Breathing life into a manual: Flexibility and creativity with manual-based treatments

From Craft to Labor: How Automation is Transforming the Practice of Psychotherapy

I argue that the emergence of ICBT (Internet Cognitive Behavioral Therapy), a novel computerized psychotherapeutic intervention, heralds a shift in the status of psychotherapy from craft to labor. Psychotherapy, as is practiced commonly today, retains its status as craft; therapists in managed settings still work within what I term an opaque bubble, their work invisible and uninterrupted, even by their immediate supervisors and managers. The therapists participating in the Israeli Ministry of Health's course training the first cohort of 'online therapists' find themselves in uncharted territory: The automation of psychotherapy in the form of ICBT constitutes the profession's first major 'division of labor,' not only minimizing the role of the human therapists, but rendering their craft transparent and controllable in ways previously unimaginable. This shift is theorized as a transition from a workmanship of risk, to a workmanship of certainty, and the potential degradation of therapists' skills and status is explored.

A method for defining the CORE of a psychosocial intervention to guide adaptation in practice: Reciprocal imitation teaching as a case example

LAY ABSTRACT

Interventions that support social communication include several "components," or parts (e.g. strategies for working with children and families, targeting specific skills). Some of these components may be essential for the intervention to work, while others may be recommended or viewed as helpful but not necessary for the intervention to work. "Recommended" components are often described as "adaptable" because they can be changed to improve fit in different settings where interventions are offered or with different individuals. We need to understand which parts of an intervention are essential (and which are adaptable) when translating interventions from research to community settings, but it is challenging to do this before studying an intervention in the community. This article presents the CORE (COmponents & Rationales for Effectiveness) Fidelity Method-a new method for defining the essential components of evidence-based interventions-and applies it to a case example of Reciprocal Imitation Teaching, an intervention that parents are taught to deliver with their young children with social communication delays. The CORE Fidelity Method involves three steps: (1) gathering information from multiple sources; (2) integrating information from previous research and theory; and (3) drafting a CORE model for ongoing use. The benefits of using the CORE Fidelity Method may include: (1) improving consistency in intervention and research materials to help all providers emphasize the most important skills or strategies; (2) clarifying which parts of the intervention can be adapted; and (3) supporting future research that evaluates which intervention components work and how they work.

Transformational leadership and employee innovation: Examining the congruence of leader and follower perceptions

Organizations are relying on their leaders to demonstrate effective leadership behavior that positively affects employee innovation. However, discrepancies are often found between leaders’ self-perception and followers’ perception of leadership. Understanding the discrepancies is critical for narrowing the leader–follower perception gap and achieving congruence between leaders and followers. This forms the motivation of this study, which aims to compare and contrast the direct and mediated (through psychological empowerment) impact of transformational leadership behavior on employee innovation performance from the perspective of both leaders and followers. Multisource data using questionnaires were collected from 66 leaders and 220 followers in the United Arab Emirates. The results show that leaders’ self-perception scores were significantly lower than that of their followers. Also, discrepancies in perceptions of the direct impact of transformational leadership behavior on employee innovation were found such that a positive and significant relationship was found for followers while no significant relationship was found for leaders. Finally, psychological empowerment mediates the relationship between transformational leadership and employee innovation performance for both leaders and followers, though leaders perceive the mediation of psychological empowerment to be stronger than followers perceive it to be. The study findings show the importance of obtaining multiple-source feedback to first assess the perceptions of both leaders and followers and then make necessary interventions (if required) to narrow perception gaps between leaders and followers since discrepancies could lead to poor organizational culture.

