Cognitive behavioral therapy: Current status and future research directions

ArticleinPsychotherapy Research 25(3) · February 2015with 3,473 Reads 
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Abstract
Cognitive behaviour therapy (CBT), an umbrella term that includes a diverse group of treatments, is defined by a strong commitment to empiricism. While CBT has a robust empirical base, areas for improvement remain. This article reviews the status of the current empirical base and its limitations, and presents future directions for advancement of the field. Ultimately, studies are needed that will identify the predictors, mediators, and moderators of treatment response in order to increase knowledge on how to personalize interventions for each client and to strengthen the impact of CBT. Efforts to advance the dissemination and implementation of CBT, innovative approaches such as practice-oriented research, and the advantages of incorporating new and existing technologies, are discussed as well.

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  • ... Exposure-based therapy for social anxiety and cognitive behavioral therapy for social anxiety (CBT-SA) have gained the most empirical support in the treatment of SAD (Deacon & Abramowitz, 2004;Chambless & Ollendick, 2001;McMain, Newman, Segal, & DeRubeis, 2015). Moreno, Méndez, and Sánchez (2000) carried out a meta-analysis comparing both behavioral and cognitive behavioral treatments (CBT, skills training, exposure, and Ellis cognitive restructuring), including studies conducted in English-and Spanish-speaking countries. ...
    ... Additionally, CBT for social anxiety has shown positive effects in the treatment of children in Mexico (Gil-Bernal & Hernández-Guzmán, 2009) and college students with public speaking anxiety in Colombia (Kalil, 2012), Chile, and Brazil (Brockveld et al. 2014). The four therapeutic elements of the CBT-SA protocol that have been successfully utilized with both US population and Latinos include (1) psychoeduca- tion, (2) cognitive restructuring, (3) exposure, and (4) relapse prevention (McMain et al., 2015;Hofmann & Otto, 2008). The duration of CBT-SA varies between 12 and 16 sessions depending on the format used, with the individual modality requiring 1 h sessions and the groups 2.5 hour sessions. ...
    Chapter
    Social anxiety disorder (SAD), formally known as social phobia, is mainly characterized by fear or anxiety of being negatively judged and evaluated by others and presenting intense crying, fear, and tremors when having a conversation, meeting with strangers in social events (e.g., eating or drinking), and speaking in public. SAD in children is characterized by problems speaking in public, asking for help at school or shops, and attending parties or events where they meet people of their same age (McEvoy et al., Clin Psychol 20:103–104, 2016; Spence and Rapee, Behav Res Ther, 86:50–67, 2016). The prevalence of SAD among Latinos is similar to the global population, though epidemiological data in Spanish-speaking countries remain unclear. Research on treatment adaptation of empirically based treatments for social anxiety is still in progress. Based on the characteristics of the Latino population with social anxiety, this chapter will provide (1) an account of social anxiety and its epidemiology in the Latino population, (2) cultural considerations when delivering treatment, and (3) a description of the gold standard treatment for SAD including session vignettes and Spanish-adapted work sheets.
  • ... Cognitive Behavioral Therapy (CBT) is a combination psychotherapy in which patients identify and correct maladaptive beliefs (the cognitive component) and utilize thought exercises or concrete actions (the behavioral component) to reduce symptoms and improve functioning [49]. In general, CBT is intended for ongoing, long-term use outside of the therapeutic setting after the specific skills are mastered with a therapist. ...
    ... In 2002, subject matter experts recommended that interventions developed for GWI be integrative, however, few integrative treatment approaches have been investigated to date [71]. With CBT showing only a modest benefit on several symptoms of GWI and no significant effect on fatigue, there was a need for additional studies of integrative approaches for the treatment of GWI [49]. ...
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    The Persian Gulf War of 1990 to 1991 involved the deployment of nearly 700,000 American troops to the Middle East. Deployment-related exposures to toxic substances such as pesticides, nerve agents, pyridostigmine bromide (PB), smoke from burning oil wells, and petrochemicals may have contributed to medical illness in as many as 250,000 of those American troops. The cluster of chronic symptoms, now referred to as Gulf War Illness (GWI), has been studied by many researchers over the past two decades. Although over $500 million has been spent on GWI research, to date, no cures or condition-specific treatments have been discovered, and the exact pathophysiology remains elusive.Using the 2007 National Institute of Health (NIH) Roadmap for Medical Research model as a reference framework, we reviewed studies of interventions involving GWI patients to assess the progress of treatment-related GWI research. All GWI clinical trial studies reviewed involved investigations of existing interventions that have shown efficacy in other diseases with analogous symptoms. After reviewing the published and ongoing registered clinical trials for cognitive-behavioral therapy, exercise therapy, acupuncture, coenzyme Q10, mifepristone, and carnosine in GWI patients, we identified only four treatments (cognitive-behavioral therapy, exercise therapy, CoQ10, and mifepristone) that have progressed beyond a phase II trial.We conclude that progress in the scientific study of therapies for GWI has not followed the NIH Roadmap for Medical Research model. Establishment of a standard case definition, prioritized GWI research funding for the characterization of the pathophysiology of the condition, and rapid replication and adaptation of early phase, single site clinical trials could substantially advance research progress and treatment discovery for this condition.
  • ... Die oben skizzierten Befunde aus RCT sind zum Großteil von wissenschaftlichen Expertengruppen durchgeführt worden und beinhalten selektive Stichproben, die oft durch Einfachdiagnosen gekennzeichnet sind (Hofmann et al. 2012;McMain et al. 2015). Die Generalisierbarkeit auf die Routineversorgung ist somit fraglich (McMain et al. 2015). ...
    ... Die oben skizzierten Befunde aus RCT sind zum Großteil von wissenschaftlichen Expertengruppen durchgeführt worden und beinhalten selektive Stichproben, die oft durch Einfachdiagnosen gekennzeichnet sind (Hofmann et al. 2012;McMain et al. 2015). Die Generalisierbarkeit auf die Routineversorgung ist somit fraglich (McMain et al. 2015). Um Aussagen über die optimale Sitzungsdosis von Psychotherapie in der therapeutischen Realversorgung treffen zu können, sind empirische Befunde aus Feldstudien zentral. ...
    Article
    Full-text available
    In Deutschland sind Kurz- und Langzeittherapie die beiden etablierten Grundformen der ambulanten psychotherapeutischen Versorgung mit kognitiver Verhaltenstherapie (KVT). In der vorliegenden Arbeit wird die empirische Evidenz zu diesen Strukturierungsformen beschrieben und kritisch diskutiert. Dazu werden Befunde aus randomisierten kontrollierten Studien (RCT) präsentiert, deren Implikationen für die optimale Sitzungsanzahl ausgeführt und wichtige Ergebnisse aus der naturalistischen Prozess-Outcome-Forschung skizziert. Zusätzlich wird anhand von aktuellen Daten der kassenärztlichen Vereinigungen die faktische Nutzung von Sitzungskontingenten in der Praxis dargelegt, um den individuellen Bedarf von Patienten in der Realversorgung zu klären. Generell zeigen die RCT-Befunde, dass starke empirische Evidenz für die Effektivität von KVT bei Einfachdiagnosen mit kurzen Sitzungskontingenten von 7 bis 20 Sitzungen vorliegt. Für die allgemeine Wirksamkeit und die differenzielle Indikation von KVT-Langzeittherapie liegen weniger empirische Befunde vor. Die Studienergebnisse decken sich mit Daten von 200.000 Patienten aus der KVT-Realversorgung zur Ausreizung von Sitzungskontingenten in Deutschland. Bei zwei Drittel der Patienten reichen kurze Therapien unter 25 Sitzungen aus, um subjektiv ausreichende klinische Verbesserungen zu erzielen. Allerdings nehmen ca. 10 % der Patienten Interventionen über 60 Therapiestunden in Anspruch. Über die Relevanz solch höherer Sitzungskontingente für den Therapieerfolg ist bei Langzeittherapien empirisch wenig bekannt. Zukünftige Forschung sollte diese genauer untersuchen und empirisch individuelle Adaptationsregeln für die optimale Sitzungsanzahl solcher Langzeittherapien identifizieren.
  • ... Psychological treatments fare better in regards to implementing change without the danger of harmful side effects and have been demonstrated to be efficacious in treating anxiety and depression [18]. However, there are still individuals with psychiatric disorders who do not respond to psychological therapies [19][20][21]. Regardless of psychological treatment offered, some research has indicated that up to 30% of individuals will discontinue therapy, 30-40% will report little or no change, and 5-15% will report negative effects as a result of therapy [22]. In addition, psychological treatments may not be accessible due to lack of availability, service constraints, or cost, even in a stepped care model [6,23]. ...
    ... As depression and anxiety continue to place increased burden on individuals, healthcare systems, and society more broadly, the need is urgent to identify effective treatment options for these conditions. Currently recommended treatment options are available and have a range of effective outcomes [21,88]. However, continued blocks to these treatments persist, including cost, side-effects and non-responders [23,89]. ...
    Article
    Full-text available
    Background: Anxiety and depression are conferring an increasing burden on society. Although treatments exist for both conditions, side effects, and difficulties accessing treatment prevent many people from receiving adequate assistance. Nutritional approaches have demonstrated some success in treating anxiety and depression. We plan to investigate whether a micronutrient formula, Daily Essential Nutrients, improves symptoms of anxiety and depression compared to a placebo in a community recruited sample. Methods: This will be a randomized, double blind placebo controlled study (RCT). Two hundred adults will be assigned to either a placebo or micronutrient group (placebo or Daily Essential Nutrients (DEN)) in a 1:1 ratio. Baseline data will be collected for 2 weeks, followed by 10 weeks of placebo or micronutrient intervention. Psychometrics will be used to measure progress and participant safety will be monitored weekly. Results: The primary outcome measures will be total scores on three measures of symptom severity at 10 weeks. Linear mixed modelling will be used to measure between group differences and effect sizes will be calculated using pooled mean scores and standard deviations over the course of the trial. Conclusions: If effective, micronutrients could provide an alternative treatment, with fewer barriers and adverse events than currently available treatments.
  • ... The therapy helps patients regulate their emotions, achieve optimal levels of activities and functioning, and maintain realistic and optimistic thinking (Broomfield et al., 2011). Apart from depression, adjunctive CBT is also effective for anxiety, schizophrenia, personality disorders, bipolar disorder, insomnia, pain management, and medical conditions related stress (McMain et al., 2015). In comparison to pharmacotherapy, CBT is associated with lower relapse rate and lack of side-effects (Broomfield et al., 2011). ...
    ... The effect of CBT on anxiety has been consistently reported (Hofmann and Smits, 2008;McMain et al., 2015). This meta-analysis found that both CBT alone and CBT combined with antidepressants significantly improved anxiety. ...
    Article
    Background: Cognitive behavioral therapy (CBT) has been widely used for post-stroke depression (PSD), but the findings have been inconsistent. This is a meta-analysis of randomized controlled trials (RCTs) of CBT for PSD. Methods: Both English (PubMed, PsycINFO, Embase) and Chinese (WanFang Database, Chinese National Knowledge Infrastructure and SinoMed) databases were systematically searched. Weighted and standardized mean differences (WMDs/SMDs), and the risk ratio (RR) with their 95% confidence intervals (CIs) were calculated using the random effects model. Results: Altogether 23 studies with 1,972 participants with PSD were included and analyzed. Of the 23 RCTs, 39.1% (9/23) were rated as high quality studies, while 60.9% (14/23) were rated as low quality. CBT showed positive effects on PSD compared to control groups (23 arms, SMD = -0.83, 95% CI: -1.05 to -0.60, P < 0.001). Both CBT alone (7 arms, SMD = -0.76, 95% CI: -1.22 to -0.29, P = 0.001) and CBT with antidepressants (14 arms, SMD = -0.95, 95% CI: -1.20 to -0.71, P < 0.00001) significantly improved depressive symptoms in PSD. CBT had significantly higher remission (6 arms, RR = 1.76, 95% CI: 1.37-2.25, P < 0.00001) and response rates (6 arms, RR = 1.41, 95% CI: 1.22-1.63, P < 0.00001), with improvement in anxiety, neurological functional deficits and activities of daily living. CBT effects were associated with sample size, mean age, proportion of male subjects, baseline depression score, mean CBT duration, mean number of CBT sessions, treatment duration in each session and study quality. Conclusion: Although this meta-analysis found positive effects of CBT on depressive symptoms in PSD, the evidence for CBT is still inconclusive due to the limitations of the included studies. Future high-quality RCTs are needed to confirm the benefits of CBT in PSD.
