Improving the efficiency of cognitive-behavioural therapy by using formal client feedback

Objective: Feedback from clients on their view of progress and the therapeutic relationship can improve effectiveness and efficiency of psychological treatments in general. However, what the added value is of client feedback specifically within cognitive-behavioural therapy (CBT), is not known. Therefore, the extent to which the outcome of CBT can be improved is investigated by providing feedback from clients to therapists using the Outcome Rating Scale (ORS) and Session Rating Scale (SRS). Method: Outpatients (n?=?1006) of a Dutch mental health organization either participated in the “treatment as usual” (TAU) condition, or in Feedback condition of the study. Clients were invited to fill in the ORS and SRS and in the Feedback condition therapists were asked to frequently discuss client feedback. Results: Outcome on the SCL-90 was only improved specifically with mood disorders in the Feedback condition. Also, in the Feedback condition, in terms of process, the total number of required treatment sessions was on average two sessions fewer. Conclusion: Frequently asking feedback from clients using the ORS/SRS does not necessarily result in a better treatment outcome in CBT. However, for an equal treatment outcome significantly fewer sessions are needed within the Feedback condition, thus improving efficiency of CBT.     

Motivational interviewing and cognitive behaviour therapy for anxiety following traumatic brain injury: A pilot randomised controlled trial

Although cognitive-behavioural therapy (CBT) is the treatment of choice for anxiety, its delivery needs to be adapted for individuals with traumatic brain injury (TBI). It also requires clients' active engagement for maximum benefit. This study was a pilot randomised controlled trial involving an anxiety treatment programme adapted for people with TBI, based on CBT and motivational interviewing (MI). Twenty-seven participants with moderate/severe TBI (aged 21–73 years, 78% males) recruited from a brain injury rehabilitation hospital were randomly allocated to receive MI?+?CBT (n?=?9), non-directive counselling (NDC)?+?CBT (n?=?10) and treatment-as-usual (TAU) (n?=?8). CBT and MI were manualised and delivered in 12 weekly individual sessions. Primary outcome was self-reported anxiety symptoms assessed at baseline, at the end of NDC/MI and immediately following CBT. Assessment was conducted by assessors blinded to group assignment. Intention-to-treat analyses showed that the two active treatment groups demonstrated significantly greater anxiety reduction than TAU. Participants receiving MI showed greater response to CBT, in terms of reduction in anxiety, stress and non-productive coping, compared to participants who received NDC. The results provided preliminary support for the adapted CBT programme, and the potential utility of MI as treatment prelude. Longer follow-up data are required to evaluate the maintenance of treatment effects.     

Group cognitive behavioural therapy for obsessive-compulsive disorder: a systematic review and meta-analysis

Objective: Behaviour therapy with exposure and response prevention (ERP) or cognitive behavioural therapy (CBT) including ERP are considered the psychological treatments of choice for obsessive–compulsive disorder (OCD), but group CBT/ERP has received relatively little research attention in the treatment of OCD. The aim of this study was to provide a meta‐analysis of the effectiveness of group CBT/ERP for OCD. Method: A systematic literature search was conducted and studies were meta‐analysed by means of the Cochrane Review Manager Program with measures of i) pre‐ to post‐effect sizes (ES) and ii) between‐group ES in comparison with different control conditions. Outcome was primarily measured on the Y‐BOCS and ES was calculated in the form of Cohens d. Results: Thirteen trials were included in the meta‐analysis. The overall pre–post‐ES of these trials of 1.18 and a between‐group ES of 1.12 compared with waiting list control in three randomized controlled studies indicate that group CBT/ERP is an effective treatment for OCD. Group CBT achieved better results than pharmacological treatment in two studies. One study found no significant differences between individual and group CBT. Conclusion: Group CBT is an effective treatment for OCD, but more studies are needed to compare the effectiveness of group and individual treatment formats.     