The Impact of Treatment Expectations on Exposure Process and Treatment Outcome in Childhood Anxiety Disorders

This study examined the relationship between caregivers' and youths' treatment expectations and characteristics of exposure tasks (quantity, mastery, compliance) in cognitive-behavioral therapy (CBT) for childhood anxiety. Additionally, compliance with exposure tasks was tested as a mediator of the relationship between treatment expectations and symptom improvement. Data were from youth (N = 279; 7-17 years old) enrolled in the Child/Adolescent Anxiety Multimodal Study (CAMS) and randomized to cognitive-behavioral therapy (CBT) or the combination of CBT and sertraline for the treatment of separation anxiety disorder, generalized anxiety disorder, and social phobia. Caregivers and youth independently reported treatment expectations prior to randomization, anxiety was assessed pre- and post-treatment by independent evaluators blind to treatment condition, and exposure characteristics were recorded by the cognitive-behavioral therapists following each session. For both caregivers and youths, more positive expectations that anxiety would improve with treatment were associated with greater compliance with exposure tasks, and compliance mediated the relationship between treatment expectations and change in anxiety symptoms following treatment. Additionally, more positive parent treatment expectations were related to a greater number and percentage of sessions with exposure. More positive youth treatment expectations were associated with greater mastery during sessions focused on exposure. Findings underscore the importance of addressing parents' and youths' treatment expectations at the outset of therapy to facilitate engagement in exposure and maximize therapeutic gains.

Self-Blame Mediates the Link between Childhood Neglect Experiences and Internalizing Symptoms in Low-Risk Adolescents

Childhood neglect is the most common type of maltreatment, ranging from minor isolated incidents to consistent failures in emotional/physical caregiving. It has been associated with developmental impairments and considered a risk factor for the emergence of psychopathology, particularly internalizing disorders. This study aimed to explore individual differences in response to the continuum of severity of neglect in community adolescents, as well as the role of specific cognitive emotion regulation strategies (CERSs) as mediators between childhood neglect and current internalizing symptoms. Low-risk adolescents (12-19 years old; M age 15.88 years; N = 123; 64 Females) completed questionnaires assessing these experiences. We employed a regression model and a simple mediation analyses. Findings indicate a positive association between childhood neglect, internalizing behaviors, and the adoption of self-blame as CERS. Moreover, the use of self-blame in response to everyday stress partially mediated the relationship between neglect and internalizing behaviors (effect size: .28). Findings support the hypothesis that even in a low risk sample, neglect is associated with internalizing symptoms, and highlight the importance of assessing individual differences in the experience of neglect. Moreover, the mediation effect of the CERSs of self-blame might serve as a potential target for psychotherapeutic interventions aimed at reducing internalizing symptoms.

Mental Health Therapy Protocols and eHealth Design: Focus Group Study

Background

Electronic health (eHealth) programs are often based on protocols developed for the original face-to-face therapies. However, in practice, therapists and patients may not always follow the original therapy protocols. This form of personalization may also interfere with the intended implementation and effects of eHealth interventions if designers do not take these practices into account.

Objective

The aim of this explorative study was to gain insights into the personalization practices of therapists and patients using cognitive behavioral therapy, one of the most commonly applied types of psychotherapy, in a youth addiction care center as a case context.

Methods

Focus group discussions were conducted asking therapists and patients to estimate the extent to which a therapy protocol was followed and about the type and reasons for personalization of a given therapy protocol. A total of 7 focus group sessions were organized involving therapists and patients. We used a commonly applied protocol for cognitive behavioral therapy as a therapy protocol example in youth mental health care. The first focus group discussions aimed at assessing the extent to which patients (N=5) or therapists (N=6) adapted the protocol. The second focus group discussions aimed at estimating the extent to which the therapy protocol is applied and personalized based on findings from the first focus groups to gain further qualitative insight into the reasons for personalization with groups of therapists and patients together (N=7). Qualitative data were analyzed using thematic analysis.

Results

Therapists used the protocol as a “toolbox” comprising different therapy tools, and personalized the protocol to enhance the therapeutic alliance and based on their therapy-provision experiences. Therapists estimated that they strictly follow 48% of the protocol, adapt 30%, and replace 22% by other nonprotocol therapeutic components. Patients personalized their own therapy to conform the assignments to their daily lives and routines, and to reduce their levels of stress and worry. Patients estimated that 29% of the provided therapy had been strictly followed by the therapist, 48% had been adjusted, and 23% had been replaced by other nonprotocol therapeutic components.