  • ... Während aktuell Tausende von randomisierten kontrollierten Psychotherapiestudien (RCTs) vorliegen, die in Hunderten von Meta-Analysen zusammengefasst wurden [Hofmann et al., 2012], sind die spezifischen Mechanismen für therapeutische Veränderungen kaum bekannt [Flückiger et al., 2015;Mander et al., 2015b;McMain et al., 2015]. Dies mag unter anderem daran liegen, dass die RCTs typischerweise komplexe Therapiemanuale evaluieren, die aus einer Vielzahl einzelner therapeutischer Bausteine zusammengesetzt sind. ...
  • ... The cognitive theory of emotional disorders developed by Beck (1) has been enormously influential in psychiatry (2)(3)(4). Hypotheses about the relationship between cognition and emotion that were derived from this theory have led to a greater understanding of many psychopathological states, and to an effective treatment modality, i.e., cognitive behavioral therapy, which has impressively shaped the psychiatry literature ever since (5)(6)(7)(8). Beck's cognitive theory posits that mood states may be discriminated on the basis of their unique cognitive contents (1,9). ...
    Article
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    Background: Beck's theory of emotional disorder suggests that negative automatic thoughts (NATs) and the underlying schemata affect one's way of interpreting situations and result in maladaptive coping strategies. Depending on their content and meaning, NATs are associated with specific emotions, and since they are usually quite brief, patients are often more aware of the emotion they feel. This relationship between cognition and emotion, therefore, is thought to form the background of the cognitive content specificity hypothesis. Researchers focusing on this hypothesis have suggested that instruments like the cognition checklist (CCL) might be an alternative to make a diagnostic distinction between depression and anxiety. Objectives: The aim of the present study was to assess the psychometric properties of the Turkish version of the CCL in a psychiatric outpatient sample. Patients and methods: A total of 425 psychiatric outpatients 18 years of age and older were recruited. After a structured diagnostic interview, the participants completed the hospital anxiety depression scale (HADS), the automatic thoughts questionnaire (ATQ), and the CCL. An exploratory factor analysis was performed, followed by an oblique rotation. The internal consistency, test-retest reliability, and concurrent and discriminant validity analyses were undertaken. Results: The internal consistency of the CCL was excellent (Cronbach's α = 0.95). The test-retest correlation coefficients were satisfactory (r = 0.80, P < 0.001 for CCL-D, and r = 0.79, P < 0.001 for CCL-A). The exploratory factor analysis revealed that a two-factor solution best fit the data. This bidimensional factor structure explained 51.27 % of the variance of the scale. The first factor consisted of items related to anxious cognitions, and the second factor of depressive cognitions. The CCL subscales significantly correlated with the ATQ (rs 0.44 for the CCL-D, and 0.32 for the CCL-A) as well as the other measures of mood severity (all Ps < 0.01). To a great extent, all items of the CCL were able to distinguish the clinical and non-clinical groups, suggesting the scale has high discriminating validity. Conclusions: The current study has provided evidence that the Turkish version of the CCL is a reliable and valid instrument to assess NATs in a clinical outpatient sample.
  • ... Palmer, 2014). CBT enjoys considerable evidence for its efficacy in a range of clinical presentations (McMain, Newman, Segal & DeRubeis, 2015). The behavioural components, such as graduated exposure, are closely tied to decades of research in experimental behaviour analysis (see Myers & Davis, 2006). ...
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    As coaching psychology finds its feet, demands for evidence-based approaches are increasing both from inside and outside of the industry. There is an opportunity in the many evidence-based interventions in other areas of applied psychology that are of direct relevance to coaching psychology. However, there may too be risks associated with unprincipled eclecticism. Existing approaches that are gaining popularity in the coaching field such as dialectic behavioural therapy and mindfulness enjoy close affiliation with Contextual Behavioral Science (CBS). In this article, we provide a brief overview of CBS as a coherent philosophical, scientific, and practice framework for empirically supported coaching work. We review its evidence base, and its direct applicability to coaching by describing CBS’s most explicitly linked intervention – Acceptance and Commitment Therapy/Training (ACT). We highlight key strengths of ACT including: its great flexibility in regard of the kinds of client change it can support; the variety of materials and exercises available; and, the varied modes of delivery through which it has been shown to work. The article lays out guiding principles and provides a brief illustrative case study of contextual behavioural coaching.
  • ... Cognitive-behavior therapy (CBT) is a well-established psychosocial intervention for psychiatric disorders, pain management, and stress related to medical conditions. [1] It has rarely provoked controversy, much less outright hostility. That is, until it was applied with apparent success to the illness of chronic fatigue syndrome (CFS) in a number of published intervention trials over the past two decades. ...
  • ... In their review, strong empirical support of differentiation based on direct comparisons between CBT and the other two treatments was found for the first four activities, while moderate support was found for the last two activities (Blagys & Hilsenroth, 2002). Another common characteristic of treatments characterized as CBT is a strong commitment to empiricism and scientific evaluation (McMain, Newman, Segal, & DeRubeis, 2015), which for therapists implies a scientist-practitioner approach to clinical practice (Stricker, 2000). ...
    Article
    Cognitive behavioral therapy (CBT) has a strong evidence base for several psychiatric disorders, however, it may be argued that currently there is no overall agreement on what counts as 'CBT'. One reason is that CBT is commonly perceived as encompassing a broad range of treatments, from purely cognitive to purely behavioral, making it difficult to arrive at a clear definition. The purpose of the present study was to explore practicing therapists' perceptions of CBT. Three hundred fifty members of two multi-disciplinary interest groups for CBT in Sweden participated. Mean age was 46 years, 68% were females, 63% psychologists and mean number of years of professional experience was 12 years. Participants completed a web-based survey including items covering various aspects of CBT practice. Overall, therapist perceptions of the extent to which different treatment techniques and procedures were consistent with CBT were in line with current evidence-based CBT protocols and practice guidelines, as were therapists' application of the techniques and procedures in their own practice. A majority of participants (78%) agreed that quality of life or level of functioning were the most important outcome measures for evaluating treatment success. Eighty percent of therapists believed that training in CBT at a basic level was a requirement for practicing CBT. There was a medium size Spearman correlation of rs=.46 between the perceived importance of research to practice and the extent to which participants kept themselves updated on research. Implications for training, quality assurance, and the effectiveness of CBT in clinical practice are discussed.
  • ... Major depressive disorder (MDD) and post-traumatic stress disorder (PTSD) are both associated with similar deficits in functional connectivity (Brown et al., 2014;Dichter et al., 2015;Fonzo et al., 2010;Johnstone et al., 2007;Lanius et al., 2010;Matthews et al., 2008;Oathes et al., 2015) and respond to treatment with cognitive behavioral therapy (CBT). Despite some controversy, the current literature also suggests that CBT is as efficacious as antidepressant medication for the treatment of MDD but with more enduring effects (Hollon et al., 2014;McMain et al., 2015;Weitz et al., 2015). In studies of PTSD, significant empirical support has been demonstrated across sites and within a variety of trauma types for cognitive processing therapy (CPT), a variant of CBT that specifically addresses PTSD (Chard, 2005;Resick et al., 2008). ...
    Article
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    Background Both major depressive disorder (MDD) and post-traumatic stress disorder (PTSD) are characterized by alterations in intrinsic functional connectivity. Here we investigated changes in intrinsic functional connectivity across these disorders as a function of cognitive behavioral therapy (CBT), an effective treatment in both disorders. Methods 53 unmedicated right-handed participants were included in a longitudinal study. Patients were diagnosed with PTSD (n = 18) and MDD (n = 17) with a structured diagnostic interview and treated with 12 sessions of manualized CBT over a 12-week period. Patients received an MRI scan (Siemens 3 T Trio) before and after treatment. Longitudinal functional principal components analysis (LFPCA) was performed on functional connectivity of the bilateral amygdala with the fronto-parietal network. A matched healthy control group (n = 18) was also scanned twice for comparison. Results LFPCA identified four eigenimages or principal components (PCs) that contributed significantly to the longitudinal change in connectivity. The second PC differentiated CBT-treated patients from controls in having significantly increased connectivity of the amygdala with the fronto-parietal network following CBT. Limitations Analysis of CBT-induced amygdala connectivity changes was restricted to the a priori determined fronto-parietal network. Future studies are needed to determine the generalizability of these findings, given the small and predominantly female sample. Conclusion We found evidence for the hypothesis that CBT treatment is associated with changes in connectivity between the amygdala and the fronto-parietal network. CBT may work by strengthening connections between the amygdala and brain regions that are involved in cognitive control, potentially providing enhanced top-down control of affective processes that are dysregulated in both MDD and PTSD.
  • ... [19] Empirical support has consistently demonstrated the effectiveness of cognitive behavioral therapy (CBT) in treating anxiety disorders such as PTSD. [20] CBT assumes the way an individual makes sense of an event is of greater consequence than the actual experiencing of the event itself. [21] Based on extensive experience treating military veterans suffering from PTSD, the United States Department of Veterans Affairs [22] recommends cognitive therapy and exposure therapy as two forms of CBT effective in treating PTSD. ...
    Article
    This manuscript investigates hospitals' use of human resource management practices to mitigate traumatic stress among hospital employees. Initially, the concept of traumatic stress is described and various groups of hospital employees and their sensitivity to traumatic stress are discussed. The three groups of employees considered are hospital's clinical first responders, hospital's non-first responder clinical care personnel, and a third group composed of all remaining hospital employees. Lastly, the manuscript considers specific human resource interventions to address traumatic stress along with directions for future research.
  • ... However, one important aspect was not among the variables investigated in their study: the specific diagnosis of the patients. Consequently, a direct comparison of the therapeutic alliance in different mental disorders is still an important research gap that needs to be addressed in future research (McMain, Newman, Segal, & DeRubeis, 2015;Stiles, Hill, & Elliott, 2015). With the current investigation, we wanted to address this issue. ...
    Article
    Objective: The therapeutic alliance is intensively investigated in psychotherapy research. However, there is scarce research on the role of the specific diagnosis of the patient in the formation of the therapeutic alliance. Hence, the aim of this study was to address this research gap by comparing the alliance in different mental disorders. Design: Our sample comprised 348 patients (mean age = 40 years; 68% female; 133 patients with depression, 122 patients with somatoform disorders, and 93 patients with eating disorders). Methods: Patients completed the Working Alliance Inventory and measures of therapeutic outcome in early, middle, and late stages of inpatient psychotherapy. We applied multivariate multilevel models to address the nested data structure. Results: All three disorder groups experienced positive alliances that increased across the course of therapy and showed similar alliance-outcome relations that were of comparable strengths as in current meta-analyses. However, we found perspective incongruence of alliance ratings from patient and therapist in the three disorder groups. Conclusions: Our results generally indicate that the working alliance is of importance irrespective of the specific mental disorder. Perspective incongruence feedback of working alliance experiences could help to strengthen coordination between patient and therapist and thereby improve the therapeutic process. Further implications of these findings are discussed. Practitioner points: We found no differences in the strengths of alliance ratings and alliance-outcome associations in depressive, somatoform, and eating disorder patients. This indicates that the working alliance is of general clinical importance irrespective of the disorder group and should be a central target in all therapies. We found perspective incongruence in alliance ratings between patient and therapist in all three disorder groups. Perspective incongruence feedback of working alliance experiences could help to strengthen coordination between patient and therapist and thereby improve the therapeutic process.
  • ... While there are currently thousands of randomized controlled psychotherapy trials (RCTs) that have been combined into hundreds of meta-analyses [Hofmann et al., 2012], little is known about the specific mechanisms of therapeutic change [Flückiger et al., 2015;Mander et al., 2015b;McMain et al., 2015]. This may be partly because the RCTs typically evaluate complex therapy manuals that have a large number of individual therapeutic modules. ...
    Article
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    Background: The modules that make up theoretical and practical training in behavioural therapy often bear little relationship to one another. Training, practice intervals and integration into relevant therapeutic interventions need to be interlinked more closely. This manuscript describes an attempt to address this topic by investigating mindfulness interventions. Method: Mindfulness workshops with intervals for self-discovery were facilitated by 27 therapy instructors. Building on this, standardised session- introducing interventions with mindfulness elements were integrated into the training therapy in 36 patients. The program was analysed in terms of acceptance, feasibility and effectiveness. Analyses of variance were used to compare the symptom reduction (Beck Depression Inventory (BDI-II), Brief Symptom Inventory (BSI)) achieved between the first session and the 15th session against that of a control group consisting of patients receiving standard treatment. Results: Positive experiences of mindfulness were disclosed during qualitative interviews. In general, the acceptance and feasibility of the theory/practice network was rated as high. According to statements made by the therapy instructors, meaningful interfaces were established between theoretical and practical training. In terms of symptom reduction, patients in the mindfulness group and the group receiving standard treatment showed similar results; there were no significant variances in this respect. Conclusion: The combination of mindfulness workshops and opening exercises building on these was found to be meaningful, but the effects were not clinically stronger than those achieved by standard treatment. Future research should aim to investigate theory/practice networks in other areas (e.g., Progressive Muscle Relaxation, compassion). Here, clinically relevant effects may be identified in addition to the positive findings on acceptance and feasibility.