Patient–therapist convergence in alliance ratings as a predictor of outcome in psychotherapy for generalized anxiety disorder

Objective: Although patients and therapists aligning over time on their perceptions of alliance quality is regarded as clinically important, few studies have examined the influence of such dyadic convergence on psychotherapy outcomes. This study tested whether early treatment convergence in patient–therapist alliance ratings was associated with subsequent worry and distress reduction in psychotherapy for generalized anxiety disorder (GAD), and whether treatment type and the dyad members’ initial alliance perceptions moderated these associations. Method: Data derived from a randomized trial for which patients with severe GAD received either 15 sessions of standard cognitive-behavioral therapy (CBT; n?=?43) or CBT integrated with motivational interviewing (n?=?42). Patients and therapists rated the alliance after each session. Patients rated worry after each session, and their distress multiple times. Results: As predicted, dyadic multilevel modeling revealed that early alliance convergence was associated with greater subsequent worry (p?=?.03) and distress (p?=?.01) reduction, and the combination of low initial patient-rated alliance and low convergence was associated with the worst outcome for the distress variable (p?=?.04). Conclusions: Results suggest that alliance convergence may be an important clinical process that bears on outcome, rendering it an important marker for therapist responsiveness.     

Attachment characteristics and treatment outcome following inpatient psychotherapy: Results of a multisite study

Abstract

Existential suffering may contribute to treatment-resistant depression. The “VITA” treatment model was designed for such patients with long-standing depression accompanied by existential and/or religious concerns. This naturalistic effectiveness study compared the VITA model (n = 50) with a “treatment as usual” comparison group (TAU; n = 50) of patients with treatment-resistant depression and Cluster C comorbidity. The TAU patients were matched on several characteristics with the VITA patients. The VITA model included existential, dynamic, narrative and affect-focused components. The VITA group had significantly greater improvement on symptom distress and relational problems during treatment and from pre-treatment to 1-year follow-up. Patients in the VITA, at follow-up, were more likely to be employed and less likely be using psychotropic medications.     

Childhood,adolescent and adult age at onset and related clinical correlates in obsessive–compulsive disorder: a report from the International College of Obsessive–Compulsive Spectrum Disorders (ICOCS)

Objective: Many studies suggest that age at onset (AAO) is an important factor for clinically differentiating patients with juvenile and adult onset of obsessive–compulsive disorder (OCD). The present international study aimed to assess the prevalence of different AAO groups and compare related socio-demographic and clinical features in a large sample of OCD patients.

Methods: A total of 431 OCD outpatients, participating in the ICOCS network, were first categorised in groups with childhood (≤12 years), adolescent (13–17 years) and adult-onset (≥18 years), then in pre-adult and adult onset (≥18 years) and their socio-demographic and clinical features compared.

Results: Twenty-one percent (n?=?92) of the sample reported childhood onset, 36% (n?=?155) adolescent onset, and 43% (n?=?184) adult onset. Patients with adult onset showed a significantly higher proportion of females compared with the other subgroups (χ^2?=^?10.9, pχ^2?=^?11.5; p?Conclusions: The present international multicentre study confirms that OCD onset occurs more frequently before adult age, with approximately one out of five patients showing childhood onset. Pre-adult onset was associated with higher rate of CBT, while adult onset was more prevalent in females.     

Efficacy of group psychotherapy for posttraumatic stress disorder: Systematic review and meta-analysis of randomized controlled trials

Objective: The present meta-analysis evaluates the efficacy of group psychotherapy for post-traumatic stress disorder (PTSD) in adults directly compared to no treatment or active treatments examined in randomized controlled trials (RCTs). Method: Electronic databases were searched for eligible studies. Effects on PTSD symptoms, depression, and anxiety were extracted. Between- and within-group effect sizes (Hedges’ g) were calculated using a random-effects model. Data were adjusted to account for dependencies among observations in groups. Results: Twenty RCTs were included comprising 2244 individuals. Results showed significant effects of group psychotherapy in reducing symptoms of PTSD compared to no-treatment control groups (k?=?13; g?=?0.70; 95% CI: 0.41; 0.99). No significant differences in efficacy were found between group psychotherapy and other active treatments (k?=?8; g?=?0.13; 95% CI: ?0.16; 0.42). Moderator analyses confirmed gender and trauma type as important moderators of within-treatment effects for PTSD. Conclusions: Group treatments are associated with improvements in symptoms of PTSD. Particularly, the efficacy of exposure-based cognitive-behavioral group therapy (group CBT) is empirically well demonstrated. Still little is known about the effects of group treatment approaches other than CBT and the comparative efficacy to alternative treatments such as individual therapy or pharmacotherapy.