Conclusions

A standard cognitive behavioral therapy protocol is not strictly and fully applied but is mainly personalized. Based on these results, the following recommendations for eHealth designers are proposed to enhance alignment of eHealth to therapeutic practice and implementation: (1) study and copy at least the applied parts of a protocol, (2) co-design eHealth with therapists and patients so they can allocate the components that should be open for user customization, and (3) investigate if components of the therapy protocol that are not applied should remain part of the eHealth applied. To best generate this information, we suggest that eHealth designers should collaborate with therapists, patients, protocol developers, and mental health care managers during the development process.

Integrating evidence-based assessment into clinical practice for pediatric anxiety disorders

BACKGROUND

Although evidence-based assessments are the cornerstone of evidence-based treatments, it remains unknown whether incorporating evidence-based assessments into clinical practice enhances therapists' judgment of therapeutic improvement. This study examined whether the inclusion of youth- and parent-reported anxiety rating scales improved therapists' judgment of treatment response and remission compared to the judgment of treatment-masked independent evaluators (IEs) after (a) weekly/biweekly acute treatment and (b) monthly follow-up care.

METHODS

Four hundred thirty six youth received cognitive-behavioral therapy (CBT), medication, CBT with medication, or pill placebo through the Child/Adolescent Anxiety Multimodal Study. Participants and parents completed the following anxiety scales at pretreatment, posttreatment, and follow-up: Screen for Childhood Anxiety and Related Disorders (SCARED) and Multidimensional Anxiety Scale for Children (MASC). IEs rated anxiety on the Clinical Global Impression of Severity (CGI-S) and Improvement (CGI-I) at posttreatment and follow-up. Therapists rated anxiety severity and improvement using scales that paralleled IE measures.

RESULTS

Fair-to-moderate agreement was found between therapists and IEs after acute treatment (κ = 0.38-0.48), with only slight-to-fair agreement found after follow-up care (κ = 0.07-0.33). Optimal algorithms for determining treatment response and remission included the combination of therapists' ratings and the parent-reported SCARED after acute (κ = 0.52-0.54) and follow-up care (κ = 0.43-0.48), with significant improvement in the precision of judgments after follow-up care (p < .02-.001).

CONCLUSION

Therapists are good at detecting treatment response and remission, but the inclusion of the parent-report SCARED optimized agreement with IE rating-especially when contact was less frequent. Findings suggest that utilizing parent-report measures of anxiety in clinical practice improves the precision of therapists' judgment.

Implementing evidence-based treatment protocols: Flexibility within fidelity

Efficacious psychological treatments exist for a variety of mental health conditions, but many who could benefit from these treatments do not receive them. Increasing efforts have been made to disseminate effective protocols, and several approaches for implementing such treatments have been proposed, including the use of protocols, principles, practices, and policies. We discuss the relative merits of disseminating protocols, and highlight the importance of employing flexibility within fidelity. We describe the benefits of using protocols, including their empirical support, guidance for decision making, and structure to facilitate training and enhance treatment integrity. We also address several criticisms that have been offered against protocols, citing data that indicates that many of the criticisms are not warranted.

Cognitive Behavioral Therapy for Anger and Aggression in a Child With Tourette’s Syndrome

Tourette syndrome (TS) is a neurodevelopmental disorder that is characterized by vocal and motor tics. Children with TS often also exhibit disruptive behaviors including sudden anger outbursts accompanied by verbal and physical aggression. This case study presents cognitive behavioral therapy (CBT) treatment of anger and aggression in a 9-year-old girl with TS, co-occurring generalized anxiety disorder (GAD), and oppositional defiant disorder (ODD). At initial assessment, tics were well-managed and disruptive behavior concerns, including near-daily tantrums lasting 20 min to 1 hr, were primary clinical concerns. The child and her mother received 12 weekly sessions of CBT for anger and aggression, with select supplements and modifications that related to the context of TS. Posttreatment assessment indicated a significant decrease in noncompliance, anger outbursts, and aggressive behavior. CBT for anger and aggression can be a useful treatment for the disruptive behaviors that often co-occur with TS.