  • ... You will see perspectives from the UK, Continental Europe, South America (Strauss, Shapiro, Barkham, Parry, & Machado, 2015), and North America (Stiles, Hill, & Elliott, 2014). We also decided to include contributions regarding research on the various traditions by leaders in our SPR community, from psychodynamic (Barber & Sharpless, 2015), cognitivebehavioral (McMain, Newman, Segal, & DeRubeis, 2015), humanistic (Angus, Watson, Elliot, Schneider, & Timulak, 2014), systemic (Heatherington, Friedlander, Diamond, Escudero, & Pinsof, 2015), to integrative (Castonguay, Eubanks-Carter, Goldfried, Muran, & Lutz, 2015). More specifically, we asked that all these contributions reflect on the past but pay particular attention to the future with the hope that they can shape it, that they can provide an itinerary for future travel of our journal and determine the possible destinations for the field. ...
    Article
    This paper serves as an introduction to the 25th anniversary issue of Psychotherapy Research. It includes a consideration of the original aims of the journal in light of the most cited articles, various developments in research orientation and methodology, and most recent publications. It demonstrates both diversity and consistency in content over time, as well as the international reach of the journal.
  • ... Our design responds to calls for research using responder analysis in the pain literature (Morley et al., 2013), and for practitioner-oriented research in the cognitive behavioural therapy literature (McMain, Newman, Segal & DeRubeis, 2015) Non-responders reported that others outside of the programme were physically or emotionally abusive, or that they were worried about such abuse. They reported more difficult communications with others. ...
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    Background: Understanding successful and unsuccessful behavioural treatment for pain is essential. Aims: We carried out a retrospective survey of 130 people who had undergone pain rehabilitation based on acceptance and commitment therapy, aiming to identify factors associated with non-response. Method: The sample was selected using the reliable change index to define 'responders' and 'non-responders' to key outcome measures. We surveyed a range of treatment-related, systemic, practical and personal factors that may have affected their treatment, and then compared 'non-responders' with 'responders', controlling for factors that might not be causal or specific to non-response. Results: Logistic regression analysis showed two themes that distinguished the groups, 'people outside programme' and 'emotional state'. Conclusions: These data have clinical implications, as such factors can be addressed directly or incorporated into an assessment of treatment 'readiness'. This study introduced a novel methodology for the investigation of pain treatment response, which allowed a broad study of clinically relevant variables, but with greater rigour than conventional self-reports of 'helpful factors' in treatment.
  • ... Cognitive behavioral therapy (CBT) is an effective treatment for both MDD and PTSD, with equally efficacious but more enduring effects than antidepressants for MDD (31)(32)(33) and with efficacy in PTSD for a variety of trauma types (34,35). The fact that various mental disorders endorsing elevated depressive symptoms can be alleviated by CBT suggests that common neural mechanisms may be engaged in treatment response. ...
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    Background Both major depressive disorder (MDD) and post-traumatic stress disorder (PTSD) are characterized by depressive symptoms, abnormalities in brain regions important for cognitive control, and response to Cognitive Behavioral Therapy (CBT). However, whether a common neural mechanism underlies CBT response across diagnoses is unknown. Methods Brain activity during a cognitive control task was measured using fMRI (Siemens 3T Trio) in 104 participants: 28 MDD, 53 PTSD, and 23 healthy controls; depression and anxiety symptoms were determined on the same day. A patient subset (n=31) entered manualized CBT and along with controls (n=19) were re-scanned at 12 weeks. Linear mixed effects models assessed the relationship between depression and anxiety symptoms and brain activity before and after CBT. Results At baseline, activation of the left dorsolateral prefrontal cortex (DLPFC) was negatively correlated with Montgomery-Asberg Depression Rating scores (MADRS) across all participants; this brain-symptom association did not differ between MDD and PTSD. Following CBT treatment of patients, regions within the cognitive control network, including ventrolateral prefrontal cortex (VLPFC) and DLPFC showed a significant increase in activity. Conclusions Our results suggest that dimensional abnormalities in the activation of cognitive control regions were associated primarily with symptoms of depression (with or without controlling for anxious arousal). Furthermore, following treatment with CBT, activation of cognitive control regions was similarly increased in both MDD and PTSD. These results accord with the RDoC conceptualization of mental disorders, and implicate improved cognitive control activation as a trans-diagnostic mechanism for CBT treatment outcome.
  • ... There is an articulated need for qualitative studies conducted alongside quantitative trials, which investigate determinants of treatment acceptability [25]. Studies that explore experiences of taking part in internet-based interventions may lead to valuable insights on how to offer more effective treatments [29,30]. As little is known about the acceptability of iCBT interventions among patients with a recent myocardial infarction, there is a need for explorative studies to investigate treatment activity and experiences among such intended end users. ...
    Article
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    Background: Knowledge about user experiences may lead to insights about how to improve treatment activity in Internet-based cognitive behavioral therapy (iCBT) to reduce symptoms of depression and anxiety among people with a somatic disease. There is a need for studies conducted alongside randomized trials, to explore treatment activity and user experiences related to such interventions, especially among people with older age who are recruited in routine care. Objective: The aim of the study was to explore treatment activity, user satisfaction, and usability experiences among patients allocated to treatment in the U-CARE Heart study, a randomized clinical trial of an iCBT intervention for treatment of depression and anxiety following a recent myocardial infarction. Methods: This was a mixed methods study where quantitative and qualitative approaches were used. Patients were recruited consecutively from 25 cardiac clinics in Sweden. The study included 117 patients allocated to 14 weeks of an iCBT intervention in the U-CARE Heart study. Quantitative data about treatment activity and therapist communication were collected through logged user patterns, which were analyzed with descriptive statistics. Qualitative data with regard to positive and negative experiences, and suggestions for improvements concerning the intervention, were collected through semistructured interviews with 21 patients in the treatment arm after follow-up. The interviews were analyzed with qualitative manifest content analysis. Results: Treatment activity was low with regard to number of completed modules (mean 0.76, SD 0.93, range 0-5) and completed assignments (mean 3.09, SD 4.05, range 0-29). Most of the participants initiated the introduction module (113/117, 96.6%), and about half (63/117, 53.9%) of all participants completed the introductory module, but only 18 (15.4%, 18/117) continued to work with any of the remaining 10 modules, and each of the remaining modules was completed by 7 or less of the participants. On average, patients sent less than 2 internal messages to their therapist during the intervention (mean 1.42, SD 2.56, range 0-16). Interviews revealed different preferences with regard to the internet-based portal, the content of the treatment program, and the therapist communication. Aspects related to the personal situation and required skills included unpleasant emotions evoked by the intervention, lack of time, and technical difficulties. Conclusions: Patients with a recent myocardial infarction and symptoms of depression and anxiety showed low treatment activity in this guided iCBT intervention with regard to completed modules, completed assignments, and internal messages sent to their therapist. The findings call attention to the need for researchers to carefully consider the preferences, personal situation, and technical skills of the end users during the development of these interventions. The study indicates several challenges that need to be addressed to improve treatment activity, user satisfaction, and usability in internet-based interventions in this population.
  • ... In the context of MDD, CBT seems to be as effective as pharmacological therapies but its effects last longer [9][10][11]. Over the last decades, the advances in neuroimaging techniques made it possible to unveil several cerebral hubs that constitute neural underpinning of several neuropsychiatric diseases including MDD. ...
    Article
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    Background: Major depressive disorder (MDD) stands among the most frequent psychiatric disorders. Cognitive behavioral therapy (CBT) has been shown to be effective for treating depression, yet its neural mechanisms of action are not well elucidated. The objective of this work is to assess the available neuroimaging studies exploring CBT's effects in adult patients with MDD. Methods: Computerized databases were consulted till April 2018 and a research was conducted according to PRISMA guidelines in order to identify original research articles published at any time in English and French languages on this topic. Results: Seventeen studies were identified. Only one study was randomized comparing CBT to pharmacological interventions, and none included an effective control. Following CBT, changes occurred in cerebral areas that are part of the fronto-limbic system, namely the cingulate cortex, prefrontal cortex and amygdala-hippocampal complex. However, the pattern of activation and connectivity in these areas varied across the studies. Conclusion: A considerable heterogeneity exists with regard to study design, adapted CBT type and intensity, and employed neuroimaging paradigms, all of which may partly explain the difference in studies' outcomes. The lack of randomization and effective controls in most of them makes it difficult to draw formal conclusion whether the observed effects are CBT mediated or due to spontaneous recovery. Despite the observed inconsistencies and dearth of data, CBT appears to exert its anti-depressant effects mainly by modulating the function of affective and cognitive networks devoted to emotions generation and control, respectively. This concept remains to be validated in large scale randomized controlled trials.
  • ... Cognitive behavioral therapy (CBT) is an effective treatment for both major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) with equally efficacious but more enduring effects compared with antidepressants [1][2][3]. The fact that various mental disorders involving depression can be alleviated by CBT suggests that common neural mechanisms may be engaged in treatment response. ...
    Article
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    Despite widespread use of cognitive behavioral therapy (CBT) in clinical practice, its mechanisms with respect to brain networks remain sparsely described. In this study, we applied tools from graph theory and network science to better understand the transdiagnostic neural mechanisms of this treatment for depression. A sample of 64 subjects was included in a study of network dynamics: 33 patients (15 MDD, 18 PTSD) received longitudinal fMRI resting state scans before and after 12 weeks of CBT. Depression severity was rated on the Montgomery-Asberg Depression Rating Scale (MADRS). Thirty-one healthy controls were included to determine baseline network roles. Univariate and multivariate regression analyses were conducted on the normalized change scores of within- and between-system connectivity and normalized change score of the MADRS. Penalized regression was used to select a sparse set of predictors in a data-driven manner. Univariate analyses showed greater symptom reduction was associated with an increased functional role of the Ventral Attention (VA) system as an incohesive provincial system (decreased between- and decreased within-system connectivity). Multivariate analyses selected between-system connectivity of the VA system as the most prominent feature associated with depression improvement. Observed VA system changes are interesting in light of brain controllability descriptions: attentional control systems, including the VA system, fall on the boundary between-network communities, and facilitate integration or segregation of diverse cognitive systems. Thus, increasing segregation of the VA system following CBT (decreased between-network connectivity) may result in less contribution of emotional attention to cognitive processes, thereby potentially improving cognitive control.
  • ... The most commonly used and investigated type of psychotherapy for somatoform disorders and MUPS is cognitive behavioural therapy (Kleinstäuber et al., 2011, Deary et al., 2007, Koelen et al., 2014. Cognitive behavioural model of somatoform disorders and MUPS refers to a self-perpetuating cycle based on the interaction of multiple factors, including somatic (physical) aspects, cognitions (thoughts), behaviour, emotions and environment (Hofmann et al., 2012, McMain et al., 2015. The treatment framework of CBT for somatoform disorders and MUPS incorporates patients' personal and environmental circumstances in the form of predisposing, precipitating and perpetuating factors. ...
    Article
    Background This systematic review and meta-analysis aimed to update and give an overview of the evidence from published literature that focused on the efficacy of cognitive behaviour therapy (CBT) in the management of somatoform disorders and medically unexplained physical symptoms (MUPS). Methods A comprehensive literature search was carried out through an electronic search of various databases on randomized controlled trials (RCTs). Primary outcome was the severity of somatic symptoms. Secondary outcomes were also measured based on severity of anxiety symptoms, severity of depressive symptoms, social functioning, physical functioning, doctor visits and the compliance with CBT, as well as follow-up visits. Effects were summarized by a random effects model using mean differences or odds ratio with 95% confidence intervals (CIs). Results A total of 15 RCTs comprising 1671 patients with somatoform disorders or MUPS were enrolled in our systematic review and meta-analysis. The main analysis revealed that CBT could alleviate somatic symptoms: -1.31 (95% CI: -2.23 to -0.39, p = 0.005); anxiety symptoms: -1.89 (95% CI: -2.91 to -0.86; p < 0.001); depressive symptoms: -1.93 (95% CI: -3.56 to -0.31; p = 0.020); improve physical functioning: 4.19 (95% CI: 1.90 to 6.49; p < 0.001). The efficacy of CBT on alleviating somatic symptoms, anxiety and depressive symptoms were sustained on follow-up. CBT may not be effective in reducing the number of doctor visits: -1.23 (95% CI: -2.97 to 0.51; p = 0.166); and improving social functioning: 3.27 (95% CI: -0.08 to 6.63; p = 0.056). The results of subgroup analysis indicated that CBT was particularly beneficial when the duration of session was more than 50 minutes to reduce the severity of somatic symptoms from pre to post treatment time, when it was group based and applied affective and developed good interpersonal strategy during the treatment. Longer duration and frequency such as more than 10 sessions and 12 weeks treatments had significant effect on reduction of the comorbid symptoms including depression and anxiety, but they may underpin low level of compliance of CBT based treatments. Conclusions: CBT is effective for the treatment of somatoform disorders and MUPS by reducing physical symptoms, psychological distress and disability.
