Acceleration of changes in session impact during contrasting time-limited psychotherapies

The Maudsley model of anorexia nervosa treatment for adolescents and young adults (MANTRa): a study protocol for a multi-center cohort study

BACKGROUND

The treatment of anorexia nervosa (AN) is often challenging due to medical complications as well as high relapse and mortality rates. Studies about effective treatment options for people with AN are particularly scarce in the adolescent population. This paper is a study protocol for a multi-center cohort study assessing the feasibility, acceptability and efficacy of a new, manualized treatment program, the "Maudsley Model of Anorexia Nervosa Treatment for Adolescents and Young Adults" (MANTRa) compared to psychotherapeutic treatment as usual (TAU).

METHODS/DESIGN

One hundred patients between 13 and 21 years who meet the inclusion criteria will receive 24 to 34 individual weekly MANTRa therapy sessions or weekly TAU sessions. Primary outcome variables will be BMI and eating disorder psychopathology 12 months after baseline. Further changes in central coherence, cognitive flexibility, emotion recognition, comorbid psychopathology (e.g. depression, obsessive-compulsive and anxiety disorders, non-suicidal self-injury), personality factors and therapeutic alliance will be assessed.

DISCUSSION

This multi-center study will examine the utility of the treatment program MANTRa for adolescents with AN and, therefore enhances the current knowledge about potential treatments for this patient group.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03535714 . Registered: 24/05/2018 (retrospectively registered, still recruiting).

Effectiveness of Briefer Coping-Focused Psychotherapy for Common Mental Complaints on Work-Participation and Mental Health: A Pragmatic Randomized Trial with 2-Year Follow-Up

Purpose The aim of this study was to assess short and long-term effectiveness of brief coping-focused psychotherapy (Brief-PsT) compared with short-term psychotherapy (Short-PsT) on work-participation (WP) and mental health. Both treatments were preceded by group education. Methods All participants were on, or at risk of, sick leave due to common mental complaints. Patients were selected for inclusion in this study based on levels of self-reported symptoms ('some' or 'seriously affected') of anxiety and depression. They were randomized to Brief-PsT (n = 141) or Short-PsT with a more extended focus (n = 143). Primary outcome was the transition of WP-state from baseline to 3 months follow-up. In addition, WP at 12 and 24 months follow-up were assessed. The secondary outcome, clinical recovery rate (CR-rate) was obtained from the Beck Depression and Beck Anxiety Inventories, at 2-year follow-up. In addition, self-reported mental health symptom severity, self-efficacy, subjective health complaints and life satisfaction were assessed. Results At 3 months follow-up, the increase in WP was significantly greater in Brief-PsT than in Short-PsT (p = 0.039). At 3 months, 60% in Brief-PsT and 51% in Short-PsT was at work, partial or full. Thereafter, these differences diminished, 84% and 80% were at work at 2-year follow up. The 2-year follow-up of the secondary outcome measurements was completed by 53% in Brief-PsT and 57% in Short PsT. CR-rate was significantly greater in Brief-PsT compared with the Short-PsT (69% vs. 51%, p = 0.024). Furthermore, there was a greater reduction in the number of subjective health complaints in Brief-PsT (4.0 vs. 1.9 p = 0.012). All other measurements favoured Brief-PsT as well, but did not reach statistical significance. Conclusions Brief coping-focused psychotherapy added to group education for persons with depression or anxiety complaints seemed more effective in enhancing early work participation compared with additional short-term psychotherapy of standard duration with more extended focus. Clinical recovery rate and decline of comorbid subjective health complaints at 2-year follow-up were also in favour of the brief coping-focused program.

Mindfulness, Self-Compassion, and Counselor Characteristics and Session Variables

Mindfulness has garnered interest as a counselor development tool for enhancing the therapeutic relationship and increasing counselor trainee effectiveness, yet empirical study of counselor mindfulness is limited. A study of the relationship between mindfulness and client perceived empathy among 55 client-counselor trainee dyads is reported. The relationships between counselor trainee mindfulness, self-compassion and ambiguity tolerance, experiential avoidance, and session depth were also examined in this exploratory study. Counselor trainee mindfulness was associated with client perceived empathy and both mindfulness and self-compassion were associated with lower experiential avoidance and greater session depth as rated by the counselor trainee. Self compassion was positively related to tolerance for ambiguity. Implications for counselors, educators, and supervisors and suggestions for practical application of mindfulness for counselor development are discussed.