The Case of Molly L

The present case study illustrates how a family cognitive-behavioral therapy (FCBT) was used to treat a 9-year-old girl diagnosed with separation anxiety disorder and agoraphobia without panic. The first half of treatment focused on teaching specific coping skills, whereas the second half consisted of exposure tasks that provided opportunities for Molly to practice what she had learned. The therapy also addressed issues of family communication and emotional expression. Through flexible application of the manual, the therapist helped Molly's parents recognize how their expectations affected their daughter's behavior and helped Molly with her own self-image and expectations for coping. Following treatment, Molly and her parents reported that her anxiety had decreased and that her coping skills had improved. Overall, this case illustrates the successful application of FCBT and highlights the importance of applying a treatment manual flexibly to address client needs.

Initial Sleep Time Predicts Success in Manual-Guided Cognitive Behavioral Therapy for Insomnia

Cognitive behavioral therapy produces significant and long-lasting improvement for individuals with insomnia, but treatment resources are scarce. A "stepped care" approach has therefore been proposed, but knowledge is limited on how to best allocate patients to different treatment steps. In this study, 66 primary-care patients with insomnia attended a low-end treatment step: manual-guided cognitive behavioral therapy (CBT) for insomnia delivered by ordinary primary-care personnel. Based on clinically significant treatment effects, subjects were grouped into treatment responders or nonresponders. Baseline data were analyzed to identify predictors for treatment success. Long total sleep time at baseline assessment was the only statistically significant predictor for becoming a responder, and sleep time may thus be important to consider before enrolling patients in low-end treatments.

The three-legged stool of evidence-based practice in eating disorder treatment: research, clinical, and patient perspectives

BACKGROUND

Evidence-based practice in eating disorders incorporates three essential components: research evidence, clinical expertise, and patient values, preferences, and characteristics. Conceptualized as a 'three-legged stool' by Sackett et al. in 1996 (BMJ), all of these components of evidence-based practice are considered essential for providing optimal care in the treatment of eating disorders. However, the extent to which these individual aspects of evidence-based practice are valued among clinicians and researchers is variable, with each of these stool 'legs' being neglected at times. As a result, empirical support and patient preferences for treatment are not consistently considered in the selection and implementation of eating disorder treatment. In addition, clinicians may not have access to training to provide treatments supported by research and preferred by patients. Despite these challenges, integrating these three components of evidence-based practice is critical for the effective treatment of eating disorders.

DISCUSSION

Current research supports the use of several types of psychotherapies, including cognitive-behavioral, interpersonal, and family-based therapies, as well as certain types of medications for the treatment of eating disorders. However, limitations in current research, including sample heterogeneity, inconsistent efficacy, a paucity of data, the need for tailored approaches, and the use of staging models highlight the need for clinical expertise. Although preliminary data also support the importance of patient preferences, values, and perspectives for optimizing treatment, enhancing treatment outcome, and minimizing attrition among patients with eating disorders, the extent to which patient preference is consistently predictive of outcome is less clear and requires further investigation. All three components of evidence-based practice are integral for the optimal treatment of eating disorders. Integrating clinical expertise and patient perspective may also facilitate the dissemination of empirically-supported and emerging treatments as well as prevention programs. Further research is imperative to identify ways in which this three-legged approach to eating disorder treatment could be most effectively implemented.

Therapist tips for the brief behavioural activation therapy for depression - revised (BATD-R) treatment manual practical wisdom and clinical nuance

Objective

This article aims to provide supportive guidance for clinicians using the brief behavioral activation treatment for depression - revised (BATD-R) manual. Expanding upon key points less explicitly addressed in the treatment manual, the goal is to convey practical wisdom and clinical nuance beyond that available in the manual, thereby enhancing therapist comfort with the approach and improving treatment delivery.