Clinical or Methodological Significance of this Article: This review provides an empirical base for group therapy as a viable treatment alternative for future PTSD practice guidelines. Although less is known about its comparative efficacy to alternative PTSD treatments such as individual therapy or pharmacotherapy, sufficient evidence exists to recommend group therapy (particularly exposure-based group CBT) for those who might not be able to access alternative treatments. Trauma type and gender proved to be important moderators of group treatment outcome. The results further indicate that the evidence base of recommendations for group therapy in current international treatment guidelines needs to be updated.     

Home-based parent training for school-aged children with attention-deficit/hyperactivity disorder and behavior problems with remaining impairing disruptive behaviors after routine treatment: a randomized controlled trial

The objective is to investigate the effectiveness of home-based behavioral parent training for school-aged children with attention-deficit/hyperactivity disorder (ADHD) and behavior problems with remaining impairing disruptive behaviors after routinely offered treatments in clinical practice. In a randomized controlled study including 73 referred children with ADHD and impairing disruptive symptoms after routine clinical pharmacotherapy and/or clinic-based parent training had been tried or, at least, offered, home-based behavioral parent training (n?=?26) was compared to a waiting list (n?=?23) and a care-as-usual home-based treatment (n?=?24). It was unknown to families which of the home-based treatments that they received. Using mixed models for repeated measures, we examined the effectiveness on the primary outcome measure of children’s severity of disruptive behaviors and on a number of secondary outcome measures [the degree to which parents experienced the disruptive behaviors as troublesome, ADHD symptoms, oppositional-defiant disorder (ODD) symptoms, and internalizing problems]. Compared to the waiting list, children receiving home-based parent training improved significantly more regarding severity of disruptive behaviors (ES?=?0.75), ADHD symptoms (ES?=?0.89), ODD symptoms (ES?=?0.65), and internalizing problems (ES?=?0.60). Compared to care-as-usual, home-based parent training was more effective in reducing disruptive behaviors (ES?=?0.57), ADHD symptoms (ES?=?0.89), and ODD symptoms (ES?=?0.88). Significantly more reduction of children’s internalizing problems was not found. In conclusion, children with ADHD and residual behavioral problems after routine treatment may benefit from home-based behavioral parent training.

     

Effectiveness of a brief psychotherapeutic intervention compared with treatment as usual for adolescent nonsuicidal self-injury: a single-centre,randomised controlled trial

Although nonsuicidal self-injury (NSSI) is a clinically significant behavior, evidence-based, specific, time-, and cost-effective treatment approaches are lacking. The aim of this study was to compare the efficacies of a brief cognitive-behavioral psychotherapy manual, the Cutting Down Programme (CDP), and treatment as usual (TAU) in the treatment of adolescent NSSI. We conducted a single-centre randomised controlled trial (RCT). Eligible participants were aged 12–17 years engaging in repetitive NSSI (at least 5 times within the past 6 months). We randomly allocated 74 participants to CDP (n?=?37) or TAU (n?=?37; in a 1:1 ratio). Outcome measures were administered before treatment (T0), directly after CDP or 4 months after baseline evaluation in the TAU group (T1), and another 6 months later (T2; primary endpoint). Primary outcome was a 50% reduction in NSSI frequency within the past 6 months at 10-month follow-up (T2). Regarding the primary outcome, there were no significant differences between the CDP (n?=?26; 70.3%) and TAU group [n?=?27; 73.0%; χ²(1)?=?0.07; p?=?0.797]; NSSI frequency within the past 6 months was significantly reduced at T2 [χ²(1)?=?12.45; p?<?0.001] with no between-group difference [χ²(1)?=?0.14; p?=?0.704]. However, we found a significant group x point of measurement interaction [χ²(2)?=?7.78; p?=?0.021] regarding NSSI within the last month indicating at T1. CDP was equally effective and achieved faster recovery compared to a significantly more intensive TAU in treating adolescent NSSI. The CDP could provide a brief and pragmatic first treatment within a stepped-care model for NSSI in routine clinical care.

Clinical Trial Registration The trial was prospectively registered in the German Registry of Clinical Trials (https://www.drks.de; DRKS00003605) and is now complete.