How much psychotherapy is needed to treat depression? A metaregression analysis

BACKGROUND

Although psychotherapies are effective in the treatment of adult depression it is not clear how this treatment effect is related to amount, frequency and intensity of therapy.

METHODS

To fill this gap in knowledge, the present metaregression analysis examined the association between the effects of psychotherapy for adult depression and several indicators of amount, frequency and intensity of therapy. The analysis included 70 studies (92 comparisons) with 5403 patients, in which individual psychotherapy was compared with a control group (e.g. waiting list, care-as-usual).

RESULTS

There was only a small association between number of therapy sessions and effect size, and this association was no longer significant when the analysis adjusted for other characteristics of the studies. The multivariable analyses also found no significant association with the total contact time or duration of the therapy. However, there was a strong association between number of sessions per week and effect size. An increase from one to two sessions per week increased the effect size with g=0.45, while keeping the total number of treatment sessions constant.

DISCUSSION

More research is needed to establish the robustness of this finding. Based on these findings, it may be advisable to concentrate psychotherapy sessions within a brief time frame.

Research setting versus clinic setting: Which produces better outcomes in cognitive therapy for depression?

OBJECTIVE

To compare the outcomes of cognitive therapy for depression under controlled and clinically representative conditions, while holding several therapist and clinical assessment factors constant.

METHOD

Treatment outcomes for a sample of 23 adults with a primary diagnosis of Major Depressive Disorder who received cognitive therapy in an outpatient clinic were compared with outcomes of 18 clients who were treated in the cognitive therapy condition of a large, multi-site randomized clinical trial of treatments for depression. All participants had been treated by one of two therapists who served as clinicians in both settings. Individuals in the two samples were diagnostically and demographically similar (approximately 50% Female, 83% White). A variety of client characteristics, assessed prior to treatment, as well as the outcomes of treatment, were examined.

RESULTS

Significantly superior treatment outcomes were observed in the individuals treated in the research study, relative to clients in the outpatient clinic, and the difference was not accounted for by intake characteristics. Individuals treated by the therapists in the RCT experienced almost three times as much improvement in depressive symptoms as clients seen in the outpatient setting.

CONCLUSIONS

If replicated, the findings suggest that differences exist between treatment outcomes in research and outpatient settings and that these differences may not simply be due to therapist experience and training, or differences in patient populations. Future research should further examine the impact of fidelity monitoring, treatment expectation and motivation, and the duration and timing of treatment protocols on clinical outcomes.

Impact of exchanges and client-therapist alliance in online-text psychotherapy

The impact of exchanges and client-therapist alliance of online therapy text exchanges were compared to previously published results in face-to-face therapy, and the moderating effects of four participant factors found significant in previously published face-to-face studies were investigated using statistical mixed-effect modeling analytic techniques. Therapists (N=30) and clients (N=30) engaged in online therapy were recruited from private practitioner sites, e-clinics, online counseling centers, and mental-health-related discussion boards. In a naturalistic design, they each visited an online site weekly and completed the standard impact and alliance questionnaires for at least 6 weeks. Results indicated that the impact of exchanges and client-therapist alliance in text therapy was similar to, but in some respects more positive than, previous evaluations of face-to-face therapy. The significance of participant factors previously found to influence impact and alliance in face-to-face therapy (client symptom severity, social support, therapist theoretical orientation, and therapist experience) was not replicated, except that therapists with the more symptomatic clients rated their text exchanges as less smooth and comfortable. Although its small size and naturalistic design impose limitations on sensitivity and generalizability, this study provides some insights into treatment impact and the alliance in online therapy.