Methods

In preparation for a randomised control trial of behavioural activation treatment for depression among substance users (the Activate Study), Professor Carl Lejuez, an author on the manual, provided training to our research team. This occurred over four days in May 2013 at the National Drug and Alcohol Research Centre in Sydney, Australia and involved in-depth discussion about treatment delivery, often addressing important issues implied but not addressed in-depth in the manual. Reflections were discussed throughout training and subsequently collated into key themes.

Results

Intricacies associated with treatment delivery were identified. Seven key themes emerged, covering: provision of the treatment rationale; therapeutic alliance and self-disclosure; behaviour monitoring; values; angles and steps; contracts; and drawing from other therapeutic approaches. A detailed discussion of how to approach these themes in treatment forms the basis of this article.

Conclusions

The current article seeks to guide therapists and provide a supplement to the BATD-R manual that will enhance the flexibility and accessibility for therapists utilising this treatment. The suggestions made are useful for straightforward cases of depression and more complicated comorbid presentations, serving as a useful complement for therapists using the manual.

Guiding CBT supervision: how well do manuals and guidelines fulfil their promise?

Written guidance is part of a coherent support system for CBT supervisors, consistent with general developments in evidence-based practice. In theory, training manuals can help by specifying educational procedures and providing support materials so as to foster fidelity, expertise and effectiveness among supervisors. Supervision guidelines can help by offering supervisors the fruits of research and expert consensus. Together with related resources, such written guidance promises to empower professionals and to benefit patients. But progress with written guidance is very limited within clinical supervision, particularly in controlled research. In marked contrast, locally developed guidance appears to have been implemented successfully within pragmatic studies, a marked achievement when also contrasted with the general healthcare literature. Using eight criteria, the available supervision research is reviewed and conclusions drawn on developing written guidance so as to better fulfil its promise.

Developmentally sensitive cognitive behavioral therapy for adolescent school refusal: rationale and case illustration

School refusal can be difficult to treat and the poorest treatment response is observed among older school refusers. This poor response may be explained, in part, by the impact of developmental transitions and tasks upon the young person, their family, and the treatment process. This paper describes and illustrates the @school program, a cognitive behavioral therapy (CBT) designed to promote developmental sensitivity when planning and delivering treatment for adolescent school refusal. Treatment is modularized and it incorporates progress reviews, fostering a planned yet flexible approach to CBT. The treatment is illustrated in the case of Allison, a 16-year-old female presenting with major depressive disorder and generalized anxiety disorder. A case formulation guided the selection, sequencing, and pacing of modules targeting predisposing, precipitating, perpetuating, and protective factors. Treatment comprised 16 sessions with Allison (interventions addressing depression, anxiety, and school attendance) and 15 concurrent sessions with her mother (strategies to facilitate an adolescent's school attendance), including two sessions with Allison and mother together (family communication and problem solving to reduce parent-adolescent conflict). Two treatment-related consultations were also conducted with Allison's homeroom teacher. Allison's school attendance improved during the course of treatment. By post-treatment, there was a decrease in internalizing behavior, an increase in self-efficacy, and remission of depressive disorder and anxiety disorder. Clinically significant treatment gains were maintained at 2-month follow-up. Factors influencing outcome may include those inherent to the @school program together with less specific factors. Special consideration is given to parents' use of both authoritative and autonomy-granting approaches when helping an adolescent to attend school.

Narrative therapy vs. cognitive-behavioral therapy for moderate depression: empirical evidence from a controlled clinical trial

BACKGROUND

Systematic studies of the efficacy of Narrative Therapy (NT) for depression are sparse.

OBJECTIVE

To evaluate the efficacy of individual NT for moderate depression in adults compared to Cognitive-Behavioral Therapy (CBT).

METHOD

Sixty-three depressed clients were assigned to either NT or CBT. The Beck Depression Inventory-II (BDI-II) and Outcome Questionnaire-45.2 (OQ-45.2) were used as outcome measures.