     

Differential effectiveness of group,individual, and conjoint treatments: An archival analysis of OQ-45 change trajectories

Objective: While empirically-supported treatment (EST) choices are continually expanding, choices regarding formats for delivery (individual only, group only, or conjoint [simultaneous individual &; group]) are often determined by agency resources or clinician preference. Studies comparing individual and group formats have produced mixed results, while recent meta-analytic reviews support format equivalence. Method: We employed a multilevel model to test for outcome differences using the OQ-45 on an outpatient archival data set of clients receiving individual-only (n?=?11,764), group-only (n?=?152) or conjoint (n?=?1557). Results: Individual and group outcomes were equivalent with some analyses showing conjoint trailing. Moderators of change included initial distress, treatment duration, intra-group dependency, and format. Conclusions: Results support meta-analytic findings of format equivalence in a naturalistic setting for group and individual. Referral practices and future results are discussed.     

Relaxation-induced anxiety: Effects of peak and trajectories of change on treatment outcome for generalized anxiety disorder

Objective: Evidence is mixed regarding whether relaxation-induced anxiety (RIA) impedes relaxation training (RT) efficacy. Unlike past studies that averaged RIA across sessions, we examined peak RIA, change in RIA level across sessions, and timing of peak RIA with outcome. Method: This was a secondary analysis of Borkovec, Newman, Pincus, and Lytle [2002. A component analysis of cognitive-behavioral therapy for generalized anxiety disorder and the role of interpersonal problems. Journal of Consulting and Clinical Psychology, 70, 288–298. doi:10.1037/0022-006X.70.2.288]. Forty-one GAD participants were assigned randomly to CBT (n?=?22) or BT (n?=?19). Both treatments contained RT and RIA ratings within 13/14 sessions. Analyses used generalized additive mixed models (GAMMs), which accounted for longitudinal nonindependence and examined nonlinear trajectories of change. Results: All participants improved significantly regardless of RIA. “Change trajectory of RIA level did not predict outcome”. Instead, lower peak RIA predicted fewer GAD symptoms at post-treatment and greater likelihood to continue to improve during follow-up. Also, timing of peak was important. Whereas lower peak early in therapy did not predict outcome, lower peak during the last third of treatment did. Peak RIA’s effect was neither accounted for by baseline symptom severity, treatment condition, comorbidity, nor by preceding or concurrent anxiety symptom change. Conclusions: People with consistently low peak RIA and/or who fully habituate to RIA by the end of therapy respond optimally to relaxation-based treatments.     

The predictive value of early response in patients with depressive disorders

Objective: Several randomized controlled trials have identified early response to psychotherapy as a predictor for later treatment outcome among patients with depressive disorders. However, supporting evidence under routine conditions is rare. This study evaluated the predictive value of early improvement for final outcomes in psychotherapy among depressive patients in the naturalistic setting of a German university outpatient clinic. Method: We used the method of percent symptom reduction to classify 639 patients with major depression or dysthymic disorder who underwent an average of 40.0 sessions (SD?=?16.3) of naturalistic cognitive–behavioral therapy (CBT) as having either an early response or an early nonresponse. Results: Early response was a good predictor for final response and remission regarding depressive symptoms (OR?=?8.75 and OR?=?5.32, respectively), as well as overall psychological distress (OR?=?3.95 and OR?=?3.16, respectively). Early nonresponse was distinctly associated with later deterioration of both depressive (OR?=?9.56) and general psychological symptomatology (OR?=?4.92). Conclusions: Early response to psychotherapy has high predictive qualities for positive later treatment outcome in depressive patients under routine CBT. Therefore, early treatment effects should be considered in clinical decision-making and treatment planning in everyday clinical practice.     

Specific and common processes as mediators of the long-term effects of cognitive-behavioral therapy integrated with motivational interviewing for generalized anxiety disorder

Objective: A trial of psychotherapy for generalized anxiety disorder (GAD) demonstrated that motivational interviewing (MI) integrated with cognitive-behavioral therapy (CBT) outperformed CBT alone on clients’ worry reduction across a 12-month follow-up. In the present study, we hypothesized and tested that less client resistance and greater client-perceived therapist empathy (specific foci of MI) would account for MI’s additive effect. Exploratory analyses assessed whether the common processes of homework completion and therapeutic alliance quality mediated the treatment effect. Method: Clients with GAD were randomized to 15 sessions of MI-CBT (n?=?42) or CBT alone (n?=?43). Worry was assessed throughout treatment and follow-up. Observers rated resistance at midtreatment, and clients reported on perceived therapist empathy, alliance, and homework completion throughout treatment. Mediation was tested with bootstrapping methods. Results: Expectedly, MI-CBT clients evidenced less resistance and perceived greater therapist empathy, each of which related to lower 12-month worry. However, when both variables were tested simultaneously, only resistance remained a significant mediator of treatment. No indirect effects through homework completion or alliance emerged. Conclusions: Reducing client resistance may be a theory-consistent mechanism through which integrative MI-CBT promotes superior long-term improvement than traditional CBT when treating GAD.

