in a community control sample (N=269) and in an OCD sample (N=57). The OCD sample had significantly more obsessive-compulsive symptoms as well as higher scores on the metacognitive constructs than the control sample. In order to perform a more stringent test of the metacognitive model of OCD and to explore the role of a third metacognitive construct, that of stop signals, a second study was conducted using a community control sample (N=304). All three metacognitive constructs were positively correlated with obsessive-compulsive symptoms. Thought-fusion beliefs and beliefs about rituals predicted obsessive-compulsive symptoms, even when controlling for worry, threat, and non-metacognitive beliefs such as perfectionism/certainty and responsibility. Results of this study provide further evidence for the importance of metacognitions in OCD.

Influence of co-morbid generalized anxiety disorder, panic disorder and personality disorders on the outcome of cognitive behavioural treatment of obsessive-compulsive disorder

This study examined co-morbid generalized anxiety disorder and/or panic disorder and personality disorders as predictors of treatment outcomes in adult outpatients with obsessive-compulsive disorder. The patients received exposure with response prevention (ERP) treatment with the addition of either elements of cognitive therapy (ERP+CT) or relaxation training (ERP+REL). It was hypothesized that the addition of cognitive interventions would yield better treatment outcomes for patients with co-morbid generalized anxiety disorder and/or panic disorder. It was also hypothesized that patients with any personality disorder would show less treatment gains in both conditions. Using intention-to-treat criteria, patients with generalized anxiety disorder and/or panic disorder co-morbidity showed less treatment gains at post-treatment across both treatment conditions. This group showed significantly more treatment gains in the ERP+CT condition at the post-treatment and the 12-month follow-up assessments compared with patients in the ERP+REL condition. However, this was not significant when comparing treatment completers. Patients with a co-morbid Cluster A or B personality disorder showed significantly less treatment gains in both treatment conditions at the 12-month follow-up assessment. Among treatment completers, patients with a Cluster C personality disorder showed significantly better outcomes at the post-treatment assessment in the ERP+REL treatment condition. These results, clinical implications, and the importance of further investigations are discussed.

Treatment motivation, treatment expectancy, and helping alliance as predictors of outcome in cognitive behavioral treatment of OCD

Predictors of improvement in obsessive-compulsive symptoms (Y-BOCS) in a randomized clinical trial with adult obsessive-compulsive disorder outpatients were examined. Results of multiple regression analyses revealed that a positive helping alliance was significantly predictive of posttreatment Y-BOCS. Treatment expectancy and high motivation to change were not significantly related to posttreatment outcome. None of the predictors were significantly related to Y-BOCS levels at 12-month follow-up, but positive alliance showed a trend to significance.

The dermatologist in military operations

The military dermatologist has a specific and significant role in military operations--in time of war as well as in peace. Many dermatologists are unfamiliar with the impact that our specialty and cutaneous disease has upon the ability of the military to fulfill the missions, duties, and responsibilities assigned by our government. This article highlights a few of the recent or ongoing types of military operations in which our specialty plays a prominent part.

Recollections of parent-child relationships in OCD out-patients compared to depressed out-patients and healthy controls

The present study examined the relationship between parental bonding in 26 psychiatric out-patients with obsessive-compulsive disorder (OCD) compared to 34 out-patients with major depressive disorder (MDD) and 41 healthy controls. The results indicated significantly lower levels of parental care and higher levels of maternal overprotection for the patients with a current principal diagnosis of depression, compared to healthy controls. In multiple regression analyses, the presence of depressive disorder was related to all Parental Bonding Inventory (PBI) subscales. When the presence of current depressive disorder was controlled for statistically, the diagnosis of OCD was not associated with abnormal patterns of parental bonding on the PBI.

Effects of aerobic exercise versus stress management treatment in fibromyalgia. A 4.5 year prospective study

To determine and compare short- and long-term effects of aerobic exercise (AE), stress management treatment (SMT), and treatment-as-usual (TAU) in fibromyalgia, 60 patients were randomized to 14 weeks of treatment by either AE, SMT or TAU. Outcome measures at baseline, midway through treatment, at treatment completion, and at 4 year follow up included a patient made drawing of pain distribution, dolorimetry of tender points, ergometer cycle test, global subjective improvement, and VAS registrations of: pain, disturbed sleep, lack of energy, and depression. Both AE and SMT showed positive short-term effects. AE was the overall most effective treatment, despite being subject to the most sceptical patient attitude prior to the study. At follow up, there were no obvious group differences in symptom severity, which for AE seemed to be due to a considerable compliance problem.