RESULTS

We found a significant symptomatic reduction in both treatments. Group differences favoring CBT were found on the BDI-II, but not on the OQ-45.2.

CONCLUSIONS

Pre- to post-treatment effect sizes for completers in both groups were superior to benchmarked waiting-list control groups.

Future directions in the design, development, and investigation of technology as a service delivery vehicle

Treatment outcome research with children and adolescents has progressed to such an extent that numerous handbooks have been devoted to reviewing and summarizing the evidence base. Ensuring that consumers of these advancements in state-of-the-field interventions have the opportunity to access, engage in, and benefit from this evidence base, however, has been wrought with challenge. As such, much discussion exists about innovative strategies for overcoming the gap between research and practice; yet no other potential solution that has received more attention in both the popular and academic press than technology. The promise of technology is not surprising given the fast-paced evolution in development and, in turn, a seemingly endless range of possibilities for novel service delivery platforms. Yet this is precisely the most formidable challenge threatening to upset the very promise of this potential solution: The rate of emerging technologies is far outpacing the field's capacity to demonstrate the conceptual or empirical benefits of such an approach. Accordingly, this article aims to provide a series of recommendations that better situate empirical enquiry at the core of a collaborative development, testing, and deployment process that must define this line of work if the promise of mental health technologies is going to be a reality for front-line clinicians and the clients they serve.

Child involvement, alliance, and therapist flexibility: process variables in cognitive-behavioural therapy for anxiety disorders in childhood

BACKGROUND

This study examined the relations between treatment process variables and child anxiety outcomes.

METHOD

Independent raters watched/listened to taped therapy sessions of 151 anxiety-disordered (6-14 yr-old; M = 10.71) children (43% boys) and assessed process variables (child alliance, therapist alliance, child involvement, therapist flexibility and therapist functionality) within a manual-based cognitive-behavioural treatment. Latent growth modelling examined three latent variables (intercept, slope, and quadratic) for each process variable. Child age, gender, family income and ethnicity were examined as potential antecedents. Outcome was analyzed using factorially derived clinician, mother, father, child and teacher scores from questionnaire and structured diagnostic interviews at pretreatment, posttreatment and 12-month follow-up.

RESULTS

Latent growth models demonstrated a concave quadratic curve for child involvement and therapist flexibility over time. A predominantly linear, downward slope was observed for alliance, and functional flexibility remained consistent over time. Increased alliance, child involvement and therapist flexibility showed some albeit inconsistent, associations with positive treatment outcome.

CONCLUSION

Findings support the notion that maintaining the initial high level of alliance or involvement is important for clinical improvement. There is some support that progressively increasing alliance/involvement also positively impacts on treatment outcome. These findings were not consistent across outcome measurement points or reporters.

Interventions in schools for children with autism spectrum disorder: Methods and recommendations

Although researchers have identified many promising teaching strategies and intervention programs for children with autism spectrum disorder, research on implementation of these interventions in school settings has lagged. Barriers to implementation include incompletely developed interventions, limited evidence of their utility in promoting long-term and meaningful change, and poor fit with school environments. To overcome these barriers, interventions need to be detailed in manuals that identify key components yet allow for flexibility, and studies need to evaluate long-term, real-life outcomes. Innovative research strategies also may be important, particularly carrying out research on new interventions in school settings from the outset, conducting partial effectiveness trials in which study personnel administer interventions in school settings, using community-partnered participatory research approaches, and redesigning interventions in a modular format.