  • ... Sin embargo, esta focalización en la eficacia en resolver trastornos psicopatológicos específicos ha olvidado de alguna manera prestar atención a la naturaleza del individuo que presenta una psicopatología concreta. La práctica clínica ha ido dejando de lado algunos aspectos muy importantes de la rica historia personal de cada individuo que impacta e influye en el desarrollo del trastorno y en su trayectoria a lo largo de la vida del sujeto o del propio tratamiento que se esté implementando (Kyrios 2016) El planteamiento transdiagnóstico necesita de una visión ideográfica que permita identificar los predictores, mediadores y moderadores de la respuesta terapéutica con la intención de incrementar el conocimiento de cómo personalizar las intervenciones para cada cliente (McMain 2015). Pero aún y con todo, sabemos que el self es un concepto extenso, confuso y enredado, sin referentes empíricos (Westen 2003). ...
    Article
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    Abordamos en este artículo una comprensión de los modelos transdiagnósticos guiados por el self y mediados por una formulación de caso de orientación transdiagnóstica, que intenta sintetizar los mecanismos transdiagnósticos de vulnerabilidad y de acción. Los conceptos actuales sobre el self permiten describir con mayor precisión patrones que permiten operativizar algunos de sus componentes y así poder avanzar en una futura metodología de evaluación con una mayor validez empírica. La implementación de tratamientos transdiagnósticos irán desde la mayor estructuración del tipo de técnicas que pueden utilizarse para modificar determinados mecanismos, siendo necesario e inevitable encajarlos con lo auténticamente individual de los pacientes que tratamos, su identidad, su self y por ende sus patrones de relación interpersonales.
  • ... Finally, poor study results may be explained by the heterogeneity of the interventional content in the evaluated SBIs. While the majority of evaluated SBIs claim to utilize techniques from CBT (Rathbone et al., 2017), the label "CBT" is often used as an umbrella term that includes a wide range of intervention strategies (McMain, Newman, Segal, & DeRubeis, 2015). As a result, it is yet unclear to what extent the use of certain interventional techniques may be associated with positive outcomes, and the field is still far from defining practical recommendations with regard to interventional content. ...
    Thesis
    Mental health problems are common in the general population and are associated with high individual and economic burden. To reduce this burden, psychotherapy research and practice have been increasingly professionalized since the latter half of the 20th century and evidence-based psychotherapeutic treatments have been made widely available. Despite the costly efforts to provide evidence-based psychotherapy on a large scale, a significant number of patients remain untreated or do not respond to available interventions. With the integration of computers into everyday life in the 1990s, research has increasingly focused on computer-based interventions (CBIs) to improve both the provision and the quality of evidence-based treatments for all patients. In the last two decades, numerous studies have demonstrated the effectiveness of CBIs for the treatment of mental health problems. In the 21st century, technology is rapidly progressing, and smartphones have gradually taken the place of personal computers in the general population. As a result, smartphone-based interventions (SBIs) are widely discussed as possible aids for the treatment of mental health problems, and there already exists a plethora of SBIs for various patient groups. However, the majority of available SBIs lack empirical evidence as they have not been evaluated in experimental studies. Hence, there exists considerable uncertainty regarding the benefits and possible treatment effects of SBIs. Moreover, most SBIs lack quality in terms of their interventional content, their use of the smartphone’s technological facilities, and their utilization of strategies that engage the patient to use the SBI regularly. Therefore, this dissertation addresses the development and evaluation of an SBI approach that uses evidence-based strategies, seizes upon the smartphones’ technological features, and applies gamification elements to increase patient engagement. Based on the promising findings for blended interventions that combine traditional face-to-face cognitive-behavioral therapy (CBT) with computerized approach-avoidance modification training (AAMT) in the treatment of alcohol use disorders and depression, the SBI approach introduced in this dissertation makes use of intervention techniques from both CBT and smartphone-based AAMT. In six studies, problem-specific SBIs that apply this combined approach are evaluated for their usability and possible effects in the treatment of various mental health problems. Study 7 presents emotion regulation (ER) as a possible common factor in psychopathology that can be targeted by a single SBI addressing patients suffering from various mental health problems. Study 1 examines the feasibility and explores possible effects of an intervention that combines a brief individual counseling session with two weeks of smartphone-based AAMT. This approach is evaluated in a sample of college students meeting criteria for problematic alcohol use. Findings on both usability and treatment effects provide preliminary evidence that the intervention can significantly reduce dysfunctional beliefs about alcohol, craving of alcohol, and alcohol consumption. Study 2 is a multi-center study that assesses the effect of smartphone-based AAMT combined with a brief individual counseling session for participants with elevated levels of body dissatisfaction. Results show that the intervention significantly reduces body dissatisfaction and symptoms of eating disorders. Study 3 evaluates a blended intervention for the reduction of procrastination. Results from this study provide preliminary evidence that a blended intervention that combines two group counseling sessions with 14 days of smartphone-based AAMT can significantly reduce both general and academic procrastination. In Study 4, the blended intervention is comprised of a brief individual psychoeducation session and smartphone-based AAMT for the training of inter- and intraindividual emotion recognition skills in alexithymic individuals. Results show that the intervention improved computer-assessed emotion recognition skills and demonstrated additional effects over a psychoeducation-only control condition. Studies 5 and 6 evaluate SBIs in samples of individuals reporting heightened levels of depression. While results from Study 5 provide preliminary efficacy for an intervention that combines 14-days of smartphone-based AAMT in combination with a psychoeducation group session, Study 6 examines the effectiveness of a stand-alone SBI targeting depressive symptoms using an automated approach that includes an increased degree of gamification. Results of Study 6 demonstrate that 14 days of training with this stand-alone SBI could significantly reduce depressive symptoms. Study 7 comprises two studies that focus on the cross-sectional assessment of deficits in ER skills with the aim to identify common factors that may be targeted by a single, transdiagnostic SBI. Comparisons between two clinical samples and a sample from the general population indicated that participants that met diagnostic criteria for a mental disorder reported lower ER skills than participants from the general population and that ER skills differed across the clinical subgroups. In conclusion, the present dissertation provides evidence that: (1) the AAMT paradigm can be successfully transferred from computers to smartphone devices as indicated by high acceptance scores, high usability ratings, and the frequent use of the SBIs by participants included in the pilot studies; (2) problem-specific SBIs that incorporate face-to-face CBT techniques with AAMT principles may be efficacious for the reduction of symptoms in the targeted mental health problems; (3) a standalone SBI that applies automated CBT techniques and technologically enriched AAMT variants may effectively reduce symptoms of depression; and that (4) ER skills are promising transdiagnostic processes that may be successfully trained in a single SBI that targets a broad range of mental health problems. Further research using larger, more heterogeneous samples including participants that meet diagnostic criteria for mental disorders is necessary to confirm the findings from this dissertation.
  • ... Salah satu metode nonfarmakologi yang efektif untuk mengurangi gejala gangguan tidur adalah Cognitive Behavior Therapy (CBT) yang tahapantahapannya khusus disusun untuk kasus insomnia (Taylor & Pruiksma, 2014). CBT adalah metode terapi yang dikembangkan oleh Aaron Beck yang bertujuan untuk mengubah distorsi kognitif untuk menghasilkan satu perilaku baru yang lebih adaptif (McMain, Newman, Segal & DeRubeis, 2015). CBT dianggap efektif menangani insomnia karena dalam intervensinya CBT merupakan gabungan dari terapi secara kognitif dan perilaku yang mana penanganan insomnia kronis memerlukan intervensi secara langsung untuk memperbaiki perilaku, pola pikir yang salah, dan hubungan antarkeduanya yang memperparah kondisi penderita (Cunnington, Junge, & Fernando, 2013). ...
  • Article
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    (KOR) 본 연구는 인지행동치료(Cognitve Behavioral Therapy: CBT)분야 학술지에서 나타난 키워드의 출현패턴을 조사하여 국내 CBT 연구의 지식구조를 규명하는 데에 목적이 있다. 국내·외에서 수행된 CBT 연구를 비교하고자 ‘인지행동치료’에서 출판된 논문 234편(2008-2019)과 ‘Cognitive Therapy and Research’에서 출판된 논문 2,316편(1977-2019)이 수집되었다. 자료는 NetMiner 4.3 프로그램으로 분석되었으며 동시출현단어 분석은 코사인 유사도 행렬을 산출하고, 네트워크를 시각화하는 절차로 수행되었다. 본 연구의 결과로 국내 CBT연구자들의 주요 관심사가 식별되었고, 국내 CBT 지식구조는 9개의 연구영역으로 범주화되었다: ‘척도 타당화’, ‘완벽주의와 속박감’, ‘조현병 환자의 인지, 정서, 관계적 특성’, ‘경계선 성격장애와 우울/양극성 장애 환자의 인지적 특성과 치료’, ‘적응과 심리적 건강’, ‘사회불안장애 환자의 인지적 특성과 치료’, ‘우울의 원인과 공존이환’, ‘수용전념치료’, ‘폭식 장애 환자의 이해와 치료’. 본 연구는 지난 11년 동안 국내 CBT 분야에서 축적된 지식을 점검하였다는 데에 의의가 있으며 국내 CBT 연구의 향후 발전과제로 임상적 실천 표준을 제고하기 위한 연구가 필요하다고 제안한다. (ENG)The purpose of this study is to examine the patterns of the keywords in journals in the field of Cognitive Behavioral Therapy (CBT) to identify the knowledge structure of CBT studies in Korea. To compare CBT studies from Korea and abroad, 234 articles (2008-2019) published on "Cognitive Behavior Therapy in Korea" and 2,316 articles (1977-2019) published on "Cognitive Therapy and Research" were collected. The data were analyzed using NetMiner 4.3. The co-word analysis was done by calculating the cosine similarity matrix of major keywords, followed by visualizing the network. The results of this study identified the main interests of Korean CBT scholars, and categorized the knowledge structure of CBT in Korea into 9 research areas: "scale validation"; "perfectionism and entrapment"; "cognitive, emotional, and relationship characteristics of schizophrenic patients"; "cognitive characteristics and treatment of borderline personality disorder and depression/bipolar disorder patients"; "adaptation and psychological health"; "cognitive characteristics and treatment of patients with social anxiety disorder"; "causes and co-morbidities of depression"; "acceptance and commitment therapy"; and "understanding and the treatment of binge eating disorder patients." This study is meaningful in that it has reviewed the accumulated knowledge in the CBT field in Korea for the past 11 years, and suggests future tasks for development to improve the standards of CBT practice.
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    Despite growing literature in evidence-based practice (EBP) for children with autism spectrum disorder (ASD), there is limited research on best practices for training the practitioners that provide EBP. In traditional clinical psychology, training often includes self-study of intervention materials followed by ongoing supervision. Although behavioral skills training (BST) has been shown to be efficacious for training skills across many environments, it has yet to be evaluated in training clinical psychology graduate students to implement an intervention for youth with ASD. In a concurrent modified multiple baseline (multiple probe) design, we evaluated the impact of a brief (3-hr) BST session on graduate student therapists’ implementation of a cognitive–behavioral therapy intervention meant to improve emotion regulation in children with ASD. Therapists showed modest additional improvements from baseline (self-study of the intervention manuals alone) in terms of the accuracy and quality of intervention delivery after receiving BST. Additionally, all therapists preferred the BST training session to self-study and said they would recommend BST to other practitioners. Future research should evaluate what specific training components result in the most improvement in therapist behavior and what, if any, added clinical significance therapist improvement serves for clients.
