Venetia Leonidaki

A self-help workbook for people with a gambling problem and their loved ones, featuring practical exercises and worksheets using CBT techniques.

We aimed to estimate the prevalence of alcohol misuse and examine its relationship with gambling severity and psychological distress in a UK treatment-seeking sample of pathological gamblers. Approximately one in four patients (27.1%) scored ≥ 8 on the Alcohol Use Disorders Identification Test (AUDIT) screening tool indicating alcohol misuse, and one in four (28.1%) reported abstinence. There was no evidence of an association between alcohol misuse and gambling severity or psychological distress level. Compared to the UK general population a significantly higher proportion demonstrated probable alcohol dependence (1.2% vs. 6.3%, p < 0.001).

This study compares completion and recovery rates between protocol-based Cognitive Behavioural Therapy (CBT), offered as a first-line therapy for common mental health problems as per national guidelines, and relational therapies (RTs), scarcely provided in the English Improving Access to Psychological Therapies (IAPT) programme. This is a non-randomised, naturalistic study in a treatment-seeking community sample (n=708). RTs consist of brief psychodynamic and relational integrative therapy. Completion rates relied on clinicians’ coding and recovery rates were calculated based on the Patient Health Questionnaires-9 and the Generalized Anxiety Disorder-7. Doubly robust regression analysis was used to control both the treatment allocation and outcome variables for pre-treatment differences between the intervention groups. Significantly more RTs clients completed treatment compared to CBT clients. No significant differences in recovery rates between CBT and RTs were found using traditional null hypothesis significance tests; the groups were found to be equivalent using equivalence tests. Only when the analysis was repeated in treatment completers, did CBT clients achieve around one quarter higher recovery rates. Both CBT and RTs appeared to be equally effective and showed recovery and completion rates equivalent to or above the national average. These findings demonstrate the advantages of therapies other than CBT. Future research is needed to replicate the equivalence between these two treatments and to explore specific patient characteristics that make one treatment more suitable and acceptable than the other.

A summary of the article published in the Journal of Psychotherapy Integration

Originally published as a special issue of Psychoanalytic Psychotherapy, this collection was timed to coincide with the publication of the new NICE guideline for the treatment of depression, which will shape the context of NHS talking therapy services for the next decade. In 2005, Professor Lord Layard demonstrated for the first time that mental health should matter to the UK Treasury. Layard showed that the cost of untreated depression was huge due to welfare spending on invalidity benefits, and that this was a social problem rising across the OECD, but more so in the UK. NICE had already published a clinical guideline recommending several talking therapies that were cost-effective. Why could no one still get them? In 2007, under New Labour, the world's first universal free-at-the-point-of-need service was launched to remedy this: IAPT Improving Access to Psychological Therapies. Thus began a race against depression, predicted by the World Health Organisation to become the leading cause of disability worldwide by 2020. But on the eve of NICE’s new guideline for depression, due in 2021, it is now clear that across large parts of the UK we are set to lose this race. Badly. Why? What went wrong? Clarke, Cundy and Yakeley have brought together a group of researchers and experts in this collection who address some of the fundamental flaws in the policy design for IAPT. By drawing attention to neglected social and interpersonal origins of depression, pointing us towards more effective approaches, and seeking to pinpoint some of the gaps in thinking during IAPT's first decade, this book offers alternative answers to what still remains Britain’s biggest social problem.

Problem gambling (PG) is a clinical diagnosis as well as a socio-political phenomenon. It has devastating effects for the individual, their family, and the society (BowdenJones & George, 2015). Increased awareness of the effects of PG and the recently introduced national strategy tackling PG (Gambling Comission, 2019) may well result in more individuals affected by PG coming forward to services. Clinical psychologists can help identify such clients and appropriately respond to their needs.

This paper critically reflects on controversial aspects of the English service model of frontline psychological therapies. The Improving Access to Psychological Therapies (IAPT) programme in England has had worldwide influence and embodied core psychotherapy debates between clinical practice, research evidence, and politics. The paper initially focuses on the definition of evidence-based therapy in the programme and the resulting dominance of protocol-based, specific-disorder, Cognitive Behavioural Therapy (CBT), which has ostracised other treatment models. The medical model, the outcome research paradigm, and the English clinical guidelines, treated as the pillars of the CBT hegemony, are critically examined. Omissions are highlighted, including the therapist’s effect, the effectiveness of psychodynamic psychotherapy and integrative practice, and the contribution of client-related factors to treatment outcome, all which contradict key principles of the IAPT philosophy. An innovative initiative to integrate a relational pathway, including brief psychodynamic and relational integrative therapy, into the English service model is then presented. The paper discusses the potential remedying effect of injecting relational therapies into the programme philosophy. Indeed, the IAPT framework has extended beyond a service model to represent a certain paradigm of what psychotherapy should look like, emphasising diagnosis and technical manuals. On the contrary, a relational pathway places the client, the therapist and an individualised approach to treatment at the heart of therapy. Thus, integrating relational therapies in IAPT would entail renegotiation of core psychotherapy dialectics, including technical knowledge versus clinician's expertise and diagnostic-driven versus individually-tailored treatments. The wider implications of such negotiations are pointed out