Supervising Child Psychiatry Fellows in Cognitive Behavioral Therapy: Crucibles and Choices

Child psychiatric fellows enter cognitive behavioral therapy (CBT) training experiences with a wide variety of backgrounds and experiences in this area of treatment. Although some child fellows have fundamental knowledge of cognitive-behavioral theory, most struggle with the CBT model and even more so, subsequently using this model to guide treatment. Unlike supervising early career mental health professionals, child residents often possess a skill set apt for CBT including using a problem-oriented focus, a tendency to use structured methods in treatment, the use of psychoeducation, and basic clinical skills including genuineness, understanding, and empathy. On the other hand, child psychiatric fellows find several areas of CBT challenging because it is often vastly different from previous experience, including more frequent and longer sessions, the use of collaborative empiricism, developing case conceptualizations, and tolerating negative affective arousal. Moreover, training climates in psychiatry departments may shape the supervision experiences. Various specific recommendations are offered to manage these crucibles. Overall, although there are significant challenges when supervising child residents in CBT rotations, having knowledge of these crucibles and access to choices for addressing these supervisory tests enhances both supervisor and supervisee competence.

What is evidence-based behavior analysis?

Although applied behavior analysts often say they engage in evidence-based practice, they express differing views on what constitutes "evidence" and "practice." This article describes a practice as a service offered by a provider to help solve a problem presented by a consumer. Solving most problems (e.g., increasing or decreasing a behavior and maintaining this change) requires multiple intervention procedures (i.e., a package). Single-subject studies are invaluable in investigating individual procedures, but researchers still need to integrate the procedures into a package. The package must be standardized enough for independent providers to replicate yet flexible enough to allow individualization; intervention manuals are the primary technology for achieving this balance. To test whether the package is effective in solving consumers' problems, researchers must evaluate outcomes of the package as a whole, usually in group studies such as randomized controlled trials. From this perspective, establishing an evidence-based practice involves more than analyzing the effects of discrete intervention procedures on behavior; it requires synthesizing information so as to offer thorough solutions to problems. Recognizing the need for synthesis offers behavior analysts many promising opportunities to build on their existing research to increase the quality and quantity of evidence-based practices.

The reciprocal relationship between alliance and symptom improvement across the treatment of childhood anxiety

This study examined changes in the therapeutic alliance and in self-reported anxiety over the course of 16 weeks of manual-based family treatment for child anxiety disorders. Eighty-six children (51.3% female; aged 7.15-14.44; 86.2% Caucasian, 14.8% minority) with a principal diagnosis of separation anxiety disorder, generalized anxiety disorder, and/or social phobia, and their parents, received family treatment for anxiety disorders in youth. Child, therapist, and parent ratings of therapeutic alliance and child ratings of state anxiety were measured each session. Latent difference score growth modeling investigated the interacting relationship. Therapeutic alliance change, as rated by the mother and by the therapist, was a significant predictor (medium effect) of latter change in child anxiety (with greater therapeutic alliance leading to later reduction in anxiety). However, changes in child-reported anxiety also predicted latter change in father- and therapist-reported alliance (small-to-medium effect). Prospective relationships between child-reported therapeutic alliance and child-reported symptom improvement were not significant. Results provide partial support for a reciprocal model in which therapeutic alliance improves outcome, and anxiety reduction improves therapeutic alliance.

Expect respect support groups: preliminary evaluation of a dating violence prevention program for at-risk youth

Expect Respect support groups, a selective prevention strategy, are designed to prevent and reduce dating violence among at-risk middle and high school students. This preliminary, uncontrolled evaluation examined changes in healthy relationship skills and emotionally and physically abusive behaviors in participants' peer and dating relationships. Self-reports (N = 144) showed significant increases in healthy relationship skills from baseline to program completion, whereas levels of victimization and perpetration remained unchanged. A subgroup of students who reported baseline levels of victimization and perpetration with means at least one standard deviation above the group mean reported significantly less victimization and perpetration at program completion.

Theoretical and practical barriers to practitioners' willingness to seek training in empirically supported treatments

To identify barriers to the dissemination of empirically supported treatments (ESTs), a random sample of psychologists in independent practice (N=1291) was asked to complete measures of attitudes towards ESTs and willingness to attend a 3-hour, 1-day, or 3-day workshop in an EST of their choice. The strongest predictor of unwillingness to obtain EST training was the amount of time and cost required for the workshop, followed by objections to the need for EST training. Psychodynamic (compared to cognitive-behavioral) and more experienced practitioners agreed more strongly with the objections to ESTs overall, as did those whose graduate schools had not emphasized psychotherapy research. Results suggest that both practical and theoretical barriers are significant obstacles to EST dissemination.