  • Chapter
    Major depressive disorder (MDD) is among the leading causes of chronic disease and a major contributor to the global burden of mental illness. Although effective antidepressant medications are available, treatment resistance is a significant issue for patients. Cognitive behavioral therapy (CBT) is an evidence-based adjunctive or stand-alone psychological therapy for treatment-resistant depression (TRD). In addition to CBT, which has high demands on cognitive functioning, simpler approaches like behavioral activation (BA) are proven to be effective for depression. To overcome the scarcity of resources in routine care and the associated treatment gaps, the Internet is suggested for the provision of standardized programs to a broader range of patients. It could reduce barriers to seek help and improve the access to treatment. This chapter aims to provide an overview about the effectiveness and applications of CBT and BA.
  • Article
    Objective: Little is known about the temporal variability of the alliance-symptom change and cohesion-symptom change relationships over the course of group therapy. These questions were examined in a sample of 373 clients receiving a transdiagnostic cognitive behavior therapy (tCBT), which culled the principle research-supported mechanisms of change for anxiety disorders. Method: The authors examined relationships between the client versions of the Working Alliance Inventory and Group Cohesion Scale in predicting subsequent symptom change, as assessed by the state scale of the State-Trait Anxiety Inventory. Results: Alliance and cohesion were significant predictors of next session anxiety scores. The alliance was consistently associated with anxiety symptoms (rs = -.152 to -.198, ps < .05), but cohesion only showed significant relationships with anxiety symptoms at Sessions 8 and 10 (Session 8, r = -.233, p = .020, and 10, r = -.236, p = .027). Alliance-anxiety relations remained constant, whereas cohesion-anxiety relations substantially increased from earlier to later sessions. Discussion: Differences that were obtained in the relation of alliance and cohesion with anxiety symptoms suggests that these processes have different roles within group tCBT. If replicated, the present findings would suggest that the dynamic relationships between alliance and cohesion and symptoms within group CBT for anxiety disorders have been an important omission in process-outcome studies. (PsycINFO Database Record
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    Background A subgroup of adolescent and young adult (AYA) survivors of cancer during adolescence report high levels of psychological distress. To date, evidence-based psychological interventions tailored to the cancer-related concerns experienced by this population are lacking. The present study aimed to (1) examine the feasibility and preliminary efficacy of an individualized cognitive behavioral therapy (CBT) intervention for AYA survivors of cancer during adolescence; and (2) identify and conceptualize cancer-related concerns as well as maintaining factors using cognitive-behavioral theory. Methods A single-arm trial, whereby AYA survivors of cancer during adolescence (aged 17–25 years) were provided individualized face-to-face CBT at a maximum of 15 sessions. Clinical outcomes were assessed at baseline, post-intervention, and three-month follow-up. Intervention uptake, retention, intervention delivery, and reliable change index scores were examined. An embedded qualitative study consisted of two unstructured interviews with each participant pre-intervention. Along with individual behavioral case formulations developed to guide the intervention, interview data was analyzed to identify and conceptualize cancer-related concerns and potential maintaining factors. Results Ten out of 213 potential participants invited into the study were included, resulting in an overall participation rate of 4.7%. Nine participants completed the intervention, with respectively seven and eight participants completing the post-intervention and three month follow-up assessment. The majority of reported cancer-related concerns and maintaining factors were conceptualized into four themes: social avoidance, fear of emotions and bodily symptoms, imbalance in activity, and worry and rumination. Conclusions Given significant recruitment difficulties, further research is required to examine barriers to help-seeking in the AYA cancer survivor population. However, the conceptualization of cancer-related concerns and maintaining factors experienced by the population may represent an important first step in the development of psychological support tailored toward AYA cancer survivors’ unique needs.
  • Article
    In this study of cognitive-behavioral therapy for depression, many patients experienced large symptom improvements in a single between sessions. These sudden gains' average magnitude was 11 Beck Depression Inventory points, accounting for 50% of these patients' total improvement. Patients who experienced sudden gains were: less depressed than the other patients at posttreatment, and they remained so IB months later. Substantial cognitive changes were observed in the therapy sessions preceding sudden gains, but few cognitive! changes were observed in control sessions, suggesting that cognitive change in the pregain sessions triggered the sudden gains, improved therapeutic alliances were also observed in the therapy sessions immediately after the sudden gains, as were additional cognitive changes, suggesting a three-stage model for these patients' recovery: preparation --> critical session/sudden gain --> upward spiral.
  • Article
    Although the gap between psychotherapy practice and research has been present for some time, recent pressures for accountability from outside the system-managed health care and biological psychiatry-necessitate that we take steps to close this gap. One such step has been for psychotherapy researchers to specify a list of empirically validated therapies. However, as researchers who also have a strong allegiance to clinical practice, we are concerned that the conceptual and methodological constraints associated with outcome research may become clinical constraints for the practicing therapist. We firmly believe that, more than ever before, the time is ripe for us to develop a new outcome research paradigm that involves an active collaboration between researcher and practicing clinician.
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    Abstract This paper describes the experience of clinicians in conducting research and collaborating with academic researchers. As part of clinical routine of a residential program for adolescent substance abusers, empirical data have been collected to assess client's needs before and after treatment, improve clinical practice, and identify barriers to change. Some of the challenges faced and the benefits learned in conducting these studies are presented. In addition to highlighting the convergence of research interests between clinicians and academicians, the conclusion offers general recommendations to foster these partnerships and solidify the scientific-practitioner model.
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    Abstract The goal of this paper is to describe the authors' experience conducting research in and for private practice. Based on two distinct research programs (one guided by a scientist practitioner leading various groups of clinicians and another from a network of practitioners and researchers), a number of practice-oriented studies are presented. Lessons learned from these collaborative projects are discussed in terms of challenges and strategies to deal with them, as well as benefits that can be earned from conducting empirical studies within clinical routine. General recommendations are then offered to foster the engagement of clinicians in their own working environment and to facilitate partnerships between researchers and practitioners in developing and implementing valid, feasible, and informative clinical studies.
  • Article
    The efficacy of Cognitive Behaviour Therapy (CBT) in the treatment of depression is now established. However, explanations for the efficacy of CBT are mixed. The evidence needed to support the explanation advanced by cognitive theory is lacking. This paper critically reviews the available empirical evidence. Forty-four outcome or process studies of therapy with depression are reviewed and 21 of these are subjected to a meta-analysis to investigate the relationship between change in cognitions and change in level of depression during different kinds of therapy. Our analysis shows that: (1) change in cognitive style occurs in all four categories of treatment: CBT, Drug Therapy, Other-Psychological Therapy, and Waiting List; (2) there was a significant difference between Waiting List and all the active treatments in change in cognitions, but not between active treatments; (3) the degree of change in cognitive style is significantly related to change in depression as measured by the Beck Depression Inventory (BDI), but not the Hamilton Rating Scale for Depression (HRS-D); and (4) the relationship between cognitive change and depression is not unique to CBT. Our findings show that CBT does provide some support for the cognitive models of depression but the relationship between cognitive change and recovery from depression is not unique to CBT.
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    Unlabelled: A significant proportion of the general population suffers from anxiety disorders, often with comorbid psychiatric conditions. Internet-delivered cognitive behavior therapy (ICBT) has been found to be a potent treatment for patients with specific psychiatric conditions. The aim of this trial was to investigate the effectiveness and cost-effectiveness of ICBT when tailoring the treatment to address comorbidities and preferences for primary-care patients with a principal anxiety disorder. One hundred participants were recruited through their primary-care contact and randomized to either treatment or an active control group. The treatment consisted of 7-10 weekly individually assigned modules guided by online therapists. At post-treatment, 46% of the treatment group had achieved clinically significant improvement on the primary outcome measure (CORE-OM) and between-group effect sizes ranged from d = 0.20 to 0.86, with a mean effect of d = 0.59. At one-year follow-up, within-group effect sizes varied between d = 0.53 to 1.00. Cost analysis showed significant reduction of total costs for the ICBT group, the results were maintained at one-year follow-up and the incremental cost-effectiveness ratio favored ICBT compared to control group. Individually tailored ICBT is an effective and cost-effective treatment for primary-care patients with anxiety disorders with or without comorbidities. Trial registration: Clinicaltrials.gov: NCT01390168.
  • Article
    Objective : The present study evaluated three technology-based methods of training mental health providers in exposure therapy (ET) for anxiety disorders. Training methods were designed to address common barriers to the dissemination of ET, including limited access to training, negative clinician attitudes toward ET, and lack of support during and following training. Method : Clinicians naïve to ET (N = 181, Mage = 37.4, 71.3% female, 72.1% Caucasian) were randomly assigned to: 1) an interactive, multimedia online training (OLT), 2) OLT plus a brief, computerized motivational enhancement intervention (OLT + ME), or 3) OLT + ME plus a web-based learning community (OLT + ME + LC). Assessments were completed at baseline, post-training, and 6 and 12 weeks following training. Outcomes include satisfaction, knowledge, self-efficacy, attitudes, self-reported clinical use, and observer-rated clinical proficiency. Results : All three training methods led to large and comparable improvements in self-efficacy and clinical use of ET, indicating that OLT alone was sufficient for improving these outcomes. The addition of the ME intervention did not significantly improve outcomes in comparison to OLT alone. Supplementing the OLT with both the ME intervention and the LC significantly improved attitudes and clinical proficiency in comparison to OLT alone. The OLT + ME + LC condition was superior to both other conditions in increasing knowledge of ET. Conclusions : Multi-component trainings that address multiple potential barriers to dissemination appear to be most effective in improving clinician outcomes. Technology-based training methods offer a satisfactory, effective, and scalable way to train mental health providers in evidence-based treatments such as ET.
  • Article
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    Advances in personalized medicine require the identification of variables that predict differential response to treatments as well as the development and refinement of methods to transform predictive information into actionable recommendations. To illustrate and test a new method for integrating predictive information to aid in treatment selection, using data from a randomized treatment comparison. Data from a trial of antidepressant medications (N = 104) versus cognitive behavioral therapy (N = 50) for Major Depressive Disorder were used to produce predictions of post-treatment scores on the Hamilton Rating Scale for Depression (HRSD) in each of the two treatments for each of the 154 patients. The patient's own data were not used in the models that yielded these predictions. Five pre-randomization variables that predicted differential response (marital status, employment status, life events, comorbid personality disorder, and prior medication trials) were included in regression models, permitting the calculation of each patient's Personalized Advantage Index (PAI), in HRSD units. For 60% of the sample a clinically meaningful advantage (PAI≥3) was predicted for one of the treatments, relative to the other. When these patients were divided into those randomly assigned to their "Optimal" treatment versus those assigned to their "Non-optimal" treatment, outcomes in the former group were superior (d = 0.58, 95% CI .17-1.01). This approach to treatment selection, implemented in the context of two equally effective treatments, yielded effects that, if obtained prospectively, would rival those routinely observed in comparisons of active versus control treatments.
  • Article
    This article addresses the long-standing gap that has existed between psychotherapy research and practice and the efforts that have been made to bridge it. It also introduces one such effort, which has consisted of 3 clinical surveys on the experiences of practitioners in using empirically supported treatments for panic disorder, social anxiety, and OCD. In contrast to attempts to close the gap by disseminating research findings to the clinician, the clinical surveys are intended to allow for practitioners to disseminate their clinical experiences to the researcher-and also to other clinicians. What we view as a "two-way bridge" initiative is a collaboration between the Society of Clinical Psychology, Division 12 of the APA, and the Psychotherapy Division of the APA-Division 29. The mechanism that has been established provides a way for clinicians to be a part of the research process, which we hope will provide evidence that can help to enhance our clinical effectiveness.