Letter to the Psychologist

A summary of the DIT model and illustration of key practical points for practitioners via clinical vignettes

Objectives: Identity development is a dynamic and complex process, influenced by social comparison (Tajfel, 1972) and existing power structures (Foucault, 1980). The game changing arrival of the Improvement Access to Psychological Therapies (IAPT) programme, the new generation of high intensity (HI) therapists, and the latest national workforce plan (PPN, 2018) have been shaping the identity of clinical psychology. This presentation aims to capture the impact of the above developments on our discipline and clinical psychologists’ (CPs) reactions to them. Design: Literature review and min audits Method: It combines a reflective comparison between the roles of HI therapists and CPs, a critical review of relevant literature and guidelines (e.g. BPS 2014), and mini audits regarding the content of clinical psychology training courses and job descriptions in the NHS. Results: Elements previously seen as unique to our discipline are now shared with HI therapists. Most IAPT vacancies are exclusively tailored to HI therapists, the content of some training courses is changing to help newly qualified psychologists be more readily eligible for psychotherapy accreditations, and clinical psychologists seem to distance themselves from primary care. Conclusions: Recent developments pose the risk of forcing CPs out of frontline mental health services and them being replaced by HI therapists. Unique aspects of our profession, such as the critical practitioner model or integrative skills, could be promoted further. A call is being made to address any preexisting fragmentation in our identity to make our professional roles more robust and competitive so the profession can more adequately adjust to the new reality moving forward.

Problem gambling is on the rise and has devastating psychosocial consequences. Monash guidelines (2011), based their recommendations on findings from Cochrane review (2012) , have so far been the point of reference worldwide. They have found cognitive behavioural therapy (CBT) and motivational interviewing (MI) to be effective in reducing problem gambling. Recent research activity, as summarised by Yakovenko & Hodgin (2016), has included studies evaluating enhanced versions of CBT and brief or online interventions and has found promising results. Yet methodological limitations in existing RCTs and smaller studies, the improved diagnostic validity following the introduction of DSM-V and the rising number of clients presenting with problem gambling call for higher quality research and an update of current guidelines. Indeed, we still know very little about the effectiveness of non-CBT psychological therapies, the optimal length/durability of CBT, and matching clients to different interventions. Problem gambling becoming a higher priority in the public health agenda may pave the way for further research to take place.

The current article focuses on client’s perspectives of the mechanisms of change in Dynamic Interpersonal Therapy (DIT), a brief psychodynamic therapy developed for the treatment of depression. Five participants were interviewed and the transcripts were analysed using Interpretative Phenomenological Analysis (IPA). The results point out four subthemes, capturing different active ingredients of DIT: therapy shedding light on previously sealed aspects of self; the relational exchange with the therapist challenging intimate fears; moving towards an interpersonal understanding of their difficulties; and putting the pieces of their lives together into a coherent narrative. Overall participants described an interplay between relational and insight-oriented mechanisms taking place. As part of the former mechanisms, participants reported the development of a secure attachment to their therapist and the provision of a new relational experience, partly via mechanisms corresponding to the concept of transference. Participants reported an increase in insight to have been achieved via an understanding of an interpersonal and emotional pattern as well as via the restoration of a coherent life-story. Processes that theoretically map onto the concept of mentalisation were also reported. The findings are discussed in relation to the DIT and psychodynamic theory about change and to relevant research literature.