Clinical or methodological significance of this article: This study further supports the long-term clinical benefit of integrating MI into CBT when treating the highly prevalent and historically difficult-to-treat condition of GAD. In particular, it points to the theory-specific mechanism of MI (helping to reduce/resolve patients’ in-treatment resistance) as accounting for the integrative treatment’s additive effect on worry reduction across a follow-up period. Therapists using CBT to treat patients with GAD should be trained to incorporate MI principles (e.g., empathy, collaboration, autonomy support) in general and in response to explicit markers of resistance.     

Client interpersonal impacts as mediators of long-term outcome in cognitive-behavioral therapy integrated with motivational interviewing for generalized anxiety disorder

Objective: A recent trial of generalized anxiety disorder treatment (Westra, H. A., Constantino, M. J., &; Antony, M. M. (2016). Integrating Motivational Interviewing With Cognitive-Behavioral Therapy for Severe Generalized Anxiety Disorder: An Allegiance-Controlled Randomized Clinical Trial. Journal of Consulting and Clinical Psychology, 84, 768–782. doi:10.1037/ccp0000098) revealed that cognitive-behavioral therapy (CBT) integrated with motivational interviewing (MI) outperformed CBT alone across a 12-month follow up. The present study examined whether this treatment effect was mediated by MI-CBT clients engaging over time in during-session interpersonal behaviors reflecting more friendly dominance, or agentic actions, and less friendly submissiveness (FS), or trustingly compliant actions both theory-specific MI mechanisms. Method: Clients received 15 sessions of MI-CBT (n?=?42) or CBT alone (n?=?43). Therapists rated client interpersonal behavior following five sessions, and clients rated their worry at baseline, each session, and 6- and 12-month follow up. Mediator and outcome variables were derived from multilevel models. Mediation was tested using a bootstrapping procedure. Results: There was a significant indirect effect for FS. As expected, CBT clients evidenced greater increases in FS than MI-CBT clients, which in turn, though unexpectedly, related to lower 12-month worry. However, long-term CBT outcomes remained inferior to MI-CBT outcomes even with CBT clients’greater increase in FS. Conclusions: Results suggest that CBT outcomes are more positive when clients trustingly comply; however, MI-CBT remained superior, but for as yet unexplained reasons.     

A randomized-controlled trial of cognitive–behavioral therapy for depression with integrated techniques from emotion-focused and exposure therapies

Background: Emotional processing (EP) is hypothesized to be a key mechanism of change in psychotherapy that may enhance its long-term efficacy. To study the effects of fostering EP in psychotherapy for depression, this randomized-controlled clinical trial compares the efficacy and pattern of change of a cognitive–behavioral therapy that integrates emotion-focused techniques within an exposure framework (Exposure-Based Cognitive Therapy for depression; EBCT-R) to a standard cognitive–behavioral therapy (CBT). Methods: One hundred and forty-nine depressed outpatients were randomized to a maximum of 22 sessions of manualized EBCT-R (N?=?77) or CBT (N?=?72). Primary outcomes were self-reported and clinician-rated depressive symptoms at posttreatment and 12-month follow-up. Secondary outcomes were self-esteem, interpersonal problems, and avoidance thoughts and behaviors. Results: Depressive symptoms improved significantly over therapy in both treatments, with large within-group effect sizes for CBT (d?=??1.95) and EBCT-R (d?=??1.77). The pattern of depression change during treatment did not differ between treatments. Symptom relief lasted over 12 months and did not differ between EBCT-R and CBT. Conclusions: Results suggest that both treatments produced significant short- and long-term improvement in depression symptoms, but the integration of emotion-focused techniques within an exposure framework did not have added benefit.