  • Article
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    Momentary intervention has been proposed as a cost-effective, generalizable, and ecologically valid method to increase the efficiency of face-to-face cognitive-behavioral therapy (CBT). The purpose of the current pilot study was to evaluate the efficacy of a six-session palmtop computer-assisted Group CBT for generalized anxiety disorder (GAD) (CAGT6) in comparison with a six-session Group CBT for GAD without the computer (CBGT6) and typical (12 session) Group CBT for GAD (CBGT12) in a randomized controlled trial. Thirty-four individuals with a primary diagnosis of GAD were randomized to one of the three conditions and completed measures of GAD and anxiety before therapy, after therapy, and at 6-, and 12-month follow-ups. Results indicated that CAGT6 was superior to CBGT6 at posttreatment, but not significantly different from CBGT12. At 6- and 12-month follow-ups, CAGT6 was neither significantly different from CBGT6, nor from CBGT12. Percentages of individuals achieving reliable change on two of the three GAD measures favored CAGT6 over CBGT6 at posttreatment, suggesting promise for the added value of the mobile technology. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
  • Article
    The primary aim of this study was to assess the overall effectiveness of individual and group outpatient cognitive behavioral therapy (CBT) for adults with a primary anxiety disorder in routine clinical practice. We conducted a random effects meta-analysis of 71 nonrandomized effectiveness studies on outpatient individual and group CBT for adult anxiety disorders. Standardized mean gain effect sizes pre- to posttreatment, and posttreatment to follow-up are reported for disorder-specific symptoms, depression, and general anxiety. The mean dropout from CBT is reported. Outpatient CBT was effective in reducing disorder-specific symptoms in completer (d=0.90-1.91) and intention-to-treat samples (d=0.67-1.45). Moderate to large (d=0.54-1.09) and small to large effect sizes (d=0.42-0.97) were found for depressive and general anxiety symptoms posttreatment. Across all anxiety disorders, the weighted mean dropout rate was 15.06%. Posttreatment gains for disorder-specific anxiety were maintained 12months after completion of therapy. CBT for adult anxiety disorders is very effective and widely accepted in routine practice settings. However, the methodological and reporting quality of nonrandomized effectiveness studies must be improved.
  • Article
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    Importance Currently, fewer than 40% of patients treated for major depressive disorder achieve remission with initial treatment. Identification of a biological marker that might improve these odds could have significant health and economic impact.Objective To identify a candidate neuroimaging “treatment-specific biomarker” that predicts differential outcome to either medication or psychotherapy.Design Brain glucose metabolism was measured with positron emission tomography prior to treatment randomization to either escitalopram oxalate or cognitive behavior therapy for 12 weeks. Patients who did not remit on completion of their phase 1 treatment were offered enrollment in phase 2 comprising an additional 12 weeks of treatment with combination escitalopram and cognitive behavior therapy.Setting Mood and anxiety disorders research program at an academic medical center.Participants Men and women aged 18 to 60 years with currently untreated major depressive disorder.Intervention Randomized assignment to 12 weeks of treatment with either escitalopram oxalate (10-20 mg/d) or 16 sessions of manual-based cognitive behavior therapy.Main Outcome and Measure Remission, defined as a 17-item Hamilton Depression Rating Scale score of 7 or less at both weeks 10 and 12, as assessed by raters blinded to treatment.Results Positive and negative predictors of remission were identified with a 2-way analysis of variance treatment (escitalopram or cognitive behavior therapy) × outcome (remission or nonresponse) interaction. Of 65 protocol completers, 38 patients with clear outcomes and usable positron emission tomography scans were included in the primary analysis: 12 remitters to cognitive behavior therapy, 11 remitters to escitalopram, 9 nonresponders to cognitive behavior therapy, and 6 nonresponders to escitalopram. Six limbic and cortical regions were identified, with the right anterior insula showing the most robust discriminant properties across groups (effect size = 1.43). Insula hypometabolism (relative to whole-brain mean) was associated with remission to cognitive behavior therapy and poor response to escitalopram, while insula hypermetabolism was associated with remission to escitalopram and poor response to cognitive behavior therapy.Conclusions and Relevance If verified with prospective testing, the insula metabolism-based treatment-specific biomarker defined in this study provides the first objective marker, to our knowledge, to guide initial treatment selection for depression.Trial Registration Registered at clinicaltrials.gov (NCT00367341)
  • Article
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    Background: Post-traumatic stress disorder (PTSD) with co-occurring severe psychopathology such as borderline personality disorder (BPD) is a frequent sequel of childhood sexual abuse (CSA). CSA-related PTSD has been effectively treated through cognitive-behavioural treatments, but it remains unclear whether success can be achieved in patients with co-occurring BPD. The aim of the present study was to determine the efficacy of a newly developed modular treatment programme (DBT-PTSD) that combines principles of dialectical behaviour therapy (DBT) and trauma-focused interventions. Methods: Female patients (n = 74) with CSA-related PTSD were randomised to either a 12-week residential DBT-PTSD programme or a treatment-as-usual wait list. About half of the participants met the criteria for co-occurring BPD. Individuals with ongoing self-harm were not excluded. The primary outcomes were reduction of PTSD symptoms as assessed by the Clinician-Administered PTSD Scale (CAPS) and by the Posttraumatic Stress Diagnostic Scale (PDS). Hierarchical linear models were used to compare improvements across treatment groups. Assessments were carried out by blinded raters at admission, at end of treatment, and at 6 and 12 weeks post-treatment. Results: Under DBT-PTSD the mean change was significantly greater than in the control group on both the CAPS (33.16 vs. 2.08) and the PDS (0.70 vs. 0.14). Between-group effect sizes were large and highly significant. Neither a diagnosis of BPD nor the severity or the number of BPD symptoms was significantly related to treatment outcome. Safety analyses indicated no increase in dysfunctional behaviours during the trial. Conclusion: DBT-PTSD is an efficacious treatment of CSA-related PTSD, even in the presence of severe co-occurring psychopathology such as BPD.
  • Article
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    Responding to an invitation to celebrate the 50th anniversary of the journal Psychotherapy, the goal of this article is to describe three general ways by which the impact of psychotherapy might be improved: (a) clinically, by encouraging the assimilation of empirically based principles of change and psychopathology research into day-to-day practice; (b) empirically, by fostering process and outcome research focused on a wide range of common factors and basic findings; as well as (c) clinically and empirically, by facilitating active collaboration of practitioners and researchers in various types of practice-oriented research. Reflected in these three potential avenues of growth are the assumptions that (a) we can improve our understanding and impact of psychotherapy by building on convergences and complementarities across different theoretical orientations, domains of research, and professional expertise, and that (b) most of the clinical and research suggestions derived by such convergence and plurality may not require drastic changes in the practice of many psychotherapists. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
  • Article
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    Cognitive behavioral therapy (CBT) refers to a popular therapeutic approach that has been applied to a variety of problems. The goal of this review was to provide a comprehensive survey of meta-analyses examining the efficacy of CBT. We identified 269 meta-analytic studies and reviewed of those a representative sample of 106 meta-analyses examining CBT for the following problems: substance use disorder, schizophrenia and other psychotic disorders, depression and dysthymia, bipolar disorder, anxiety disorders, somatoform disorders, eating disorders, insomnia, personality disorders, anger and aggression, criminal behaviors, general stress, distress due to general medical conditions, chronic pain and fatigue, distress related to pregnancy complications and female hormonal conditions. Additional meta-analytic reviews examined the efficacy of CBT for various problems in children and elderly adults. The strongest support exists for CBT of anxiety disorders, somatoform disorders, bulimia, anger control problems, and general stress. Eleven studies compared response rates between CBT and other treatments or control conditions. CBT showed higher response rates than the comparison conditions in 7 of these reviews and only one review reported that CBT had lower response rates than comparison treatments. In general, the evidence-base of CBT is very strong. However, additional research is needed to examine the efficacy of CBT for randomized-controlled studies. Moreover, except for children and elderly populations, no meta-analytic studies of CBT have been reported on specific subgroups, such as ethnic minorities and low income samples.
  • Article
    Although associations with outcome have been inconsistent, therapist adherence and competence continues to garner attention, particularly within the context of increasing interest in the dissemination, implementation, and sustainability of evidence-based treatments. To date, research on therapist adherence and competence has focused on average levels across therapists. With a few exceptions, research has failed to address multiple sources of variability in adherence and competence, identify important factors that might account for variability, or take these sources of variability into account when examining associations with symptom change. Objective: (a) statistically demonstrate between-and within-therapist variability in adherence and competence ratings and examine patient characteristics as predictors of this variability and (b) examine the relationship between adherence/competence and symptom change. Method: Randomly selected audiotaped sessions from a randomized controlled trial of cognitive-behavioral therapy for panic disorder were rated for therapist adherence and competence. Patients completed a self-report measure of panic symptom severity prior to each session and the Inventory of Interpersonal Problems-Personality Disorder Scale prior to the start of treatment. Results: Significant between-and within-therapist variability in adherence and competence were observed. Adherence and competence deteriorated significantly over the course of treatment. Higher patient interpersonal aggression was associated with decrements in both adherence and competence. Neither adherence nor competence predicted subsequent panic severity. Conclusions: Variability and "drift" in adherence and competence can be observed in controlled trials. Training and implementation efforts should involve continued consultation over multiple cases in order to account for relevant patient factors and promote sustainability across sessions and patients.
  • Article
    Background: Only a third of patients with depression respond fully to antidepressant medication but little evidence exists regarding the best next-step treatment for those whose symptoms are treatment resistant. The CoBalT trial aimed to examine the effectiveness of cognitive behavioural therapy (CBT) as an adjunct to usual care (including pharmacotherapy) for primary care patients with treatment resistant depression compared with usual care alone. Methods: This two parallel-group multicentre randomised controlled trial recruited 469 patients aged 18-75 years with treatment resistant depression (on antidepressants for ≥6 weeks, Beck depression inventory [BDI] score ≥14 and international classification of diseases [ICD]-10 criteria for depression) from 73 UK general practices. Participants were randomised, with a computer generated code (stratified by centre and minimised according to baseline BDI score, whether the general practice had a counsellor, previous treatment with antidepressants, and duration of present episode of depression) to one of two groups: usual care or CBT in addition to usual care, and were followed up for 12 months. Because of the nature of the intervention it was not possible to mask participants, general practitioners, CBT therapists, or researchers to the treatment allocation. Analyses were by intention to treat. The primary outcome was response, defined as at least 50% reduction in depressive symptoms (BDI score) at 6 months compared with baseline. This trial is registered, ISRCTN38231611. Findings: Between Nov 4, 2008, and Sept 30, 2010, we assigned 235 patients to usual care, and 234 to CBT plus usual care. 422 participants (90%) were followed up at 6 months and 396 (84%) at 12 months, finishing on Oct 31, 2011. 95 participants (46%) in the intervention group met criteria for response at 6 months compared with 46 (22%) in the usual care group (odds ratio 3·26, 95% CI 2·10-5·06, p<0·001). Interpretation: Before this study, no evidence from large-scale randomised controlled trials was available for the effectiveness of augmentation of antidepressant medication with CBT as a next-step for patients whose depression has not responded to pharmacotherapy. Our study has provided robust evidence that CBT as an adjunct to usual care that includes antidepressants is an effective treatment, reducing depressive symptoms in this population. Funding: National Institute for Health Research Health Technology Assessment.
  • Article
    The limitations of pharmacotherapy and the acceptance of the stress–vulnerability model have contributed to an increase in adjunctive psychosocial therapies for bipolar disorder. While considerable attention has been given to cognitive-behavioral therapy (CBT) for bipolar disorder, the practical significance of CBT in reducing manic symptoms remains unexplored. The purpose of the present meta-analytic study is to determine the overall effect of CBT in reducing manic symptoms of adults diagnosed with a bipolar disorder. The results of the meta-analysis showed CBT had a small effect; weighted mean d of −0.26 (CI: −0.54 to 0.02, p > .05). The strengths and limitations of the study, as well as the need for future research are discussed.
  • Article
    review the conceptual underpinnings and empirical status of the cognitive and cognitive-behavioral interventions / despite their common core, these approaches differ with respect to the processes presumed to mediate and the procedures used to produce change / try to highlight this variability and to examine its relation to clinical efficacy depression and the prevention of relapse / panic and the anxiety disorders / eating disorders and obesity / child and adolescent disorders / substance abuse and the prevention of relapse / treatment of personality disorders / behavioral medicine / marital distress (PsycINFO Database Record (c) 2012 APA, all rights reserved)
  • Article
    Discusses ecological momentary assessments (EMAs), recently developed approaches for assessing behavioral and cognitive processes in their natural settings. Four qualities define EMA methods: 1) phenomena are assessed as they occur, 2) assessments are dependent upon careful timing, 3) assessments usually involve a substantial number of repeated observations, and 4) assessments are usually made in the environment that the S typically inhabits. Phenomena for which EMAs are relevant are reviewed, particularly rapidly fluctuating processes such as affect, pain perception, and coping efforts. Issues relevant to the application of EMAs are addressed, including choice of sampling scheme. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
  • The quality control of therapy in routine clinical practice depends to a large degree on the ability of therapists to evaluate accurately their own performance in administering therapy. However, the literature in many fields casts doubt on the accuracy of people's self-evaluations. This study aimed to examine the accuracy of therapists' judgments about their own competence in cognitive therapy. Twenty-two therapists rated a tape of one of their cognitive therapy sessions from the middle of therapy using the Cognitive Therapy Scale (CTS) and provided information about their profession and their training in cognitive therapy. An independent expert rater, blind to all information about the therapist, also rated these tapes on the CTS. Therapists were coded as Competent or Less Competent on the basis of the observer-rated CTS score. Whilst there was a significant correlation between self-ratings and expert ratings of competence, therapists significantly over-rated their competence relative to the expert rater. Less competent therapists over-rated their own competence to a greater degree than therapists who met criteria for competence. The finding that therapists, especially less competent therapists, over-rate their competence in cognitive therapy has serious implications for ensuring effective practice of cognitive therapy in routine clinical situations.