Dynamic interpersonal therapy (DIT) is a brief manualised psychodynamic intervention for depression. This is a first study exploring clients’ experiences of DIT specifically and brief, manualised psychodynamic psychotherapy (PP) in general. Interpretative phenomenological analysis was the methodology employed. Five participants completed a semi-structured interview, three weeks to ten months after completing DIT. The scores of pre- and post-therapy outcome measures of depression and anxiety were also available. Two emerging superordinate themes are presented here: (1) ‘The Distinct Features of DIT’, referring to how its therapeutic style and time limitations were experienced and (2) the ‘Impact of Therapy’, referring to perceived outcomes. While previous findings showed that therapist’s perceived limited activity in long-term PP was experienced as hindering/unhelpful, the perceived sense of direction in DIT appeared adequate to most participants. Secondly, the time limitations provoked complex responses. Reactions to the distinct elements of DIT are to be treated both as therapeutic opportunities and as challenges. Further, in line with psychoanalytic theory, most participants described relational changes that went beyond symptom relief and remained in progress after therapy ended. Intriguingly, there was no consistency between participants’ qualitative accounts of change and the scores of the outcome measures. © 2015 The Association for Psychoanalytic Psychotherapy in the NHS

There are varied approaches to the use of appraisal guidelines in qualitative research (QR). Drawing on my experience of critically appraising interview-based studies, included in a qualitative review in psychotherapy research that is under preparation, I reached the following conclusion: that such an appraisal process could benefit from the employment of appraisal criteria that would facilitate a consistent, transparent, and comprehensive comparative appraisal of the included studies. To meet these requirements, I have developed a new, qualitative appraisal tool which, unlike existing appraisal frameworks, uses highly operationalised and specialised criteria tailored to the needs of interview studies in psychology/psychotherapy. I believe that this tool could be highly suitable for assisting with the appraisal process in similar reviews integrating qualitative evidence. Here I present this tool for consideration and discuss its potential practical utility and its theoretical implications for the field of QR in psychology. I finally recommend safeguards against its uncritical use.

Objective: This review aims to offer a qualitative synthesis of helpful and unhelpful/hindering aspects of individual psychotherapy, based on adults’ narrative accounts of their overall experience of therapy. Method: 2152 records were screened against several inclusion and exclusion criteria. Results: 16 articles were included in this review. The methodological quality of the articles was evaluated. Their findings were synthesised using thematic analysis. Five broad themes of the helpful aspects of therapy and four broad themes of the unhelpful aspects of therapy were identified. Discussion: Implications for research and clinical practice are discussed.

Research Questions 1. Are the scores of Spirituality/Religiousness (S/R) significantly different between individuals recovering from substance use in 12-step rehabilitation programs and those recovering in eclectic programs? 2. Is there any association between length of abstinence and scores of S/R in individuals recovering from substance use? 3. Does the above association (if any) differ significantly between individuals recovering in 12-step programs and those in eclectic programs? Conclusions The scores of most dimensions of S/R are significantly higher in the 12-step group compared to the eclectic group. Surprisingly, greater length of abstinence did not relate to higher scores of S/R in individuals recovering from substance use in rehabilitation centres. This appeared to be the case for both 12-step and eclectic rehabilitations.

This contribution reviews the international literature about dual diagnosis, meaning patients who have simultaneously mental health problems and substance use disorders and discusses epidemiology, clinical characteristics, but primarily etiopathogenesis and different treatment models and interventions. The epidemiological data coming from large-scale studies in the general population in USA, Australia and UK demonstrate the close relationship between mental health problems and substance use disorders. Also, the results from Greek research projects support this close relationship, but their research designs have significant limitations. Multiple and high risks are common in this population, like violent or suicidal behavior, self-harm, physical problems, while they appear less responsive to treatment. Subsequently, different models for etiopathogenesis of dual diagnosis have been suggested: (a) Causal relationship: secondary substance use disorder is subsequent of primary mental illness (self-medication hypothesis, supersenstivity model) or vice versa (alcohol, cannabis, and cocaine use trigger or contribute to development of mental illness). (b) Third factor as the cause of both mental and substance use disorders (genetic factor, neuropathology, traumatic experience, personality characteristics, multiple factors). (c) Comorbidty is due to chance. (d) Each disorder mutually exacerbates the other, regardless the cause. Here, the relationship between alcohol and depression is discussed further as example. The ideas and the research-evidence which support each of these models are presented. Also there is an overview of different treatment models: (a) Consecutive treatment: mental health treatment and substance misuse treatment are provided consecutively. (b) Parallel treatments: the patient attends programs of both mental health and substance use services simultaneously. (c) Integrated treatment: the same clinical team addresses both mental health issues and substance use disorders. The first two models have significant weaknesses due to lack of focus on the interaction of the different disorders or to administrative and managerial barriers. On the other hand, integrated programs appear to overcome these limitations. They use modified interventions provided by the same team in order to address the multiple needs of the patients. Different types of integrated programs are discussed. More pragmatist inter ventions should also be taken into consideration. It is expected that some direction for research and clinical practice to Greece will emerge from this contribution.