Cognitive behaviour therapy (CBT) for depression by computer vs. therapist: patient experiences and therapeutic processes

Abstract This case series compares patient experiences and therapeutic processes between two modalities of cognitive behaviour therapy (CBT) for depression: computerized CBT (cCBT) and therapist-delivered CBT (tCBT). In a mixed-methods repeated-measures case series, six participants were offered cCBT and tCBT in sequence, with the order of delivery randomized across participants. Questionnaires about patient experiences were administered after each session and a semi-structured interview was completed with each participant at the end of each therapy modality. Therapy expectations, patient experiences and session impact ratings in this study generally favoured tCBT. Participants typically experienced cCBT sessions as less meaningful, less positive and less helpful compared to tCBT sessions in terms of developing understanding, facilitating problem-solving and building a therapeutic relationship.

Measuring youths' perceptions of counseling impact: description, psychometric evaluation, and longitudinal examination of the Youth Counseling Impact Scale v.2

The Youth Counseling Impact Scale (YCIS) is an empirically validated treatment progress measure that assesses youths' perceptions of the short term effectiveness of therapy. Since its initial publication, the original 10-item measure has been shortened to ease measurement burden and revised to include a question about a youth's insight into his or her strengths. The current study describes the development of the revised YCIS (v.2) and evaluates its psychometric properties. Additionally, this study examines whether the YCIS (v.2) total score or subscale scores change over time and investigates whether there are gender or age differences for youths' perceptions of the impact of therapy. Results found the revised version obtained comparable information to that of the original measure, and that the revised version retained the factor structure of the original model with one primary general factor of Counseling Impact and two secondary factors (Insight and Change). Results also suggested that while the YCIS (v.2) total score and Change subscale score did not change linearly over the course of treatment, the Insight subscale score showed a small but significant linear increase over time. No significant differences in YCIS scores based on youth age or gender were found. The implication of these findings, the clinical and empirical utility of this measure, and its limitations are discussed.

Baseline training in cognitive and psychodynamic psychotherapy during a psychologist training program. Exploring client outcomes in therapies of one or two semesters

This effectiveness study explored the outcomes of 187 clients seen by 187 students undergoing baseline training in psychotherapy. Clients reduced their symptoms (SCL-90) and increased their positive self-image (SASB introject) during the therapy. Multiple regression analyses showed no differences between the cognitive and the psychodynamic training approaches and no differences between one and two semesters duration of the therapies. However, 2-3% of variance in end states was accounted for by the interaction between the variables, indicating a moderating effect of duration in the two approaches. Outcomes for clients in the cognitive training approach were significantly better with two semesters than with one semester, while there was no such difference in the psychodynamic approach. Consequences for baseline training are discussed.

Relationship between mental states in depression: the assimilation model perspective

Metacognitive theories describe relationships between mental-affective self-states, including the capacity of one self-state to reflect upon another self-state. The assimilation model is a metacognitive approach that understands self-states as made of traces of experiences at different levels of integration. Psychological problems are understood as impaired accessibility of certain self-states to the person's normal awareness. These states are distressing or otherwise subjectively problematic when they emerge. This exploratory study used the assimilation framework to describe mental states in 17 clients who participated in a clinical trial of cognitive-behavioral therapy for depression. Three clinically sophisticated raters examined transcripts of 1h-long psychotherapy session per client to construct qualitative descriptions of self-states and their relationship patterns in these depressed individuals. We then systematically compared and integrated these raters' descriptions of the clients' self-states. In each case, we found a conflict between two internally incompatible states: an interpersonally submissive state and an interpersonally dominant one, a pattern consistent with the model's theoretical description of depression.

The clinical effectiveness of cognitive therapy for depression in an outpatient clinic

BACKGROUND

Cognitive therapy (CT) has been shown to be efficacious in the treatment of depression in numerous randomized controlled trials (RCTs). However, little evidence is available that speaks to the effectiveness of this treatment under routine clinical conditions.

METHOD

This paper examines outcomes of depressed individuals seeking cognitive therapy at an outpatient clinic (N=217, Center for Cognitive Therapy; CCT). Outcomes were then compared to those of participants in a large NIMH-funded RCT of cognitive therapy and medications as treatments for depression.