  • Article
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    Psychotherapy is regarded as the first-line treatment for people with borderline personality disorder. In recent years, several disorder-specific interventions have been developed. This is an update of a review published in the Cochrane Database of Systematic Reviews in 2006. To assess the effects of psychological interventions for borderline personality disorder (BPD). We searched the following databases: CENTRAL 2010(3), MEDLINE (1950 to October 2010), EMBASE (1980 to 2010, week 39), ASSIA (1987 to November 2010), BIOSIS (1985 to October 2010), CINAHL (1982 to October 2010), Dissertation Abstracts International (31 January 2011), National Criminal Justice Reference Service Abstracts (15 October 2010), PsycINFO (1872 to October Week 1 2010), Science Citation Index (1970 to 10 October 2010), Social Science Citation Index (1970 to 10 October 2010), Sociological Abstracts (1963 to October 2010), ZETOC (15 October 2010) and the metaRegister of Controlled Trials (15 October 2010). In addition, we searched Dissertation Abstracts International in January 2011 and ICTRP in August 2011. Randomised studies with samples of patients with BPD comparing a specific psychotherapeutic intervention against a control intervention without any specific mode of action or against a comparative specific psychotherapeutic intervention. Outcomes included overall BPD severity, BPD symptoms (DSM-IV criteria), psychopathology associated with but not specific to BPD, attrition and adverse effects. Two review authors independently selected studies, assessed the risk of bias in the studies and extracted data. Twenty-eight studies involving a total of 1804 participants with BPD were included. Interventions were classified as comprehensive psychotherapies if they included individual psychotherapy as a substantial part of the treatment programme, or as non-comprehensive if they did not.Among comprehensive psychotherapies, dialectical behaviour therapy (DBT), mentalisation-based treatment in a partial hospitalisation setting (MBT-PH), outpatient MBT (MBT-out), transference-focused therapy (TFP), cognitive behavioural therapy (CBT), dynamic deconstructive psychotherapy (DDP), interpersonal psychotherapy (IPT) and interpersonal therapy for BPD (IPT-BPD) were tested against a control condition. Direct comparisons of comprehensive psychotherapies included DBT versus client-centered therapy (CCT); schema-focused therapy (SFT) versus TFP; SFT versus SFT plus telephone availability of therapist in case of crisis (SFT+TA); cognitive therapy (CT) versus CCT, and CT versus IPT.Non-comprehensive psychotherapeutic interventions comprised DBT-group skills training only (DBT-ST), emotion regulation group therapy (ERG), schema-focused group therapy (SFT-G), systems training for emotional predictability and problem solving for borderline personality disorder (STEPPS), STEPPS plus individual therapy (STEPPS+IT), manual-assisted cognitive treatment (MACT) and psychoeducation (PE). The only direct comparison of an non-comprehensive psychotherapeutic intervention against another was MACT versus MACT plus therapeutic assessment (MACT+). Inpatient treatment was examined in one study where DBT for PTSD (DBT-PTSD) was compared with a waiting list control. No trials were identified for cognitive analytical therapy (CAT).Data were sparse for individual interventions, and allowed for meta-analytic pooling only for DBT compared with treatment as usual (TAU) for four outcomes. There were moderate to large statistically significant effects indicating a beneficial effect of DBT over TAU for anger (n = 46, two RCTs; standardised mean difference (SMD) -0.83, 95% confidence interval (CI) -1.43 to -0.22; I(2) = 0%), parasuicidality (n = 110, three RCTs; SMD -0.54, 95% CI -0.92 to -0.16; I(2) = 0%) and mental health (n = 74, two RCTs; SMD 0.65, 95% CI 0.07 to 1.24 I(2) = 30%). There was no indication of statistical superiority of DBT over TAU in terms of keeping participants in treatment (n = 252, five RCTs; risk ratio 1.25, 95% CI 0.54 to 2.92).All remaining findings were based on single study estimates of effect. Statistically significant between-group differences for comparisons of psychotherapies against controls were observed for BPD core pathology and associated psychopathology for the following interventions: DBT, DBT-PTSD, MBT-PH, MBT-out, TFP and IPT-BPD. IPT was only indicated as being effective in the treatment of associated depression. No statistically significant effects were found for CBT and DDP interventions on either outcome, with the effect sizes moderate for DDP and small for CBT. For comparisons between different comprehensive psychotherapies, statistically significant superiority was demonstrated for DBT over CCT (core and associated pathology) and SFT over TFP (BPD severity and treatment retention). There were also encouraging results for each of the non-comprehensive psychotherapeutic interventions investigated in terms of both core and associated pathology.No data were available for adverse effects of any psychotherapy. There are indications of beneficial effects for both comprehensive psychotherapies as well as non-comprehensive psychotherapeutic interventions for BPD core pathology and associated general psychopathology. DBT has been studied most intensely, followed by MBT, TFP, SFT and STEPPS. However, none of the treatments has a very robust evidence base, and there are some concerns regarding the quality of individual studies. Overall, the findings support a substantial role for psychotherapy in the treatment of people with BPD but clearly indicate a need for replicatory studies.
  • Article
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    The working alliance between therapist and patient is an important component of effective interventions for borderline personality disorder (BPD). The current study examines whether client personality affects the development of the working alliance during the treatment of BPD, and whether this influences treatment effectiveness. Data was based on 87 patients with BPD who were participants in a randomized controlled trial comparing Dialectical Behavior Therapy (DBT) and general psychiatric management. Higher levels of trait Agreeableness were associated with steeper increases in working alliance throughout treatment, but only in the DBT condition. Increases in working alliance were in turn associated with better clinical outcomes. Mediation models revealed a significant indirect path from Agreeableness to better clinical outcomes, mediated through larger improvements in working alliance over time. These results highlight the role that patient personality can play during the therapeutic process, with a specific focus on the importance of Agreeableness for alliance development.
  • Article
    Numerous studies have provided supportive evidence for the efficacy of exposure-based treatments for many psychological disorders. However, surprisingly few therapists use exposure therapy in the clinical setting. Although the limited use of exposure-based treatments may be partially attributable to a shortage of suitably trained therapists, exposure therapy also suffers from a “public relations problem” predicated upon concerns that it is cruel and at odds with some ethical considerations (e.g., first do no harm). This article provides an overview of ethical issues and considerations relevant to the use of exposure therapy. It is argued that the degree to which ethical issues become problematic in implementing exposure-based treatments is largely dependent upon the therapist's ability to create an adequately safe and professional context. Specific strategies that may be employed for avoiding potential ethical conflicts in the use of exposure-based treatments are discussed.
  • Article
    Reviews the research on computer programs for the assessment and cognitive behavioral treatment of anxiety disorders. Empirical findings on the use of computers for clinical diagnoses, as substitutes for paper and pencil assessment measures, as the sole providers of behavior therapy, and as an adjunct to clinician guidance are presented. Desktop and ambulatory computer technology and programs are described, their advantages and disadvantages are discussed, and suggestions for future research are provided. Although this review focuses on anxiety disorder research, most of the basic points that are made with respect to the computer technology and research apply to computer assessment and therapy as it relates to other disorders.
  • Article
    Full-text available
    Research in the dissemination of evidence-based practices (EBPs) suggests that practitioners' knowledge of and attitudes towards EBPs influence their decisions to adopt such practices. This study investigated the relationships between practitioner background variables and EBP knowledge and attitudes, as well as the relationship between knowledge and attitudes among public sector youth direct service providers (n = 240). Findings suggest that knowledge and attitudes relate to practitioners' most advanced degree, practice setting, and licensure status. Additionally, lack of knowledge in the form of EBP under-identification was related to negative attitudes. Findings are discussed as they relate to the dissemination of EBPs.
  • Article
    This study evaluated the efficacy of methods of training community mental health providers (N=132) in dialectical behavior therapy (DBT) distress tolerance skills, including (a) Linehan's (1993a) Skills Training Manual for Borderline Personality Disorder (Manual), (b) a multimedia e-Learning course covering the same content (e-DBT), and (c) a placebo control e-Learning course (e-Control). Participants were randomized to a condition, and the training took place in a highly structured and controlled learning environment. Assessments were completed at baseline, post-training, and 2, 7, 11, and 15 weeks following training. The results indicate that one or both of the active DBT conditions outperformed the control condition on all outcomes except motivation to learn and use the treatment. While clinicians preferred e-DBT over the Manual and found it more helpful and engaging, the active DBT conditions generally did not differ on the primary outcomes of knowledge and self-efficacy, with the exception that e-DBT significantly outperformed the Manual on knowledge at the 15-week follow-up. E-DBT also produced the highest rate of applying and teaching the newly learned skills in clinical practice. Overall, results from this study support the efficacy of e-Learning in disseminating knowledge of empirically supported treatments to clinicians, while also indicating that treatment manuals can be effective training tools.
  • Article
    To assess the efficacy of peer support for reducing symptoms of depression. Medline, PsycINFO, CINAHL and CENTRAL databases were searched for clinical trials published as of April 2010 using Medical Subject Headings and free text terms related to depression and peer support. Two independent reviewers selected randomized controlled trials (RCTs) that compared a peer support intervention for depression to usual care or a psychotherapy control condition. Meta-analyses were conducted to generate pooled standardized mean differences (SMD) in the change in depressive symptoms between study conditions. Seven RCTs of peer support vs. usual care for depression involving 869 participants were identified. Peer support interventions were superior to usual care in reducing depressive symptoms, with a pooled SMD of -0.59 (95% CI, -0.98 to -0.21; P=.002). Seven RCTs with 301 total participants compared peer support to group cognitive behavioral therapy (CBT). There was no statistically significant difference between group CBT and peer interventions, with a pooled SMD of 0.10 (95% CI, -0.20 to 0.39, P=.53). Based on the available evidence, peer support interventions help reduce symptoms of depression. Additional studies are needed to determine effectiveness in primary care and other settings with limited mental health resources.
  • Article
    Full-text available
    The authors describe the development and psychometric properties of a new measure called the Skills of Cognitive Therapy (SoCT) in depressed adults and their cognitive therapists. The 8-item SoCT assesses patients' understanding and use of basic cognitive therapy (CT) skills rated from the perspectives of both observers (SoCT-O; therapists in this report) and patients (SoCT-P). Ratings of patients' skill usage are made on 5-point Likert-type scales ranging from 1 (never) to 5 (always or when needed). Higher scores reflect greater patient skill in applying cognitive therapy principles and coping strategies. To develop this scale, a 33-item pool was used, rated by both patients and their therapists at the middle and end of CT (Ns = 359-416), and evaluated the reliability and concurrent and predictive validity of both versions of the scale. The SoCT has excellent internal consistency reliability and moderate correlations between the observer and patient versions. It is important to note that the SoCT showed good predictive validity for response when collected at the midpoint of acute phase CT. Considering both patients' self-ratings and clinicians' SoCT ratings, the odds ratio for responding to CT was 2.6. The practical utility of the SoCT is discussed, as well as its theoretical importance in research of patient CT skills (e.g., acquisition, comprehension, and generalization) as putative moderators or mechanisms of symptom change in the therapy.
  • Article
    Technology-based self-help and minimal contact therapies have been proposed as effective and low-cost interventions for anxiety and mood disorders. The present article reviews the literature published before 2010 on these treatments for anxiety and depression using self-help and decreased therapist-contact interventions. Treatment studies are examined by disorder as well as amount of therapist contact, ranging from self-administered therapy and predominantly self-help interventions to minimal contact therapy where the therapist is actively involved in treatment but to a lesser degree than traditional therapy and predominantly therapist-administered treatments involving regular contact with a therapist for a typical number of sessions. In the treatment of anxiety disorders, it is concluded that self-administered and predominantly self-help interventions are most effective for motivated clients. Conversely, minimal-contact therapies have demonstrated efficacy for the greatest variety of anxiety diagnoses when accounting for both attrition and compliance. Additionally, predominantly self-help computer-based cognitive and behavioral interventions are efficacious in the treatment of subthreshold mood disorders. However, therapist-assisted treatments remain optimal in the treatment of clinical levels of depression. Although the most efficacious amount of therapist contact varies by disorder, computerized treatments have been shown to be a less-intensive, cost-effective way to deliver empirically validated treatments for a variety of psychological problems.