Trial registration: ClinicalTrials.gov Identifier: NCT01012856     

Development and preliminary validation of a Finnish version of the Eating Disorder Examination Questionnaire (EDE-Q)

Background: Eating behaviour can be viewed as a continuum, ranging from extremely restrictive to extremely disinhibited eating. Valid and reliable instruments are needed to ensure detection of individuals with risk for eating disorders (ED). Self-report methods are the most feasible, cost, and time efficient. One of the most widely used self-reports is the Eating Disorder Examination Questionnaire (EDE-Q).

Aim: The aim of this study was to develop a Finnish version of the EDE-Q version 6.0 and to assess its psychometric properties in adolescents, adults, and ED patients.

Methods: The present study utilized data from three different samples: adolescents (n?=?242), adults (n?=?133), and ED patients (n?=?52). The patient group comprised different EDs, but individual ED diagnoses were not studied separately. Data was collected January 2014 through June 2015.

Results: The Finnish version of the EDE-Q showed acceptable-to-excellent internal consistency on all sub-scales in all three samples and discriminated patients from healthy individuals. Female participants generally scored higher than male and sex differences were more pronounced among the younger age group.

Conclusions: The Finnish version of the EDE-Q can, based on this study, be regarded as reliable, valid, and functional. Further studies are needed to evaluate the population norms and to test the validity in individual ED diagnoses.     

Discrepancies in therapist and client ratings of global improvement following cognitive behavioral therapy for social phobia and their differential relations with symptom improvement at post-treatment and 12-month follow-up

Abstract

Objective: This study aimed to examine discrepancies in client and therapist ratings of global improvement and their relations to symptom improvement at post-treatment and 12-month follow-up. Method: Participants (N = 59) with social phobia received eight sessions of cognitive behavioral therapy (CBT). Participants and therapists rated improvement following each session. Participants also rated improvement at follow-up. Participants completed symptom severity self-reports at post-treatment and follow-up. Results: Clients consistently rated themselves as more improved than therapists. Relative to client ratings, therapist post-treatment ratings of improvement were related to more indices of symptom change at both timepoints. Conclusions: Results suggest that therapist ratings have good predictive utility of client-reported change in symptoms.     

Unpacking the therapist effect: Impact of treatment length differs for high- and low-performing therapists

Objective: Differences between therapists in their average outcomes (i.e., therapist effects) have become a topic of increasing interest in psychotherapy research in the past decade. Relatively little work, however, has moved beyond identifying the presence of significant between-therapist variability in patient outcomes. The current study sought to examine the ways in which therapist effects emerge over the course of time in psychotherapy. Method: We used a large psychotherapy data set (n?=?5828 patients seen by n?=?158 therapists for 50,048 sessions of psychotherapy) and examined whether outcomes diverge for high-performing (HP) and low-performing (LP) therapists as treatment duration increases. Results: Therapists accounted for a small but significant proportion of variance in patient outcomes that was not explained by differences between therapists' caseload characteristics. The discrepancy in outcomes between HP and LP therapists increased as treatment duration increased (interaction coefficient?=?0.071, p?p?=?.040). Conclusions: Indeed, patterns of change previously described ignoring between-therapist differences (e.g., dose-effect, good-enough level model) may vary systematically when disaggregated by therapist effect.     

Therapists' thoughts on therapy: Clinicians' perceptions of the therapy processes that distinguish schema,cognitive behavioural and psychodynamic approaches

Abstract

Objective: Debates continue over shared factors in therapy processes between different theoretical orientations. By seeking the opinions of practicing clinicians, this study aimed to elucidate the similarities and differences between cognitive-behavioural (CBT), psychodynamic (PDT), and schema therapy (ST) approaches. Method: Forty-eight practitioners aligning with one of the three approaches were asked to identify crucial processes in their therapy using a modified online version of the Psychotherapy Process Q-set. Results: Distinct differences between each theoretical orientation with few shared common factors were found. A comparison with ratings from previous studies indicated that CBT therapists have not changed over the last 20 years, whereas PDT therapists have changed and the differences appeared consistent with modern PDT theory. Conclusions: The differences between the therapy approaches were consistent with theories underlying each model. PDT therapists valued a neutral relationship, CBT therapists emphasized a didactic interaction, and therapists form a ST orientation placed a greater emphasis on emotional involvement.