RESULTS

The CCT is shown to be a clinically representative setting, and 61% of participants experienced reliable change in symptoms over the course of treatment; of those, 45% (36% of the total sample) met criteria for recovery by the end of treatment. Participants at CCT had similar outcomes to participants treated in the RCT, but there was some evidence that those with more severe symptoms at intake demonstrated greater improvement in the RCT than their counterparts at CCT.

LIMITATIONS

The CCT may not be representative of all outpatient settings, and the structure of treatment there was considerably different from that in the RCT. Treatment fidelity was not assessed at CCT.

CONCLUSIONS

Depressed individuals treated with cognitive therapy in a routine clinical care setting showed a significant improvement in symptoms. When compared with outcomes evidenced in RCTs, there was little evidence of superior outcomes in either setting. However, for more severe participants, outcomes were found to be superior when treatment was delivered within an RCT than in an outpatient setting. Clinicians treating such patients in non-research settings may thus benefit from making modifications to treatment protocols to more closely resemble research settings.

The effect of affective bibliotherapy on clients' functioning in group therapy

Abstract The effect of affective group bibliotherapy (GB) was compared to affective group therapy (GT) on patients' functioning in therapy and their session impression. Three small groups totaling twenty-five in-patients in a hospital in Israel participated in the study. Clients concurrently participated in both group types, undergoing three sessions in each condition. In-therapy behaviors were assessed through the Client Behavior System (CBS; Hill & O'Brien, 1999). Results indicated that in the GB condition compared to the GT condition, clients showed less resistance, used simple responses less frequently, and expressed greater affective exploration. The Session Evaluation Questionnaire (SEQ; Stiles et al., 1994) was used to measure clients' impressions of the sessions. Results indicated that patients evaluated the two treatment conditions equally. Overall, the results support earlier findings, suggesting that affective bibliotherapy can be an effective method of treatment.

Linguistic analyses of natural written language: unobtrusive assessment of cognitive style in eating disorders

OBJECTIVE

Linguistic style analysis is introduced as a method of nonreactive measurement of cognitive style in individuals with eating disorders (ED).

METHOD

A journaling exercise was implemented on an ED inpatient unit. Thirty-four written essays collected from an unselected sample of 11 patients were analysed with the Linguistic Inquiry and Word Count, with regard to predefined text categories. At each session, self-report of participant well-being and session impact were assessed.

RESULTS

Compared to essays from a student control group, and message-board entries of individuals who had recovered from an anorexia nervosa (AN), the inpatient journals displayed the highest rates of self-related words, negative emotion words, and the lowest rate of positive emotion words. Inpatients used more anxiety words and fewer words that refer to social processes and eating concerns than individuals who had recovered from an AN. Associations were found between linguistic categories, prewriting well-being, and postwriting evaluation.

CONCLUSION

Linguistic style analysis offers insights into cognitive styles, and provides a promising approach for their unobtrusive measurement in ED.

Enhancing Interpersonal Psychotherapy for Mothers and Expectant Mothers on Low Incomes: Adaptations and Additions

Intervening with depressed women during their childbearing years, especially with those on low incomes, is critically important. Not only do mothers and expectant mothers suffer unnecessarily, but their untreated depression has critical negative consequences for their families. Despite this, these women have proven especially difficult to engage in psychotherapy. In this paper we describe several adaptations and additions we have made to a brief form of Interpersonal Psychotherapy (IPT) to meet the needs of mothers and expectant mothers living on low incomes in the community who suffer from depression, but face significant practical, psychological, and cultural barriers to engaging in and staying in treatment. In addition, we present some preliminary data on the extent to which our enhanced, brief IPT approach promotes improvements in treatment engagement and retention relative to usual care for expectant mothers on low incomes.

Online Data Collection for Psychotherapy Process Research

A preliminary investigation addressed the feasibility of using a specially designed online database to collect psychotherapy session impact and therapist-client alliance data and compared these online measures to published results of their paper-and-pencil counterparts. Participants drawn from a psychology department clinic, a student counseling center, and community agencies visited an online site to report on each of their sessions. Some clients and therapists visited the online database on a regular basis; however, client recruitment and participation was problematic. Equivalence between the online and paper-and-pencil forms was supported, with minor qualifications, by comparable distributions of participant responses on the measures' scales. More direct contact with clients might increase their participation.