  • Article
    Technology-based self-help and minimal contact therapies have been proposed as effective and low-cost interventions for addictive disorders, such as nicotine, alcohol, and drug abuse and addiction. The present article reviews the literature published before 2010 on computerized treatments for drug and alcohol abuse and dependence and smoking addiction. Treatment studies are examined by disorder as well as amount of therapist contact, ranging from self-administered therapy and predominantly self-help interventions to minimal contact therapy where the therapist is actively involved in treatment but to a lesser degree than traditional therapy and predominantly therapist-administered treatments involving regular contact with a therapist for a typical number of sessions. In the treatment of substance use and abuse it is concluded that self-administered and predominantly self-help computer-based cognitive and behavioral interventions are efficacious, but some therapist contact is important for greater and more sustained reductions in addictive behavior.
  • Article
    Early intervention services for psychosis aim to detect emergent symptoms, reduce the duration of untreated psychosis, and improve access to effective treatments. To evaluate the effectiveness of early intervention services, cognitive-behavioural therapy (CBT) and family intervention in early psychosis. Systematic review and meta-analysis of randomised controlled trials of early intervention services, CBT and family intervention for people with early psychosis. Early intervention services reduced hospital admission, relapse rates and symptom severity, and improved access to and engagement with treatment. Used alone, family intervention reduced relapse and hospital admission rates, whereas CBT reduced the severity of symptoms with little impact on relapse or hospital admission. For people with early psychosis, early intervention services appear to have clinically important benefits over standard care. Including CBT and family intervention within the service may contribute to improved outcomes in this critical period. The longer-term benefits of this approach and its component treatments for people with early and established psychosis need further research.
  • Article
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    Depression and anxiety disorders are common and treatable with cognitive behavior therapy (CBT), but access to this therapy is limited. Review evidence that computerized CBT for the anxiety and depressive disorders is acceptable to patients and effective in the short and longer term. Systematic reviews and data bases were searched for randomized controlled trials of computerized cognitive behavior therapy versus a treatment or control condition in people who met diagnostic criteria for major depression, panic disorder, social phobia or generalized anxiety disorder. Number randomized, superiority of treatment versus control (Hedges g) on primary outcome measure, risk of bias, length of follow up, patient adherence and satisfaction were extracted. 22 studies of comparisons with a control group were identified. The mean effect size superiority was 0.88 (NNT 2.13), and the benefit was evident across all four disorders. Improvement from computerized CBT was maintained for a median of 26 weeks follow-up. Acceptability, as indicated by adherence and satisfaction, was good. Research probity was good and bias risk low. Effect sizes were non-significantly higher in comparisons with waitlist than with active treatment control conditions. Five studies comparing computerized CBT with traditional face-to-face CBT were identified, and both modes of treatment appeared equally beneficial. Computerized CBT for anxiety and depressive disorders, especially via the internet, has the capacity to provide effective acceptable and practical health care for those who might otherwise remain untreated. Australian New Zealand Clinical Trials Registry ACTRN12610000030077.
  • Article
    It is widely acknowledged that the prevalence of depression in the general population is high, but that it is even higher for patients with medical disorders. Yet, the effectiveness of psychological treatments in these patient populations has not been firmly established. We conducted a meta-analysis of randomized controlled studies examining the effects of psychological treatments in patients with 1 of 10 different medical disorders and elevated levels of depression. Extensive searches were performed in PubMed, PsycINFO, Embase, and the Cochrane Central Register of Controlled Trials. We included 23 studies. The overall effect size of the 15 studies that compared psychological treatments with a waitlist or care-as-usual control group was d=1.00 [95% confidence interval (CI), 0.57-1.44] but declined to d=0.42 (95% CI, 0.27-0.58) after removing two outliers with extremely high effects. We tested the type of disorder, inclusion based on diagnostic criteria or symptoms, type of treatment, treatment format, type of control group, and intention-to-treat or completers analyses, but none of these variables were significantly associated with the effect. The four studies that compared one type of psychotherapy to another showed a positive effect of cognitive behavioral therapy and interpersonal therapy compared to supportive therapy (d=0.42; 95% CI, 0.14-0.69). There were not enough studies (n=3) to draw any conclusions about the comparison of psychotherapy to pharmacotherapy. We conclude that the effects of psychological treatment of patients with medical disorders are very similar to those found in otherwise healthy patients. Treating this comorbid depression should be one of the priorities in medical care settings.
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    Aim of this systematic review was critical presentation of psychosocial approaches in bipolar disorders with regard to their fundamentals and impact on the clinical course and outcome of the illness. PubMed, Medline, PsycINFO and Turkish databases between 1980 and 2009 were searched by using keywords "bipolar disorder" and "psychotherapy", "psychosocial approaches", "psychological intervention". Randomized controlled trials, reviews and meta analysis were included. Fifty studies met the inclusion criteria where four types of interventions -psychoeducation, family focused, cognitive behavioral and interpersonal psychosocial rhythm therapy-were studied. Twenty two of 24 original research papers were randomized controlled trials, 23 were reviews and 3 were meta analysis. In almost all studies psychotherapeutic approach was applied as adjunctive to pharmacotherapy. Group psychoeducation was more effective in preventing manic relapses, whereas cognitive behavioral and family focused therapies showed efficacy in preventing depressive episodes. Additional benefits on such secondary outcomes as medication compliance, number and duration of hospitalizations, time to recurrence were reported. Effects on functionality and quality of life were assessed rarely, but reported to be beneficial. Cultural adaptation studies are scarce and needs exploration. Psychosocial interventions adjunctive to pharmacotherapy in bipolar disorder seem to be effective in relapse prevention. Stage of illness where the therapy is initiated and the targeted episode for prevention varies between interventions. Future studies are needed to strengthen the place of psychosocial interventions in treatment guidelines and would contribute to narrow the gap between effectiveness of pharmacotherapy and functional improvement.
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    Recognizing an urgent need for increased access to evidenced-based psychological treatments, public health authorities have recently allocated over $2 billion to better disseminate these interventions. In response, implementation of these programs has begun, some of it on a very large scale, with substantial implications for the science and profession of psychology. But methods to transport treatments to service delivery settings have developed independently without strong evidence for, or even a consensus on, best practices for accomplishing this task or for measuring successful outcomes of training. This article reviews current leading efforts at the national, state, and individual treatment developer levels to integrate evidence-based interventions into service delivery settings. Programs are reviewed in the context of the accumulated wisdom of dissemination and implementation science and of methods for assessment of outcomes for training efforts. Recommendations for future implementation strategies will derive from evaluating outcomes of training procedures and developing a consensus on necessary training elements to be used in these efforts.
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    There is no clear evidence to guide mental health professionals in assessing and treating angry clients. Recent reviews have considered cognitive and behavioral approaches to the treatment of anger, but little is known about the potential effectiveness of other treatment modalities. A meta-analytic review was conducted to examine the effects of treating dimensions of anger by using various psychological treatments found in the scientific literature. The final analysis included 96 studies and 139 treatment effects. The nine types of psychological treatments included cognitive, cognitive behavior therapy, exposure, psychodynamic, psychoeducational, relaxation-based, skills-based, stress inoculation, and multicomponent. The overall weighted standardized mean difference across all treatments was 0.76 (95% confidence interval [CI], 0.67-0.85, Q = 403.13, df 138, p < .001, I(2) = 65.76), which suggests that psychological treatments are generally effective in treating anger. The results also suggest a considerable degree of variability in the effect sizes of specific treatments for anger. The results show that at least some of the variability may be explained by the number of treatment sessions offered to participants, the use of manuals to guide delivery of the treatment, the use of fidelity checks, the setting of the research, and whether the study was published or unpublished. This review builds on previous evidence of the effectiveness of psychological treatments of maladaptive anger, and it provides the basis for developing evidence-based guidelines for specific populations with anger problems.
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    The current study examined whether the personality traits of self-criticism or dependency moderated the effect of stressful life events on treatment response. Depressed outpatients (N = 113) were randomized to 16 weeks of cognitive-behavioral therapy, interpersonal psychotherapy, or antidepressant medication (ADM). Stressful life events were assessed with the Bedford College Life Events and Difficulties Schedule. Severe events reported during or immediately prior to treatment predicted poor response in the ADM condition but not in the psychotherapy conditions. In contrast, nonsevere life events experienced prior to onset predicted superior response to treatment. Further, self-criticism moderated the relation of severe life events to outcome across conditions, such that in the presence of severe stress those high in self-criticism were less likely to respond to treatment than were those low in self-criticism.
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    Cognitive-behavioral therapies for anxiety disorders are highly efficacious (e.g., Butler, Chapman, Forman, & Beck, 2006; Deacon & Abramowitz, 2004). These treatments nevertheless remain underutilized and difficult to access for many of the patients who suffer from these conditions (e.g., Norton & Hope, 2005). We identify various barriers to the wide-scale dissemination of these treatments, including those that are applicable to empirically supported treatments more generally (e.g., lack of training opportunities, failure to address practitioner concerns) as well as those that may be relatively specific to CBT for anxiety disorders (e.g., practitioner concerns around using exposure interventions). We offer suggestions for overcoming these barriers, including specific guidance about continued accumulation of a supportive research base, making the appeals that are necessary to obtain required funding and organizational support, and the training of practitioners to deliver these treatments. Advocates of CBT for anxiety disorders will need to demonstrate that these treatments are cost effective, if wide-scale dissemination is to occur. In the United States, advocacy with third party payers will also be necessary. Although providing such steps may prove to be a difficult endeavour, the patients who stand to benefit from this work deserve nothing less.
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    The authors sought to evaluate the clinical efficacy of dialectical behavior therapy compared with general psychiatric management, including a combination of psychodynamically informed therapy and symptom-targeted medication management derived from specific recommendations in APA guidelines for borderline personality disorder. This was a single-blind trial in which 180 patients diagnosed with borderline personality disorder who had at least two suicidal or nonsuicidal self-injurious episodes in the past 5 years were randomly assigned to receive 1 year of dialectical behavior therapy or general psychiatric management. The primary outcome measures, assessed at baseline and every 4 months over the treatment period, were frequency and severity of suicidal and nonsuicidal self-harm episodes. Both groups showed improvement on the majority of clinical outcome measures after 1 year of treatment, including significant reductions in the frequency and severity of suicidal and nonsuicidal self-injurious episodes and significant improvements in most secondary clinical outcomes. Both groups had a reduction in general health care utilization, including emergency visits and psychiatric hospital days, as well as significant improvements in borderline personality disorder symptoms, symptom distress, depression, anger, and interpersonal functioning. No significant differences across any outcomes were found between groups. These results suggest that individuals with borderline personality disorder benefited equally from dialectical behavior therapy and a well-specified treatment delivered by psychiatrists with expertise in the treatment of borderline personality disorder.
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    This paper highlights the development of pharmacological and nonpharmacological treatments for pathological gambling and is based on a review of the literature published in the past 12 months. The efficacy of naltrexone treatment for pathological gambling has been replicated in a double-blind, placebo-controlled, confirmatory study. For mood stabilizers, whereas carbamazepine and topiramate continued to produce positive results, olanzapine failed to show superior outcomes compared with placebo control. Two new pharmacological agents for pathological gambling, N-acetyl cysteine and modafinil, produced significant improvement for pathological gamblers. Several studies examined the outcomes of nonpharmacological treatments. Recent studies showed that cognitive-behavioral therapy failed to produce superior outcomes compared with other less costly methods such as brief interventions. Two new nonpharmacological treatment methods have been reported, including the use of videoconferencing in delivering ongoing supervisions after exposure therapy and the congruence couple therapy, which aims to heal the person as a system whole. Recent treatment outcomes studies address not only the effectiveness, but also the efficacy of different treatment approaches. Results of two meta-analysis studies showed that nonpharmacological treatments have a larger overall effect size than pharmacological treatments; however, owing to the diversity in study designs, it is unclear whether nonpharmacological treatments are more effective than pharmacological treatments at this point.
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    Random regression models (RRMs) were used to investigate the role of initial severity in the outcome of 4 treatments (cognitive-behavior therapy [CBT], interpersonal psychotherapy [IPT], imipramine plus clinical management [IMI-CM], and placebo plus clinical management [PLA-CM]) for outpatients with major depressive disorder seen in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Initial severity of depression and impairment of functioning significantly predicted differential treatment effects. A larger number of differences than previously reported were found among the active treatments for the more severely ill patients; this was due, in large part, to the greater power of the present statistical analyses.