A model of therapist competencies for the empirically supported cognitive behavioral treatment of child and adolescent anxiety and depressive disorders

While a plethora of cognitive behavioral empirically supported treatments (ESTs) are available for treating child and adolescent anxiety and depressive disorders, research has shown that these are not as effective when implemented in routine practice settings. Research is now indicating that is partly due to ineffective EST training methods, resulting in a lack of therapist competence. However, at present, the specific competencies that are required for the effective implementation of ESTs for this population are unknown, making the development of more effective EST training difficult. This study therefore aimed to develop a model of therapist competencies for the empirically supported cognitive behavioral treatment of child and adolescent anxiety and depressive disorders using a version of the well-established Delphi technique. In doing so, the authors: (1) identified and reviewed cognitive behavioral ESTs for child and adolescent anxiety and depressive disorders, (2) extracted therapist competencies required to implement each treatment effectively, (3) validated these competency lists with EST authors, (4) consulted with a panel of relevant local experts to generate an overall model of therapist competence for the empirically supported cognitive behavioral treatment of child and adolescent anxiety and depressive disorders, and (5) validated the overall model with EST manual authors and relevant international experts. The resultant model offers an empirically derived set of competencies necessary for effectively treating children and adolescents with anxiety and depressive disorders and has wide implications for the development of therapist training, competence assessment measures, and evidence-based practice guidelines for working with this population. This model thus brings us one step closer to bridging the gap between science and practice when treating child and adolescent anxiety and depression.

Core principles in cognitive therapy with youth

Cognitive therapy (CT) is increasingly being adopted by child psychiatrists for a variety of clinical problems. This article explains the cardinal principles, practices, and processes associated with this approach. More specifically, a brief overview of the treatment model is offered along with an emphasis on case conceptualization and modular format for treatment. The value of collaboration, guided discovery, establishing a good therapeutic alliance, empiricism, and transparency in clinical work, as well as bringing the head and heart to consensus, is explained. Finally, the hallmark session structure that characterizes CT is delineated.

Implementing trauma-focused CBT with fidelity and flexibility: a family case study

Effective approaches for the treatment of childhood posttraumatic stress disorder and traumatic grief are needed given the prevalence of trauma and its impact on children's lives. To effectively treat posttraumatic stress disorder in children, evidence-based practices should be implemented with flexibility and responsiveness to culture, developmental level, and the specific needs of the family. This case study illustrates flexibility with fidelity in the use of a manualized treatment, describing the implementation of Trauma Focused-Cognitive Behavior Therapy with three traumatized family members-a caregiver and two children. Particular attention is paid to the use of creative strategies to tailor interventions to the individual clients while maintaining fidelity to the principles and components of this evidence-based treatment.

Effectiveness of group cognitive-behavioral treatment for childhood anxiety in community clinics

This study evaluated the effectiveness of cognitive-behavioral treatment for childhood anxiety in a community clinic setting in Hong Kong, China. Forty-five clinically-referred children (age 6-11 years) were randomly assigned to either a cognitive-behavioral treatment program or a waitlist-control condition. Children in the treatment condition showed significant reduction in anxiety symptoms-both statistically and clinically-whereas children in the waitlist condition did not. After the waitlist period was over, the control group also received the treatment program and showed a similar reduction in symptoms. For the full sample of 45 children, the effectiveness of the intervention was significant immediately after treatment and in 3- and 6-month follow-ups. In addition, children's anxiety cognition and their ability to cope with anxiety-provoking situations fully mediated the treatment gains. These results offer empirical support for cognitive-behavioral treatment programs in a non-Western cultural context and plausible mediators for how cognitive-behavioral therapy works.