Dose-effect relations and responsive regulation of treatment duration: the good enough level

This study examined rates of improvement in psychotherapy as a function of the number of sessions attended. The clients (N=1,868; 73.1% female; 92.4% White; average age=40), who were seen for a variety of problems in routine primary care mental health practices, attended 1 to 12 sessions, had planned endings, and completed the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) at the beginning and end of their treatment. The percentage of clients achieving reliable and clinically significant improvement (RCSI) on the CORE-OM did not increase with number of sessions attended. Among clients who began treatment above the CORE-OM clinical cutoff (n=1,472), the RCSI rate ranged from 88% for clients who attended 1 session down to 62% for clients who attended 12 sessions (r=-.91). Previously reported negatively accelerating aggregate curves may reflect progressive ending of treatment by clients who had achieved a good enough level of improvement.

Comparative effects of short-term psychodynamic psychotherapy and cognitive-behavioral therapy in depression: a meta-analytic approach

This article reviews the efficacy of short-term psychodynamic psychotherapy (STPP) in depression compared to cognitive-behavioral therapy (CBT) or behavioral therapy (BT). In this review, only studies in which at least 13 therapy sessions were performed have been included, and a sufficient number of patients per group were treated (N > or = 20). With regard to outcome criteria, the results were reviewed for improvements in depressive symptoms, general psychiatric symptoms, and social functioning. Six studies met the inclusion criteria.

RESULTS

In 58 of the 60 comparisons (97%) performed in the six studies and their follow-ups, no significant difference could be detected between STPP and CBT/BT concerning the effects in depressive symptoms, general psychiatric symptomatology, and social functioning. Furthermore, STPP and CBT/BT did not differ significantly with regard to the patients that were judged as remitted or improved. According to a meta-analytic procedure described by R. Rosenthal (1991) the studies do not differ significantly with regard to the patients that were judged as remitted or improved after treatment with STPP or CBT/BT. The mean difference between STPP and CBT/BT concerning the number of patients that were judged as remitted or improved corresponds to a small effect size (post-assessment: phi = 0.08, follow-up assessment: phi = 0.12). Thus, STPP and CBT/BT seem to be equally effective methods in the treatment of depression. However, because of the small number of studies which met the inclusion criteria, this result can only be preliminary. Furthermore, it applies only to the specific forms of STPP that were examined in the selected studies and cannot be generalized to other forms of STPP. Further studies are needed to examine the effects of specific forms of STPP in both controlled and naturalistic settings. Furthermore, there are findings indicating that 16-20 sessions of both STPP and CBT/BT are insufficient for most patients to achieve lasting remission. Future studies should address the effects of longer treatments of depression.

Counselling and interpersonal therapies for depression: towards securing an evidence-base

Both generic counselling (delivered by BACP level counsellors in primary care settings) and the interpersonal therapies place a central value on the role and function of relationships--both within and outside the practice setting - as a vehicle for understanding and treating people presenting with depression. Recent studies have compared generic counselling with antidepressant medication, usual GP care, cognitive-behaviour therapy (CBT), and as an adjunct to GP care (i.e. in combination with GP care). Findings suggest either that there is no difference between generic counselling and other treatment conditions, or that there are small advantages to counselling over usual GP care but only in the short-term with such differences disappearing at 1-year. Studies investigating the interpersonal therapies (IPT) have established that the content of such therapies differ in their content from behavioural and cognitive therapies despite the outcomes being broadly similar. Considerable research effort has focused on the process of change in IP therapies. Important factors include the level of prior commitment by the patient to psychological therapy and their confidence in the therapist. Patients with well assimilated problems tend to do better in CBT than psychodynamic-interpersonal therapy. Therapists need to be flexible and responsive to patient needs particularly concerning interpersonal and attachment issues. Future research in counselling needs to identify the effective components of generic counselling and relate these to a theoretical base. In the IP therapies, there needs to be a greater focus on the change outside the therapy session and on the effectiveness of such therapies in non-research settings.